Brigham and Women's Hospitals

Palliative Care

Updated: April 14, 2020

Please see also Pallicovid.app for one-page guides, pocket cards, nursing resources, and related information.

Dyspnea & Acute Pain

Anxiety related to dyspnea or end of life

  1. For general anxiety, please see the “Anxiety” section of Psychiatry.
  2. Non-pharmacologic:
  1. Counseling (Spiritual, Psychocological, SW), Reiki
  1. Pharmacologic
  1. Benzodiazepines (if patient is not delirious; can use in either intubated or non-intubated pts)
  1. Lorazepam (longer half-life) 0.5-2 mg PO/SL q4-6h PRN; 0.5-2 mg IV q2h PRN
  2. Midazolam (shorter half-life) 0.2-0.5 mg IV slowly q 15 min PRN or 0.1-0.3 mg/hr IV infusion
  1. SSRI/SNRI: Continue home dose if possible. If NPO, replace with prn benzodiazepine

Non-opioid management of dyspnea

  1. Non-Pharmacologic for Dyspnea:
  1. Positioning: sitting patient up in bed, if possible. See also Anxiety above.
  1. Pharmacologic:
  1. Please see discussion on NSAIDs, which may be appropriate in some patients. Acetaminophen may also be used.
  2. Ativan (as above) can be used to ease the anxiety associated with dyspnea, but would avoid in patients who have had a previous paradoxical reaction (i.e. worsened agitation).

Opioid management of dyspnea and acute pain

  1. General principles:
  1. Additional information, including algorithm for opioid-induced respiratory depression is available at: DFCI Pink Book
  2. ALWAYS use PRN boluses to address acute, uncontrolled symptoms. PRN bolus dosing should be 10-20% of the 24-hour opioid dose
  1. For opioid naive patients:

Normal GFR

Abnormal GFR (<50)

No COPD

  • Morphine 5-10mg PO q3h PRN (use the 20mg/ml concentrate)

  • Morphine 2-4mg IV q2h PRN
  • Hydromorphone 1-2mg PO q3h PRN

  • Hydromorphone 0.1-0.2mg IV q2h PRN

COPD

  • Morphine 2-5mg PO q4h PRN (use the 20 mg/ml concentrate)

  • Morphine 1-2 mg IV q2h PRN
  • Hydromorphone 2-4mg PO q4h PRN

  • Hydromorphone 0.2-0.4mg IV q2h PRN

  1. If patient is not well managed with the above, add opioid infusion:
  1. Consider drip If > 3 bolus doses in 8 hours
  2. Calculate initial dose with total mg used/8 hours
  1. e.g. 1+2+2+2= 7 mg; begin drip at 7mg/8 hr = 1 mg/h
  2. Depending on symptoms and goals of care, consider reducing hourly rate by 30-50%. If patient is at end of life, would use 100% of hourly rate.
  1. Continue PRN dosing at current dose (if effective) or titrate as per above.
  1. For Opioid tolerant patients:
  1. If able to take PO:
  1. Continue current long-acting doses if renal and hepatic function tolerate
  2. Continue current oral PRN dose if effective q4h prn
  1. If ineffective, increase dose by 50% and order range of up to 3 x basal dose
  1. e.g. 5 mg PO MS q3h prn; increase to 7.5 mg; 7.5-22 mg PO q3h PRN
  1. If unable to take PO, severe or rapidly escalating symptoms:
  1. Convert as-needed PO doses to IV pushes as needed
  1. Use the IV Conversion chart (see chart below, or DFCI Pink Book)
  2. Decrease PRN dose by ⅓ for incomplete cross-tolerance when switching between opioid classes
  1. e.g. to convert 20 mg of oxycodone to IV hydromorphone: 20 mg oxy = 1.5 mg IV hydromorphone; 1.5 mg x ⅔ =1 mg IV
  1. Convert PO long-acting/ sustained release opioids to an infusion:
  1. Calculate 24-hour dose of PO sustained release (SR) morphine
  1. Divide by 3 for the total 24h mg IV (Morphine PO/IV = 3:1)
  1. Divide the 24h mg IV total by 24h for the hourly drip rate (mg)
  1. e.g. 30 mg SR PO morphine q8 hr= 90 mg PO in 24 h; 90 mg /3 = 30 mg IV dose; 30 mg / 24 h~ 1 mg/hr IV morphine infusion
  1. Continue PRN dosing. PRN dose should be 100-200% of opioid drip rate
  1. e.g. 1 mg/hr IV morphine infusion; PRN dose is 1-2 mg IV q2h

