Overview of palliative medicine

Palliative medicine is a comprehensive, interdisciplinary approach to medical care that aims to relieve suffering and provide optimal quality of life in patients with serious or life-threatening illnesses. Crucial components of palliative medicine include symptom relief (e.g., pain management, treatment of nausea), assistance in the organization of nursing and social services, and psychological support of patients and their families. Palliative care has been shown to improve patient symptoms and quality of life, decrease hospital admissions, and reduce bereavement among family members. Accordingly, if a patient desires or meets criteria for palliative care referral, it should be initiated as quickly as possible.

Pharmacological management of symptoms in palliative medicine

Pharmacological therapy of symptoms in individuals receiving palliative care depends on:

• Individual assessment and periodic reassessment of symptoms
• Exclusion of potential drug interactions
• Thorough evaluation of side effects

Management of symptoms in palliative patients
Symptoms	Management
Pain	Administration of slow-release opioids according to a fixed time schedule and use of PRN medication (fast-acting opioids, injections) Opioid dosage should be increased in terminally ill patients to provide sufficient pain relief. For details, see pain management. Nociceptive pain Neuropathic pain See also pain concepts in palliative care.
Gastrointestinal symptoms	Nausea and vomiting: metoclopramide , haloperidol, levomepromazine , dimenhydrinate Loss of appetite: dexamethasone or prednisolone Thirst: oral care Constipation: lactulose, macrogol, sodium picosulfate, paraffin Diarrhea Addressing the possible cause (paradoxical diarrhea or administration of laxatives should be excluded) Fluid and electrolyte replacement from an early stage on
Pulmonary symptoms	Dyspnea: fast-acting morphine (e.g., morphine drops); breathing and relaxation techniques Cough: Treatment depends the type of cough (productive/non-productive) and either involves administration of protussives or antitussives. In refractory disease, hydrocodone may be an option. Corticosteroids may be an alternative.
Psychological symptoms	Anxiety and depression: benzodiazepines, antidepressants, antipsychotics, and psychotherapy Delirium: antipsychotics, benzodiazepines Fatigue Regular exercise, physical therapy, and psychotherapy have been shown to have positive effects. Corticosteroids (e.g., dexamethasone, methylprednisolone) may be used to improve short-term stamina.
Final phase	Restlessness/agitation: midazolam, lorazepam Delirium: haloperidol , metoclopramide Death rattle: butylscopolamine, if necessary [2]
Note: Some of the listed drugs are not approved for the indication, application, or dosage mentioned above. However, experts recommend the off-label use of these drugs because of the observed benefits for palliative patients.

Oral administration is the route of choice in palliative medicine!

Pain concepts in palliative care

In palliative medicine, pain is not only understood according to its quality but also as different pain concepts:

• Total pain: a holistic understanding of pain in palliative medicine, including physical, emotional, social, and spiritual distress (e.g., sorrow, anxiety, despair).
• Mixed pain: Peripheral pain and neuropathic pain occur simultaneously.
• Emotional pain: describes the influence of emotions on pain
• Cancer pain: 60–90% of oncological patients experience pain, which may be caused by the following factors.
  • Disorders associated with the tumor (e.g., thrombosis, paraneoplastic syndrome)
  • Therapy: postoperative pain, side effects of radiotherapy or chemotherapy (e.g., mucositis, polyneuropathies, stomach ulcer associated with NSAIDs)
  • Tumor effects: infiltration of soft tissue and bones; compression of nerves, lymphatic vessels, or blood vessels; cerebral edema

References:^[1][2][3]

The health care system measures the outcome (quality of results) of medical treatment and its influence on the current and future health of patients and their quality of life. Outcome measurements may be subgrouped into general and specific measurements. General outcome measurements assess, for instance, the physical and psychological aspects of an illness, while specific outcome measurements focus on the evaluation of symptoms, clinical situations, or patient populations.

• Common outcome measurements in palliative medicine
  • Numeric rating scale (NRS) and visual analog scale (VAS)
    • One-dimensional scales that are based on self-reported data: NRS scale 0–10, VAS scale 0–100
    • E.g., report of pain level, level of respiratory distress, nausea, quality of life, satisfaction, stress
  • Tools to assess functional performance of individuals receiving palliative care: Karnofsky performance status scale, palliative performance status (PPS), Eastern Cooperative Oncology Group (ECOG) performance status

Basics of communication with palliative patients

• Be honest
• Use open-ended questions
• Routinely assess patient understanding
• Deliver bad news by setting; the stage and delivering the news in an empathetic yet comprehensible manner
• Have a clear follow-up in plan in place to facilitate better communication between provider and patient
• Understand that patients' desires can differ from those of family members.

NURSE model

The NURSE model is a roadmap for practitioners to address and respond to the emotions of patients empathetically.

	Element	Description
N	Name	Name the patient's emotions
U	Understand	Express understanding for the patient's emotions
R	Respect	Respect the patient for coping with the situation
S	Support	Offer support
E	Explore	Explore the emotions

SPIKES protocol for communicating bad news ^[4]

The SPIKES protocol is based on empirical data and guidelines and helps practitioners to break bad news to patients.

SPIKES protocol
	Element	Description
S	Setting	Setting up the interview and arranging for some privacy Involvement of significant others Avoidance of interruptions Providing information about the time frame of the interview to the patient
P	Perception	Determination of the patient's perception of the situation Open-ended questions Patients are asked to explain illness/therapy/prognosis in their own words
I	Invitation	Obtaining a patient's invitation to talk about certain topics Offering opportunities to talk at a later point of time
K	Knowledge	Warning the patient that bad news/prognosis is coming before giving knowledge and information Avoidance of technical terms Use of short and precise sentences Avoidance of excessive bluntness
E	Emotions	Identification of emotional triggers and addressing the patient's emotions with empathic responses (nonverbal communication)
S	Summary	Summary and strategy planning (treatment options, prognosis, next consultation, offering palliative support, inquiring about patient's needs and wishes)

References:^[1][4]

Definition

• Type of palliative care specifically given to patients at the end of life
• Goal
  • Preserve the dignity of patients during the final stages of life.
  • Provide maximum comfort to the patient.
  • Ensure pain relief (including administration of opioids, anxiolytics, or sedatives).
  • Prioritize positive effects over potential negative effects (e.g., pain relief over the risk of respiratory depression), according to the ethical principle of double effect.

Who is eligible for hospice care?

• Estimated life expectancy < 6 months
• Patients are usually on Medicare, Medicaid, or private insurance plans.
• The patient (and family) has made the decision to stop curative or life-preserving treatment in order to maximize quality of life.

Not all treatment should be withdrawn. Antibiotics, for example, can still be given if the patient develops an infection.

Where does hospice care take place?

• Patients can receive hospice care at home, in a skilled nursing facility, or at a hospital.
  • Home hospice services may consist of regular nursing visits, assistance with activities of daily living (e.g., cooking, cleaning, bathing, etc.), or support for home medical equipment (e.g., hospital beds, walkers, bedside commodes, etc.).
  • Hospice care in a hospital or nursing facility may be indicated if the patient's pain or symptoms require more specialized care.
• Services are available 24 hours a day, 7 days a week.

References:^[5]