Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-gxg78 Total loading time: 0 Render date: 2024-12-26T23:01:06.735Z Has data issue: false hasContentIssue false

Chapter 53 - Introduction to Palliative Care

from Section IV - Principles of Care for the Elderly

Published online by Cambridge University Press:  30 June 2022

By
Molly Hanson ,
Kristine Swartz  and
Brooke Worster
Edited by
Jan Busby-Whitehead ,
Samuel C. Durso ,
Christine Arenson ,
Rebecca Elon ,
Mary H. Palmer  and
William Reichel
Jan Busby-Whitehead
Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso
Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson
Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon
Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer
Affiliation:
University of North Carolina, Chapel Hill
William Reichel
Affiliation:
Georgetown University Medical Center
Get access

Summary

Palliative care, an approach to care that improves the quality of life of patients and families, has rapidly become the standard of care for patients with serious illness in recent decades. A large body of quality evidence supports interprofessional palliative care delivery as a means to improve symptom control, mood, and communication and result in less aggressive treatment at the end of life. One large component of this palliative care is skilled, structured communications; meeting with patient, family, and other medical specialists involved with complex patient care. Additionally, focus on pain and symptom control requires a nuanced approach, especially in the older adult at higher risk of drug-related adverse events. Increasingly important to understand is the complexity in use and prescription of opioids. They have both intended and unintended consequences of use; both effective pain control in serious illness and diversion or misuse. Pain, nausea, vomiting, dyspnea, and delirium increase in prevalence as patients burden of illness increases. Pharmacotherapy and non-medication-based interventions are both often effective as patients approach the end of life. Hospice remains the gold standard of care for dying patients, but because many people still die in hospital settings, it is critical that clinicians are knowledgeable in providing end-of-life care.

Keywords

palliative careend of lifeopioidscommunicationquality of lifesymptom managementhospicepolypharmacydelirium
Type
Chapter
Information
Reichel's Care of the Elderly
Clinical Aspects of Aging
 , pp. 650 - 663
Publisher: Cambridge University Press
Print publication year: 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

