U.S. Pharmacist

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Geriatric Palliative Care

When the Focus Shifts from Cure to Comfort

Mary Ann E. Zagaria, PharmD, MS, CGP
Senior Care Consultant Pharmacist and
President of MZ Associates, Inc. Staten Island, NY

5/18/2007

US Pharm. 2007;32(5):28-34.

It
has been said that disease is a confrontation, a triumph over which is merely a reprieve from the inevitable end.1 Death, on the other hand, may be viewed as a simple event occurring in sequence of nature's ongoing flow. 1 While accurate and eloquently stated, that simple event can be quite a harrowing experience for patient and family alike.

In the United States, the majority of deaths occur in the geriatric population.2 Seniors often develop multiple chronic medical problems and endure complicated medical courses.2 Furthermore, there is the condition of frailty associated with symptomatic long-term disease, decline in function, and abbreviated survival.3 The application of multidisciplinary, team-based palliative approaches, in conjunction with up-to-date geriatrics knowledge, can be beneficial in the treatment of the frail elderly in light of the complexity of their coexisting medical, psychological, and social needs.3

Frail Elderly
While the aging process varies among individuals, for most seniors the decline in organ function does not affect the body's function during normal daily activities; only when a very demanding task is attempted or when a disorder develops do patients usually notice the decline.4 Many clinicians recognize frailty in older adults as a syndrome of decline in function and health with clinical features including loss of strength, low levels of activity, slowed performance, poor endurance or fatigue, and weight loss.3 While this condition may be controlled by available approaches to care, the presence of three or more of these features has been associated with adverse outcomes, including new or worsened function impairment, falls, hospitalization, and death.3 Clearly, when frailty is severe, it is highly appropriate to deliver palliative care focused on relief of discomfort and optimal quality of life.3

Many seniors, as well as family members and caregivers, are not aware of or presented with the options and services available to assist with end-of-life care.5 It is important, therefore, to ensure providerñpatient/caregiver communication in the care of the frail elderly and to discuss advance care planning, palliative care, and hospice referral.3 Families should discuss and complete a living will and health care proxy before a palliative plan is necessary, since many dying patients are too ill to communicate their wishes at the time an end-of-life care plan is proposed.6,7

Goal of Palliative Care

Palliative care physicians require skill to address the needs of frail seniors with life-limiting illness as they approach the end of life.2 It is important for clinicians to embrace the concept and importance of allowing a dying patient, and his or her family members, control and participation in end-of-life care.5 While pain and management of symptoms (TABLE 1) appear obvious in terms of importance to the dying patient, reports indicate that other issues rank important as well, including communication about treatment decisions, preparation for death, achieving completion, contributing to others, and being known as a whole person.8 Despair and hopelessness may result if spiritual distress is not resolved, further contributing to anxiety and depression; in some cases suicide may ensue.6 Therefore, effective palliative care requires a broad multidisciplinary approach for the care of individuals with a wide variety of illnesses who have reached the stage where focus shifts from cure to comfort. Additionally, this approach involves the family and makes use of available community resources.

According to clinical practice guidelines published by the National Consensus Project for Quality Palliative Care, the goal of palliative care is "to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies"; this includes effective pain and symptom management, as well as psychosocial and spiritual care of the patient and the family.9,10

The World Health Organization (WHO) provides further elaboration by indicating that palliative care affirms life and regards dying as a normal process; it intends neither to hasten nor postpone death.11 The WHO offers support systems to help patients live as actively as possible until death and to help the family cope during the patient's illness and in their own bereavement.11 Through these services, the WHO notes an enhanced quality of life and the potential for a positive influence on the course of an illness. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life (e.g., chemotherapy or radiation therapy), and includes investigations needed to better understand and manage distressing clinical complications.11 Usually led by the physician, the interdisciplinary team also includes nurses, social workers, pharmacists, dietitians, clergy, volunteers, friends, and patient advocates.




