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Chapter 92 Palliative Care 1493

TABLE Treatment of Common Problems in the Final Days (Adult Patient)
92.4
Problem Agent(s) Routes, Doses
Baseline pain Concentrated oxycodone or morphine solution PO/SL q4h around the clock; individualized
Morphine or hydromorphone tablets PR q4h; individualized
Fentanyl a Transdermal; individualized
Methadone liquid PO; individualized
Acetaminophen, naproxen PR tid to qid
Dexamethasone (requires compounding) PR daily to bid
Breakthrough pain Concentrated oxycodone or morphine solution PO or per gastric tube q4h around the clock; individualized
Fentanyl a Transmucosal (buccal, sublingual); individualized
“Death rattle” Scopolamine Transderm Scop patch 1–3q3 days; gel
Hyoscyamine 0.125–0.25 SL tid to qid
Glycopyrrolate 0.2–0.4 mg IV tid to qid or 1–2 mg po bid to tid
Atropine 0.4 mg SL q4–6h
Dyspnea (anxiety) Lorazepam 1 mg PO, SL, q2–4h
Chlorpromazine 25 mg PO, PR q4–12h; or 12.5 mg IV q4–8h
Dyspnea (other) Morphine/oxycodone 5–10 mg SL oral concentrate q2h
Morphine 2–4 mg IV q1h
Nausea Combinations of lorazepam, metoclopramide, PR q6h; compounded suppositories with desired agents (depending on
dexamethasone, and/or haloperidol presumed cause of nausea)
Anxiety Lorazepam 1 mg PO, SL, q2–4h
Diazepam suppository 5–10 mg PR daily
All liquid PO medications can be given per gastric tube.
a Fentanyl only for opioid tolerant patients.
h, Hour; IV, intravenously; PO, orally; PR, rectally; q, every; qid, four times a day; SL, sublingually; tid, three times a day.
Modified from Abrahm JL: A physician’s guide to pain and symptom management in cancer patients, ed 3, Baltimore, 2014, Johns Hopkins University Press.

Adults reimburses hospice programs about $186 per day per patient (as of
fiscal year 2013) to provide the routine care described in Table 92.5.
Common physical symptoms that occur in the last week to days Therefore, the cost of transfusions typically required for many
before an adult’s death from cancer include pain (70%), noisy or patients with hematologic malignancies, even at the end of life, may
moist breathing (60%), urinary incontinence or retention, dyspnea, make it difficult for hospice programs to enroll patients insured by
12
and nausea and vomiting. Patients may also experience fatigue. Medicare alone. Other insurance programs may allow their patients
Hunger and thirst are unusual. Treatments for problems at the end to receive transfusions and hospice care. Notably, many children are
of life are reviewed in Table 92.4. Patient and family wishes and not referred to hospice because their illness experience is inconsistent
options about the setting for end-of-life care should be explored. with hospice specifications—prognosis is uncertain; there is a blend-
Some evidence suggests that patients with cancer who die at home ing of goals, which can result in more costly health care; and providers
have better quality of life, and their caregivers have better bereave- lack pediatric expertise. Importantly, the Patient Protection and
ment outcomes than cancer patients who die in the hospital. However, Affordable Care Act now requires state Medicaid programs to allow
given the potentially high symptom burden in the final moments of children with a life-limiting illness to receive both hospice care and
life, such as bleeding or dyspnea, more research is needed to under- curative treatments concurrently; the full effect of this change remains
stand barriers to hospice care and patient and family outcomes in to be seen.
hematologic malignancies. 27
BEREAVEMENT
HOSPICE PROGRAMS
Bereavement follow-up by the professional team is an intrinsic
In the four weeks prior to his death, my father lived under the care component of comprehensive pediatric palliative care. Bereaved
of five different institutions in two states. Only the last place, the families often express the sentiment of a double loss: loss of their
hospice, appeared willing or able to provide care and comfort to a child and loss of their oncology team whom they have known and
man who was obviously at the end of his life. 2 trusted, often over months and years. Parental grief has been recog-
— (Bereaved family member) nized as more intense and longer lasting than other types of grief.
Contact from a team member after the child’s death can assuage the
In the United States, most hospice care takes place in the home, family’s sense of abandonment and the palliative care team can serve
although patients can be admitted to nursing homes for brief periods a crucial preventive role by identifying families at particular risk for
(usually 5 days) to provide a respite for the family caregivers, or to prolonged grief disorders and identifying resources for them.
the hospital (usually for up to 14 days) if symptoms cannot be Each bereaved person’s loss is unique, but many people manifest
controlled at home. Early referral to hospice programs improves similar symptoms of grief, some of which become less persistent as
outcomes, and in many cases hospice care is the only effective way they rebuild their lives. Recurrent intense symptoms typically occur
to support these patients and families at home at the end of life. The at the anniversary of the death of the patient but can occur at
Medicare Hospice Benefit does not require a do not resuscitate status, unpredictable times, induced by reminders of the deceased. Survivors
but it does require that the attending physician and the hospice appreciate calls or letters from the patient’s physician and nurses. For
medical director certify that the patient has a prognosis of 6 months patients enrolled in hospice programs, a formal bereavement program
or less to live if the disease follows its usual course. Medicare is offered for the family throughout the first year after the patient’s