The Commonwealth Fund, The New York Times, Harvard T.H. Chan School of Public Health. Being Seriously Ill in America Today, 2018.Google Scholar
World Health Organization. WHO definition of palliative care, 2008. www.who.int/cancer/palliative/definition/en.Google Scholar
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition, 2018. www.nationalconsensusproject.org.Google Scholar
Bakitas, M, Lyons, KD, Hegel, MT, Balan, S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer. JAMA. 2009; 302(7):741–749.CrossRefGoogle ScholarPubMed
Jack, B, Hillier, V, Williams, A, et al. Hospital based palliative care teams improve the symptoms of cancer patients. Palliat Med. 2003; 17(6):498–502.Google Scholar
Kavalieratos, D, Corbelli, J, Zhang, D. Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. JAMA. 2016; 316(20)2104–2114.CrossRefGoogle ScholarPubMed
Hui, D, Hannon, BL, Zimmermann, C, Bruera, E. Improving patient and caregiver outcomes in oncology: Team‐based, timely, and targeted palliative care. CA: A Cancer Journal for Clinicians. 2018; 68(5):356–376.Google Scholar
May, P, Garrido, MM, Cassel, JB, et al. Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from? Palliat Med. 2017; 31(4):378–386.CrossRefGoogle ScholarPubMed
Bendaly, EA, Groves, J, Juliar, B, Gramelspacher, GP. Financial impact of palliative care consultation in a public hospital. J Palliat Med. 2008; 11(10):1304–1308.Google Scholar
Gade, G, Venohr, I, Conner, D, et al. Impact of an inpatient palliative care team: A randomized control trial. J Palliat Med. 2008; 11(2):180–189.Google Scholar
Hanson, LC, Usher, B, Spragens, L, Barnard, S. Clinical and economic impact of palliative care consultation. J Pain Symptom Manage. 2008; 35(4):340–346.Google Scholar
Morrison, RS, Penrod, JD, Cassel, JB, et al. Cost savings associated with U.S. hospital palliative care consultation programs. Arch Intern Med. 2008; 168(16):1783–1790.Google Scholar
Norton, SA, Hogan, LA, Holloway, RG, Temkin-Greener, H, Buckley, MJ, Quill, TE. Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients. Crit Care Med. 2006; 35(6):1530–1535.CrossRefGoogle Scholar
Penrod, JD, Partha, D, Luhrs, C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006; 9(4):855–860.Google Scholar
Armstrong, B, Jenigiri, B, Hutson, SP, Wachs, PM, Lambe, CE. The impact of a palliative care program in a rural Appalachian community hospital: A quality improvement process. Am J Hosp Palliat Care. 2013; 30(4):380–387.Google Scholar
Cassarett, D, Pickard, A, Bailey, FA, et al. Do palliative consultations improve patient outcomes? J Am Geriatr Soc. 2008; 56:593–599.Google Scholar
Temel, JS, Greer, JA, Muzikansky, A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363(8):733–741.Google Scholar
Greer, JA, Tramontano, AC, McMahon, PM, et al. Cost analysis of a randomized trial of early palliative care in patients with metastatic nonsmall-cell lung cancer. J Palliat Med. 2016 (Aug.); 19(8):842–848.CrossRefGoogle ScholarPubMed
Center to Advance Palliative Care. Mapping Community Palliative Care: A Snapshot, 2019. www.capc.org.Google Scholar
Goldsmith, B, Dietrich, J, Du, Q, Morrison RS: Variability in access to hospital palliative care in the United States. J Palliat Med. 2008; 11:1094–1102.Google Scholar
Morrison, RS, Maroney-Galin, C, Kralovec, PD, Meier DE: The growth of palliative care programs in United States hospitals. J Palliat Med. 2005; 8:1127–1134.Google Scholar
Weissman, DE, Meier, DE. Identifying patients in need of a palliative care assessment in the hospital setting: A consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011; 14(1):1–7.Google Scholar
Quill, TE, Abernethy, AP. Generalist plus specialist palliative care: Creating a more sustainable model. N Engl J Med. 2013; 368(13):1173–1175.Google Scholar
Back, AL, Arnold, RM, Baile, WF, et al. Faculty development to change the paradigm of communication skills in oncology. J Clin Oncol. 2009; 27:1137–1141.Google Scholar
Kurz, J, Hayes, E. End of life issues action: Impact of education. Int. J. Nursing Educ. Scholarship. 2006; 3(1):1–13.Google Scholar
Robinson, K, Sutton, S, von Gunten, CF, et al. Assessment of the education for physicians on End-of Life Care (EPEC) project. J Palliat Med. 2004; 7(5):637–645.Google Scholar