Geriatric Palliative Care
Most medical knowledge organizes patients by disease, one disease per patient, and most health care provision organizes patients by program/site, one site at a time. 8 Excellence in end-of-life care, however, requires integrating for multiple diseases (i.e., comorbidities as seen in many geriatric patients) and for multiple programs/sites (e.g., hospital, home, assisted-living facility [ALF], nursing home).8 While an emphasis on optimizing quality of life and function are common to geriatrics and palliative medicine, geriatric palliative care is distinct in its focus on the geriatric syndromes (e.g., frailty and failure to thrive, falls, dizziness, syncope, delirium, sleep disorders, incontinence, pressure ulcers, disorders of temperature regulation) and on the provision of care in a variety of care settings.2 It is essential to have expertise in the diagnosis and management of the geriatric syndromes and in the complexities of various long-term care settings in order to provide high-quality palliative care to elderly patients.2

Furthermore, some frail elderly adults do not require a nursing homeñlevel of care and choose to reside, and ultimately to die, in ALFs, as they consider this setting to be their home.12 Theoretically, dying in place with the assistance of a palliative care program in the ALF can be part of the aging-in-place continuum. Experts note, however, that given the diversity of state regulation, settings, services, and the ability and willingness of staff, adopting this approach in the ALF setting will require much collaboration. 12

Palliative care is considered "upstream" if it is introduced when a chronic condition is initially diagnosed and thus provided in a noninstitutional setting throughout an individual's life and disease course, including appropriate curative interventions.12 Indicators of quality palliative care are: advance care planning, pain and symptom management, interdisciplinary involvement, care planning, staff education, and quality of life.12 Those working in the arena of palliative care strive to make it available across all treatment settings to benefit persons with life-limiting illness.8

Hospice

A hospice program provides support services to patients and their families, in addition to noncurative medical treatment for patients with terminal illnesses and a life expectancy of six months or less.5 Most hospice patients receive care in their homes where they feel most comfortable. However, many hospice patients continue to reside in the nursing home setting or assisted living residences; a smaller number receive services while still in the hospital.

Pharmacists can assist appropriate individuals in availing themselves of a hospice program, especially by enrolling in a timely fashion, to benefit by the comprehensive services provided. Data illustrate that recommendations by hospice pharmacists, as well as clinical interventions, significantly help patients achieve positive outcomes that affect quality of life.13

A recent study released in the New England Journal of Medicine reports a method to improve communication (i.e., set of communication guidelines for family conferences) between clinicians in the intensive care unit and family members of a dying patient. 14,15 The researchers reported this method significantly reduces feelings of stress, anxiety, and depression in family members and allows them to express their emotions and arrive at a more realistic expectation of the outcome.14,15

Pain Control

Untreated pain may manifest in a variety of ways, including refusal of care (i.e., physical assistance or handling of the patient may exacerbate pain), agitated behaviors, depression, anxiety, and insomnia.16 Quality care requires regular assessment of pain intensity. This is done over time to grasp and understand the individual variables that exacerbate pain and promote pain relief in an individual patient. This concept has driven the phrase "fifth vital sign," referring to pain and the need for its ongoing assessment.

To control persistent pain, analgesic medication should be dosed on a regular, round-the-clock basis; this additionally helps to avoid anxiety associated with the anticipation of pain. To relieve breakthrough pain, escalating pain, or an exacerbation of a preexisting morbidity that may contribute to the underlying pain, a rescue as-needed (prn) order is recommended as part of the palliative analgesic regimen. Monitoring the use of rescue prn medications is an integral component of the ongoing pain assessment process, enabling the clinician to recalculate an appropriate and adequate round-the-clock palliative dosage regimen for comfort. Patients who are cognitively intact may effectively participate in their own treatment by using prescribed patient-controlled analgesia.8 A critical part of quality pain management is managing adverse effects, including anticipating and preventing them (e.g., constipation, excessive sedation, which may lead to respiratory depression).10 Relieving and preventing the patient's physical and emotional symptoms is a priority because this enables the team to focus on addressing the patient's religious and spiritual needs.6,17

Classic clinical practice guidelines for selecting analgesic therapy include:
1. select the appropriate analgesic medication;
2. prescribe the appropriate dose;
3. administer via the appropriate route;
4. schedule the appropriate dosing interval;
5. prevent persistent pain and relieve breakthrough pain;
6. aggressively titrate the dose of the medication;
7. prevent, anticipate, and manage the side effects of the drug;
8. consider a sequential trial of analgesics; and
9. use appropriate adjuvant medications.18

The Role of the Pharmacist

According to the highlights of the 2006 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting, programs supported the continuum of care in pain management and palliative care as presenters described opportunities for pharmacists to work not only within their current practice setting, but collaboratively with colleagues in other environments.10

