Guiding the Transition To Comfort Care

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.