Bernacki, R, Hutchings, M, Vick, J, et al. Development of the Serious Illness Care Program: A randomised controlled trial of a palliative care communication intervention. BMJ Open. 2015; 5(10):e009032.Google Scholar
Weissman, DE. Conducting a Family Goal Setting Conference. Milwaukee: Palliative Care Center, Medical College of Wisconsin, 2007.Google Scholar
Sullivan, AM, Lakoma, MD, Block, SD. The status of medical education in end of life care: A national report. J Intern Med. 2003; 18:685–695.Google Scholar
Khader, KA, Jarrah, SS, Alasad, J. Influence on nurses’ characteristics and education on their attitudes toward death and dying: A review of the literature. Int J Nurs Midwifery. 2010; 2(1):1–9.Google Scholar
Fallowfield, L, Jenkins, V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004; 363:312–319.Google Scholar
Brown, VA, Parker, PA, Furbur, L, Thomas, AL. Patient preferences for the delivery of bad news: The experience of a UK Cancer Centre. Eur J Cancer Care. 2011; 20:56–61.Google Scholar
Jenkins, V, Fallowfield, L, Saul, J. Information needs of patients with cancer: Results from a large study in UK cancer centres. Briti J Cancer. 2001; 84:48–51.Google Scholar
Bruera, E, Neumann, CM. The uses of psychotropics in symptom management in advanced cancer. Psycho‐Oncology. 1998; 7(4):346–358.Google Scholar
Hermann, C, Looney, S. The effectiveness of symptom management in hospice patients during the last seven days of life. J Hosp Palliat Nurs. 2001; 3(3):88–96.Google Scholar
Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press, March 19, 2015.Google Scholar
Abrahm, JL. A Physician’s Guide to Pain and Symptom Management in Cancer Patients, 2nd edition. Baltimore, MD: The Johns Hopkins University Press, 2005.Google Scholar
Jacox, A, Carr, DB, Payne, R, et al. Management of Cancer Pain: Clinical Practice Guideline No. 9. Rockville, MD: Agency for Health Care and Policy Research, US Department of Health and Human Services, Public Health Service, 1994, p. 23. AHCPR publication 94–0592.Google Scholar
Eisenberg, E, McNicol, ED, Carr, DB. Efficacy and safety of opioid agonists in the treatment of neuropathic pain of nonmalignant origin: Systemic review and meta-analysis of randomized controlled trials. JAMA. 2005; 293:3043–3052.Google Scholar
Yarnitsky, D, Eisenberg, E. Neuropathic pain: Between positive and negative ends. Pain Forum. 1998; 7:241–242.Google Scholar
AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacologic management of persistent pain in older persons. J Am Geriatr Soc. 2009; 57:1331–1346.Google Scholar
AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 2002; 50:S205–S224.Google Scholar
Herr, K, Coyne, PJ, Key, T, et al. Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manag Nurs. 2006; 7(2):44–52.Google Scholar
Fine, PG. Opioid analgesic drugs in older people. Clin Geriatr Med. 2001; 17:479–487.Google Scholar
Pergolizzi, J, Boger, RH, Budd, K, et al. Opioids and the management of chronic severe pain in the elderly: Consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008; 8:287–313.Google Scholar
Derby, S, O’Mahony, S, and Tickoo, R. Elderly patients. In: Ferrell, BR and Coyle, N, eds. Oxford Textbook of Palliative Nursing, 3rd edition. New York: Oxford University Press, 2010, pp. 713–743.Google Scholar
Mercadante, S, Arcuir, E. Opioids and renal function. J Pain. 2004; 5:2–19.Google Scholar
Jones, MR, Viswanath, O, Peck, J, Kaye, AD, Gill, JS, Simopoulos, TT. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther. 2018; 7(1):13–21.Google Scholar
Ellenbogen, MI, Segal, JB. Differences in opioid prescribing among generalist physicians, nurse practitioners, and physician assistants. Pain Med (United States). 2020; 21(1):76–83.Google Scholar
Yasin, JT, Leader, AE, Petok, A, Garber, G, Stephens, B, Worster, B. Validity of the screener and opioid assessment for patients with pain-revised (SOAPP-R) in patients with cancer. J Opioid Manag. 2019; 15(4):272–274.Google Scholar