A position paper published by the ASHP on "The Pharmacist's Role in Hospice and Palliative Care" may be employed as a reference for those pharmacists interested, or currently practicing, in not only palliative care and hospice but pain management as well.10,19 The outlined roles include:
1. assessing the appropriateness of medication orders and ensuring the timely provision of effective medications for symptom control;
2. counseling and educating the hospice team about medication therapy;
3. ensuring that patients and caregivers understand and follow the directions provided with medications;
4. providing efficient mechanisms for extemporaneous compounding of nonstandard dosage forms;
5. addressing financial concerns;
6. ensuring safe and legal disposal of all medications after death, and;
7. establishing and maintaining effective communication with regulatory and licensing agencies. 10,19



Summary and Conclusion
While misinformed individuals view palliative care as an absence of care approach, it is actually compassionate, integrated care that offers a multidisciplinary team approach to address the medical, psychological, and social needs of patients and their families. Pharmacists may assist in this effort by raising awareness and participating in the services and options available to assist with end-of-life care when the focus shifts from cure to comfort. Data illustrate that pharmacists involved in end-of-life palliative care, through their recommendations and clinical interventions, significantly help patients achieve positive outcomes that affect their quality of life.

References

1. Nuland SB. How We Die. New York, NY: Alfred A. Knopf; 1993:10.

2. Kapo J, Morrison LJ, Liao S. Palliative care for the older adult. J Palliat Med. 2007;10:185-209.

3. Boockvar KS, Meier DE. Palliative care for frail older adults: "there are things I can't do anymore that I wish I could . . .". JAMA. 2006;296:2245-2253.

4. Beers MH, Jones TV, Berkwits M, et al., eds. The Merck Manual of Health & Aging. Whitehouse Station, NJ: Merck Research Laboratories; 2004:183-197.

5. Zagaria ME. End-of-life care in the elderly. US Pharm. 2003;28(1):20-23.

6. Steinhauser KE, Clipp EC, Tulsky JA. Evolution in measuring the quality of dying. J Palliat Med. 2002;5:407-414.

7. Zagaria ME. Legal Aspects of Eldercare: The living will, health care proxy and do-not-resuscitate (DNR) Order. US Pharm. 2002;27(12):68.

8. Lorenz K, Lynn J. Care of the Dying Patient. In: Hazzard WR, Blass JP, Halter JB, et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill, Inc.; 2003:323-334.

9. National Consensus Project for Quality Palliative Care Web site. Available at: www.nationalconsensusproject.org. Accessed December 28, 2006.

10. ASHP 2006: Highlights of the 2006 American Society of Health-System Pharmacists Midyear Clinical Meeting. Methadone, Pain Management, and Palliative Care. Released February 2, 2007. Available at: www.medscape .com/viewarticle/550895. Accessed March 30, 2007.

11. World Health Organization. Palliative care is an essential part of cancer control and can be provided relatively simply and inexpensively. Available at: http://www.who.int/cancer/palliative/en/. Accessed March 22, 2007.

12. Mitty EL. Assisted Living: Aging in place and palliative care. Geriatr Nurs. 2004;25:149-163. Available at: www.medscape.com/viewarticle/481617. Accessed March 28, 2007.

13. Lee J, McPherson ML. Outcomes of recommendations by hospice pharmacists. Am J Health-Syst Pharm. 2006;63:2235-2239.

14. VALUE process helps families cope with end-of-life choices in the intensive care unit. Hospitals & Health Networks. March 2007:68-70.

15. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356:469-478.

16. Martin CM. Understanding palliative care. The Consultant Pharmacist. 2006;21:698-713.

17. Cohen AB, Koenig HG. Spirituality in palliative care. Geriatric Times. 2002;Nov/Dec:25.

18. Levy MH. Pharmacologic treatment of cancer pain. New Engl J Med. 1996;335:1124-1132.

19. American Society of Health-System Pharmacists. ASHP statement on the pharmacist's role in hospice and palliative care. Am J Health-Syst Pharm. 2002;59:1770-1773.

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U.S. Pharmacist is a monthly journal dedicated to providing the nation's pharmacists with up-to-date, authoritative, peer-reviewed clinical articles relevant to contemporary pharmacy practice in a variety of settings, including community pharmacy, hospitals, managed care systems, ambulatory care clinics, home care organizations, long-term care facilities, industry and academia. The publication is also useful to pharmacy technicians, students, other health professionals and individuals interested in health management. Pharmacists licensed in the U.S. can earn Continuing Education credits through Postgraduate Healthcare Education, LLC, accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

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