Abbreviated Opioid Equianalgesic Table (for complete table and an example conversion see DFCI Pink Book)

Drug

PO/PR (mg)

Subcut/IV (mg)

Morphine

30

10

Oxycodone

20

n/a

Hydromorphone

7.5

1.5

Fentanyl

(See table below for transdermal conversions)

n/a

0.1 (100 mcg)

Nausea and Vomiting

  1. Match treatment to etiology of nausea:
  1. Chemoreceptor Trigger Zone (blood brain barrier breakdown)
  1. haloperidol, metoclopramide, ondansetron, olanzapine, aprepitant
  1. Gastrointestinal:
  1. ondansetron, metoclopramide, dexamethasone (if malignant obstruction)
  1. CNS cortical centers:
  1. lorazepam for anticipatory nausea, dexamethasone (tumor burden causing ICP)
  1. Vestibular:
  1. meclizine, scopolamine, diphenhydramine
  1. Additional information can be found at the DFCI Green Book. See page 11 for more dosing recommendations:
  1. Ondansetron 8-24mg/day IV/PO (max single dose 16mg) *causes constipation*
  2. Haloperidol 0.5-2 mg IV/PO q 4-8 hours *EPS unlikely at these low doses*
  3. Metoclopramide 10-40 mg IV/PO TID-QID *pro-motility*
  4. Olanzapine 2.5-10 mg PO/dissolvable daily *off label, effective for concurrent anxiety, will not exacerbate constipation*
  5. Prochlorperazine 10 mg PO TID-QID (max 40 mg/day) 25 mg PR BID *very sedating, overlaps with haloperidol, metoclopramide, perphenazine*
  6. Meclizine 25-50 mg PO daily

Constipation

  1. If able to take oral agents, start:
  1. Senna 2 tabs PO qhs, can increase up to 2 tabs PO TID if needed
  2. Polyethylene Glycol 17gm packet PO QD-BID prn
  3. Avoid Docusate given lack of data demonstrating benefit
  1. If unable to take oral agents, suggest Bisacodyl suppository PR daily prn signs of abdominal discomfort/distention likely due to constipation.
  2. For more information, see DFCI Pink Book

Care of The Imminently Dying Patient

General principles

  1. Signs and symptoms of imminent death
  1. Somnolence
  2. Warmth, and later cooling and mottling of extremities
  3. Change in respiratory pattern, intermittent apnea, Cheyne-Stokes pattern
  4. Gurgling sounds from oropharynx (often more distressing to family than patient)
  1. Symptom management
  1. Should follow the guidelines provided in sections above
  2. Intensive Comfort Measures Guidelines (BWH Policy 5.5.5) (Partners login required)
  1. Communication
  1. See common questions from families

Intensive Palliative Care Unit

  1. The Palliative Care Service has opened the COVID-19 Intensive Palliative Care Unit (COVID-IPCU) and suspended the usual oncology IPCU service. The COVID-IPCU is intended as a unit for end of life care during the COVID pandemic. The Palliative Care Team aims to leverage the interdisciplinary expertise of the IPCU team and Palliative Medicine clinicians to provide symptom management and psychosocial support quickly and effectively for patients likely to die from COVID-19, whether or not they have cancer.
  2. The admission criteria to the COVID IPCU are as follows:
  1. COVID-19+ or pending results
  2. Experiencing organ failure such that the patient would be expected to die without life sustaining treatments and an estimated prognosis of less than a week
  3. Patient/family assenting to comfort-focused care
  4. Code Status is “DNR/DNI/LLST (Comfort)” or “DNR/DNI” with no escalation of care to the ICU
  5. Communication with the COVID-IPCU team is required prior to transfer; page “IPCU” in the Partners Paging Directory

Visitors

  1. Visitor guidance is changing. Please see Visitors section of infection control. If the patient is expected to pass away within 72 hours many units have policies that permit exceptions.