Ho, JFV, Yaakup, H, Low, GSH, Wong, SL, Tho, LM, Tan, SB. Morphine use for cancer pain: A strong analgesic used only at the end of life? A qualitative study on attitudes and perceptions of morphine in patients with advanced cancer and their caregivers. Palliat Med. 2020; 34(5):619–629.Google Scholar
Edwards, H, Bennett, M. Access to opioids for patients with advanced disease. Curr Pharm Des. 2019; 25(30):3203–3208.Google Scholar
Kirvela, M, et al. The pharmacokinetics of oxycodone in uremic patients undergoing renal transplantation. J Clin Anesth. 1996; 8:13–18.Google Scholar
Paramanandam, G, Prommer, E, Schwenke, DC. Adverse effects in hospice patients with chronic kidney disease receiving hydromorphone. J Palliat Med 2011; 14(9):1029–1033.Google Scholar
Kornick, CA, et al. A safe and effective method for converting cancer patients from intravenous to transdermal fentanyl. Cancer. 2001; 92:3056–3061.Google Scholar
Varvel, JR, et al. Absorption characteristics of transdermally administered fentanyl. Anesthesiology. 1989; 70:928–934.Google Scholar
Miller, KE, Miller, MM, Jolley, MR. Challenges in pain management at the end of life. Am Fam Physician. 2001; 64:1227–1234.Google Scholar
Vadalouca, A, et al. Opioid rotation in patients with cancer: A review of the current literature. J Opioid Manag. 2008; 4(4):213–250.Google Scholar
Jage, J. Opioid tolerance and dependence – Do they matter? Eur J Pain. 2005; 9:157–162.Google Scholar
O’Connor, AB, Dworkin, RH. Treatment of neuropathic pain: An overview of recent guidelines. Am J Med. 2009; 122:S22–S32.CrossRefGoogle ScholarPubMed
Paulsen, O, et al. Do corticosteroids provide analgesic effects in cancer patients? A systematic literature review. J Pain Symptom Manage. 2013; 46:96–105.Google Scholar
Zuardi, AW. History of cannabis as a medicine: A review. Rev Bras Psiquiatr. 2006; 28(2):153–157.Google Scholar
Whiting, PF, Wolff, RF, Deshpande, S, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA – J Am Med Assoc. 2015; 313(24):2456–2473.Google Scholar
Wong, GY, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: A randomized controlled trial. JAMA. 2004; 291(9):1092–1099.Google Scholar
Paley, CA, et al. Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007753. doi: 10.1002/14651858.CD007753.pub2.Google Scholar
Wood, GJ, et al. Management of intractable nausea and vomiting in patients at the end of life: “I was feeling nauseous all of the time … Nothing was working.” JAMA. 2007; 298(10):1196–1206.Google Scholar
Bentley, A, Boyd, K. Use of clinical pictures in the management of nausea and vomiting: a prospective audit. Palliat Med. 2001; 15(3):247–253.Google Scholar
Bruera, E, et al. Chronic nausea in advanced cancer patient: A retrospective assessment of a metoclopramide-based antiemetic regimen. J Pain Symptom Manage. 1996; 11(3):147–153.Google Scholar
Lundstrom, S, Zachrisson, U, Furst, CJ. “When nothing helps”: Propofol as sedative and antiemetic in palliative cancer care. J Pain Symptom Manage. 2005; 30(6):570–577.CrossRefGoogle ScholarPubMed
Mahler, DA, et al. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest. 2010; 137(3):674–691.Google Scholar
Luce, JM, Luce, JA. Management of dyspnea in patients with far advanced lung disease: “Once I lose it, it’s kind of hard to catch it …” JAMA. 2001; 285:1331–1337.Google Scholar
Jennings, AL, et al. Opioids for palliation of breathlessness in advanced disease and terminal illness. Cochrane Database Syst Rev. 2001; 3.Google Scholar
Thorns, A, Sykes, N. Opioid use in last week of life and implications for end-of-life decision-making. Lancet. 2000; 356(9227):398–399.Google Scholar
Smoller, JW, Pollack, MH, Otto, MW, Rosenbaum, JF, Kradin, RL. Panic anxiety, dyspnea, and respiratory disease: Theoretical and clinical considerations. American Journal of Respiratory and Critical Care Medicine. 1996; 154(1):6–17.Google Scholar
Man, GC, Hsu, K, Sproule, BJ. Effect of alprazolam on exercise and dyspnea in patients with chronic obstructive pulmonary disease. CHEST Journal. 1986; 90(6):832–836.Google Scholar
Barzansky, B, Vesloski, JJ, Miller, R, Jonas, HS. Education in end-of-life care during medical school and residency training. Acad Med. 1999; 74(10):s102–s104.Google Scholar
