Palliative Care: Procedures and Goals of Care

Palliative Care
Written By Sydney Oesch

Episode Notes

  1. Malignant Bowel Obstruction

    1. Considerations

      1. Complete or partial

      2. Location

      3. Patient’s prognosis, functional status, goals of care

    2. Management options

      1. Surgical

        1. Factors that predict failure: evidence of residual/recurrent tumor on imaging, peritoneal disease, multiple sites of disease, ascites, hypoalbuminemia (<3.5), age > 65

        2. Most successful: one transition point, low likelihood of carcinomatosis

      2. Tube Decompression

        1. Nasogastric tube (NGT)

          1. Temporary; long term use can cause nasal cartilage erosion, ear infections, aspiration pneumonia, esophagitis

          2. Uncomfortable, require flushing, can become occluded

        2. Gastrostomy tubes (G tube) / Venting Percutaneous endoscopic gastrostomy tubes (PEG)

          1. Most common method of non-surgical decompression

          2. Can have PO liquids for comfort

        3. Gastrojejunostomy tubes (GJ)

          1. Helpful if duodenal obstruction (i.e. proximal aortic lymphadenopathy(

      3. Colonic Stent

        1. Useful for extracolonic pelvic tumors that cause extrinsic compression

        2. Good in short term; ~⅓ will need re-intervention long term

        3. Left-sided lesions easier to intervene

        4. Contraindications: perforation, rectal lesions w/i 5 cm of dentate line, disseminated peritoneal carcinomatosis, multifocal stenotic segments of bowel

          1. Relative contraindications: bowel ischemia, avastin

  2. Ascites

    1. Paracentesis

      1. If large volume, may need every 1-2 wks depending on symptoms

      2. Complications: bleeding, infection, damage to surrounding structures, risk of hypotension with large volume fluid removal, secondary peritonitis

    2. Peritoneal Port/Catheter

      1. Consider if pt can’t tolerate repeated paras

      2. Complications: leakage around insertion site, infection, hypoalbuminemia, hypotension, hyponatremia

  3. Malignant Pleural Effusions

    1. Thoracentesis

      1. As needed; majority will reaccumulate w/i 30 days

    2. Pleural Catheter

      1. Tunneled drainage catheter

    3. Pleurodesis

      1. Chemical agent used to cause inflammation and adhere the layers of the pleura

    4. Which One?

      1. No difference in rates of dyspnea

      2. Tunneled catheters have more adverse events like infection and blockage

  4. Palliative Radiation

    1. Typically delivered over a short number of fractions with a higher relative radiation dose per fraction

    2. Symptoms amenable include bleeding and compression symptoms

  5. Advance Care Planning

    1. Process throughout the entire care continuum that discusses end of life wishes and care

    2. The Conversation Project

      1. https://theconversationproject.org/

      2. Has conversation guides that patients can fill out for different types of difficult conversations

    3. Do this early on; can be done in conjunction with cancer-directed therapy

  6. Advance Directives

    1. AKA living will or medical power of attorney

    2. Document which delineates a patients’ end of life wishes

    3. Can download state-specific advance care directives through National Hospice and Palliative Care Organization

    4. Shown to reduce distress of patient/family/caregivers, improve patient’s sense of control and and quality of life, decrease caregiver burden

  7. Vital Talk

    1. https://www.vitaltalk.org/

    2. App called Vital Tips 3

    3. Goal is to help clinicians enhance their communication skills, with a focus on conversations about serious illness

  8. Goals of Care

    1. Early Conversations

      1. Framework acronym: PAUSE

        1. Pause to make time for the discussion early in the disease process

        2. Ask permission to have the conversation

        3. Uncover the patient’s values

        4. Suggest identification of a surrogate decision maker

        5. Expect emotion

      2. Assess decision-making capacity and identify surrogate decision maker early in the process

      3. Ask whether the patient has completed an advance directive or if they know what these are

    2. Later Conversations

      1. Framework acronym: REMAP

        1. Reframing the clinical situation/prognosis with the patient’s current clinical situation or status

        2. Expecting emotion

        3. Mapping the patient’s values

        4. Aligning yourself with the patients values

        5. Plan - medical treatments, where care will take place, options for palliative interventions

      2. Assess the following:

        1. Whether patients’ values have shifted from early on

        2. Determine and document the preferred location of death for the patient

        3. Ensure that advance directive is filled out

        4. Documented code status

        5. Revisit hospice (even if not candidate yet) to normalize this

  9. Code Status Discussions

    1. Ask

      1. Over half of patients in the hospital may be presumed to be “full code”, in which the healthcare team documents full code status without actually asking the patient

