Palliative Care on the CCFP exam

Approach

• Do not delay palliative care in serious illness, whatever the diagnosis and whatever other treatment she is getting.
• Starting it early improves symptom control, quality of life and family satisfaction.
• Pain near the end of life is common in every patient group, not only in cancer. Ask about it.
• Review drugs taken for long-term risk, such as statins, blood pressure pills and diabetes pills. Stop those whose benefit would come after her likely lifespan.
• Keep drugs that prevent discomfort, such as a laxative taken with an opioid.
• Breathless with normal oxygen levels? Oxygen does not help. A fan moving air works about as well.

Approach

• Set goals of care with the patient, the family and the wider team. Revisit them when the illness or the place of care changes.
• Pain has many layers: body, mind, family and meaning. Drugs alone rarely fix it. Use a team approach whenever you can.
• Refer to physiotherapy or occupational therapy for mobility. Being stuck in bed can constipate more than opioids do.
• Make sure the patient can get and afford the drugs. Sign them up for provincial palliative drug coverage where it exists.
• Respect traditional, cultural and spiritual healing practices alongside Western care.
• Call a palliative care specialist for pain not better within 72 hours of titration, for toxicity, or for severe kidney or liver failure.

Approach

• Ask what she thinks is causing a symptom, how it affects her family, and what worries her most.
• Ask about her goals, and what level of a symptom she can live with.
• Pain rarely comes alone. Ask about breathlessness, nausea and constipation, and treat them too.
• Ask about money, a will, and who will decide for her if she cannot.
• Ask about faith, culture and spiritual or traditional practices. Some people see symptoms, or visions of loved ones, in spiritual terms.
• If she cannot speak, look for grimacing, restlessness and moaning. Use a tool such as the Pain Assessment in Advanced Dementia scale.
• Think about her goals before you order any test.

Approach

• Reassess pain at the drug's peak, after any change, with each new pain, and when the old plan stops working.
• Give opioids by the clock, not only as needed. Add a breakthrough dose of about 10% of the total daily dose.
• Reassess when she uses 3 or more breakthrough doses in 24 hours. Change the regular dose no more than every 24 hours, unless pain is severe.
• Start low and go slow in kidney or liver failure and in older people.
• Warn about the 3 common side effects: confusion or sleepiness, nausea, and constipation. The first two often settle in 3 to 7 days.
• Confusion, sleepiness or twitching can mean opioid toxicity. Lower the dose or switch to another opioid, and get palliative advice.
• Start a laxative with the first opioid dose and keep it going. Docusate alone does not prevent opioid constipation.

Approach

• Start advance care planning early: who decides if she cannot, and what she values.
• Planning ahead brings care closer to her wishes and means fewer days in hospital.
• Ask about each choice on its own: antibiotics, going to hospital, a breathing tube, where she wants to die.
• Goals change. Ask again when the illness gets worse or a move to another setting comes up.
• Weigh the burden of each test or treatment against its benefit. Ask if it needs a move to hospital.
• Tube feeding and fluids into a vein may not help near the end. They can cause fluid overload and discomfort.