Steinhauser, KE, Clipp, EC, McNeilly, M, Christakis, NA, McIntyre, LM, Tulsky, JA. In search of a good death: Observations of patients, families, and providers. Ann Intern Med. 2000; 132(10):825–832.Google Scholar
Cross, SH, Warraich, HJ. Changes in the place of death in the United States. N Engl J Med. 2019; 381(24):2369–2370.CrossRefGoogle ScholarPubMed
Hospice Facts and Figures, NHPCO. www.nhpco.org/research.Google Scholar
Hospice Benefits, Medicaid. www.medicaid.gov/medicaid/benefits/hospice-benefits/index.html.Google Scholar
Billing for Medicare Hospice Patients. www.vitas.com/for-healthcare-professionals/medicare-hospice-benefit-and-physician-billing/physician-billing-for-medicare-hospice-patients.Google Scholar
Gallagher, R, Krawczyk, M. Family members’ perceptions of end-of-life care across diverse locations of care. BMC Palliat Care. 2013; 12(1):25.Google Scholar
Virdun, C, Luckett, T, Lorenz, K, Davidson, PM, Phillips, J. Dying in the hospital setting: A meta-synthesis identifying the elements of end-of-life care that patients and their families describe as being important. Palliat Med. 2017; 31(7):587–601.Google Scholar
Bear, AJ, Bukowy, EA, Patel, JJ. Artificial hydration at the end of life. Nutr Clin Pract. 2017; 32(5):628–632.Google Scholar
Prado, BL, Pereira, AZ, Gonçalves, SEA, Cendon Filha, SP, Lucio, F, Souza, PMR. Artificial nutrition in palliative care cancer patients. J Clin Oncol. 2018; 36(15 suppl.):e22190–e22190.Google Scholar
Mccann, RM, Hall, WJ, Groth Juncker, A. Comfort care for terminally ill patients: The appropriate use of nutrition and hydration. JAMA J Am Med Assoc. 1994; 272(16):1263–1266.CrossRefGoogle Scholar
Mercadante, S, Marinangeli, F, Masedu, F, et al. Hyoscine butylbromide for the management of death rattle: Sooner rather than later. J Pain Symptom Manage. 2018; 56(6):902–907.Google Scholar
Watts, T, Willis, D, Noble, S, Johnston, B. Death rattle: Reassuring harbinger of imminent death or a perfect example of inadequacies in evidence-based practice. Curr Opin Support Palliat Care. 2019; 13(4):380–383.Google Scholar
Casarett, DJ, Inouye, SK, Snyder, L. Diagnosis and management of delirium near the end of life. Ann Intern Med. 2001; 135(1):32–40.Google Scholar
Finucane, A, Jones, L, Leurent, B, et al. 52 Drug therapy for delirium in terminally ill adults: A Cochrane systematic review. BMJ Support Palliat Care. 2018; 8(3):379.2–380.Google Scholar
Hosker, CMG, Bennett, MI. Delirium and agitation at the end of life. BMJ. 2016; 353.CrossRefGoogle Scholar
Wholihan, D, Olson, E. The doctrine of double effect: A review for the bedside nurse providing end-of-life care. J Hosp Palliat Nurs. 2017; 19(3):205–211.Google Scholar
Sykes, N, Thorns, A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med. 2003; 163(3):341–344.Google Scholar
Bodnar, J. A review of agents for palliative sedation/continuous deep sedation: Pharmacology and practical applications. J Pain Palliat Care Pharmacother. 2017; 31(1):16–37.Google Scholar
Geng, HM, Chuang, DM, Yang, F, et al. Prevalence and determinants of depression in caregivers of cancer patients: A systematic review and meta-analysis. Med (United States). 2018; 97(39).Google Scholar
Bovero, A, Tosi, C, Botto, R, Opezzo, M, Giono-Calvetto, F, Torta, R. The spirituality in end-of-life cancer patients, in relation to anxiety, depression, coping strategies and the daily spiritual experiences: A cross-sectional study. J Relig Health. 2019; 58(6):2144–2160.Google Scholar
Balboni, TA, Fitchett, G, Handzo, GF, et al. State of the science of spirituality and palliative care research part II: Screening, assessment, and interventions. J Pain Symptom Manage. 2017; 54(3):441–453.CrossRefGoogle ScholarPubMed
Plonk, WM, Arnold, RM. Terminal care: The last weeks of life. J Palliat Med. 2005; 8(5):1042–1054.Google Scholar
Nielsen, MK, Neergaard, MA, Jensen, AB, Vedsted, P, Bro, F, Guldin, MB. Predictors of complicated grief and depression in bereaved caregivers: A nationwide prospective cohort study. J Pain Symptom Manage. 2017; 53(3):540–550.Google Scholar
Lloyd, SL, Striley, CW. Marijuana use among adults 50 years or older in the 21st century. Gerontology & Geriatric Medicine. 2018; 4:1–14.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×