        1. Studies show up to half of these patients may actually desire something else

      2. Framework

        1. Frame the conversation as a part of routine care

          1. Let the patient know you have these discussions with everyone

          2. While you aren’t necessarily expecting to have to implement someone’s code status, we want to make sure we understand the patients’ goals

        2. Discuss patient’s expectations of what code outcomes are

          1. 44% of patients who get CPR in the hospital have ROSC

            1. Rate of undergoing CPR and being discharged from hospital is about half of that

            2. With metastatic cancer ~17-20%

            3. ~10% of pts who get CPR will leave the hospital with the same functional status in which they entered

          2. Describe the likelihood the patient will be discharged from the hospital if resuscitated and factor in the patients’ comorbidities when making this calculation

        3. Describe what is involved in a code

          1. Describe, step by step, the resuscitative measures

          2. Describe complications related to CPR

        4. Tell the patient this status can be changed at any time

      3. Charles von Gunten (2001): roadmap for code discussions

References

1. Bakitas MA, Tosteson TD, Li Z, et al. Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015;33(13):1438–1445; doi: 10.1200/JCO.2014.58.6362.

2. Wright AA, Zhang B, Alaka Ray M, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA 2008;300(14):1665.

3. Nicholson AB, Watson GR, Derry S, et al. Methadone for cancer pain. Cochrane Database of Systematic Reviews 2017;2017(2); doi: 10.1002/14651858.CD003971.PUB4/MEDIA/CDSR/CD003971/IMAGE_T/TCD003971-AFIG-FIG03.PNG.

4. Vilkins AL, Sahara M, Till SR, et al. Effects of Shared Decision Making on Opioid Prescribing after Hysterectomy. Obstetrics and Gynecology 2019;134(4):823–833; doi: 10.1097/AOG.0000000000003468.

5. Nelson G, Fotopoulou C, Taylor J, et al. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges-2023 update-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Gynecol Oncol 2023;173:58–67; doi: 10.1016/j.ygyno.2023.04.009.

6. Roeland EJ, Bohlke K, Baracos VE, et al. Management of Cancer Cachexia: ASCO Guideline. 2020.

7. Murphy JD, Triplett DP, Lebrett WG, et al. Effect of Palliative Care on Aggressiveness of End-of-Life Care Among Patients With Advanced Cancer Special Series: Palliative Care ORIGINAL CONTRIBUTION Special Series: Palliative Care ORIGINAL CONTRIBUTION ASSOCIATED CONTENT Effect of Palliative Care on Aggressiveness of End-of-Life Care Among Patients With Advanced Cancer. 2017; doi: 10.1200/JOP.

8. Childers JW, Back AL, Tulsky JA, et al. REMAP: A framework for goals of care conversations. J Oncol Pract 2017;13(10):e844–e850; doi: 10.1200/JOP.2016.018796.

9. Anonymous. Home - VitalTalk. n.d. Available from: https://www.vitaltalk.org/ [Last accessed: 4/27/2025].

10. von Gunten CF. Discussing do-not-resuscitate status. J Clin Oncol 2001;21(9 Suppl); doi: 10.1200/JCO.2003.01.159.

11. Anonymous. The Conversation Project - Staff. n.d. Available from: https://theconversationproject.org/about/ [Last accessed: 4/27/2025].

12. Anonymous. Advance Care Planning: Advance Directives for Health Care | National Institute on Aging. n.d. Available from: https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care [Last accessed: 4/27/2025].

13. Anonymous. Fast Facts | Palliative Care Network of Wisconsin | Edited by Sean Marks, MD | Directory | Quiz. n.d. Available from: https://www.mypcnow.org/fast-facts/ [Last accessed: 4/27/2025].

14. Anonymous. Forms for Patients and Providers | Washington State Department of Health. n.d. Available from: https://doh.wa.gov/data-and-statistical-reports/health-statistics/death-dignity-act/forms-patients-and-providers [Last accessed: 4/27/2025].

15. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58(3):297–308; doi: 10.1016/S0300-9572(03)00215-6.

16. Kazaure HS, Roman SA, Sosa JA. Epidemiology and outcomes of in-hospital cardiopulmonary resuscitation in the United States, 2000-2009. Resuscitation 2013;84(9):1255–1260; doi: 10.1016/j.resuscitation.2013.02.021.

 

Sydney Oesch
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Palliative Care: Introduction and Symptom Management