Compassionate Extubation

  1. For Brigham and Women’s suggested protocol, please see this handbook page. (Partner’s login required)
  2. See also Von Gunten and Weissman, Palliative Care Fast Fact #33, Ventilator Withdrawal Protocol
  3. For staff and visitor safety, we do not recommend physical extubation, but rather patient should be weaned down to PSV 0/0 with FiO2 0.21 to maintain a closed circuit

Palliative Sedation

  1. See Salacz and Weissman, Palliative Care Fast Fact #106, Controlled Sedation for Refractory Suffering
  2. BWH Palliative Sedation in the non-ICU Setting Policy (BWH Policy 1.4.13 (Partners login required)

Terminal Delirium

  1. For general delirium, please seeDelirium” section in Psychiatry
  2. Diagnosis: CAM method
  1. Use the Confusion Assessment Method (CAM)
  2. CAM is positive if (1) AND (2) and EITHER (3) or (4) are present
  1. Acute often fluctuating change in mental status (vs dementia)
  2. Difficulty focusing attention
  3. Disorganized thinking (rambling, illogical flow of ideas)
  4. Altered level of consciousness (too sedated or too hyperactive)
  1. Treatment:
  1. Non-pharmacologic:
  1. Daytime lights, nighttime dark. Frequent reorientation. Reverse contributing medical conditions as able.
  2. Consult Psychiatry; for terminal delirium, consult Palliative Care
  1. Pharmacologic
  1. Additional information available at: Guidelines for Acute Hospital Acquired Delirium (Partners login required)
  2. Alter existing medications and treat comorbid symptoms.
  3. QTc prolonging agents <65 yo or DNR/I +LLST Comfort Measures
  1. Haloperidol, Mild agitation:0.5-1.0 mg IV or 1 to 2 mg PO q6h and 1-2 mg q2h PRN.; Moderate agitation: 2-4 mg IV; Severe agitation: 4-10 mg Maximum dose: 20 mg / 24 hours
  2. If refractory, olanzapine, 2.5 to 5 mg (PO, SL, or IV) q12 hr and 2.5 mg q4h PRN; Maximum dose: 30mg / 24 hours
  1. QTc prolonging agents ≥ 65 yo or frail
  1. Haloperidol, Mild agitation 0.25 -0.5 mg IV or 1 to 2 mg PO q6h and 1 mg q2h PRN; Moderate agitation: 1-2 mg IV; Severe agitation: 2 mg IV Maximum dose: 20 mg / 24 hours
  1. Non-QTc prolonging agents
  1. Aripiprazole (Abilify), 5 mg PO daily; maximum dose 30 mg daily
  2. Valproic Acid 125-250mg IV q8h PRN.

Excessive Salivary Secretions at the End of Life

  1. For secretions with significant mucous, evaluate benefit/burden of repositioning and deep suctioning
  2. Communicate with families to expect sounds:
  1. Reassure them that although the “rattling” sound is distressing to hear, the patient is not experiencing difficulty breathing or having to clear phlegm from his or her throat. The rattling sound comes from the movement of air over secretions pooled in the throat and airways.
  1. Pharmacologic management (not to be used with secretions with significant mucous)
  1. Glycopyrrolate 0.2 – 0.4mg IV q2hrs prn secretions, rattling sound
  2. Hyoscyamine 0.125-0.25mg PO q4hrs prn secretions, rattling sound
  3. Scopolamine 1.5mg TD q72hrs if patient not awake and no apparent delirium or history of delirium. NB The patch will take ~ 12 hours to take effect
  4. Avoid using > 2 of these at the same time; if more than one is required, monitor for development of anticholinergic crisis

Communication Skills

  1. Skills for COVID-19 Scenarios
  1. The BWH Division of Palliative Medicine has created brief videos outlining common communication tasks in COVID-19 across settings
  1. ICU Conversation #1: Sharing concern illness may get worse
  2. ICU Conversation #2: Discussing Illness getting worse/GOC
  3. ICU Conversation #3: Talking about Dying
  4. Hospital Medicine #1: GOC & Code Status (goals c/w intubation)
  5. Hospital Medicine #2: GOC & Code Status (goals not c/w intubation)
  6. ED #1: GOC & Code Status (goals not c/w intubation)
  1. Experts at VitalTalk have created a COVID-19 Communication Guide. See also: Suggested Language for COVID-19 scenarios
  1. Important Skills for All Conversations
  1. Respond to emotion with empathy
  1. Key Skill: NURSE Statements (Back et al. CA Cancer J Clin 2005)
  1. Name, Understand, Respect, Support, Explore
  2. NURSE Skills for Responding to Emotion
  1. Assess Understanding & Delivering Information
  1. Key Skill: ASK-TELL-ASK (Back et al. CA Cancer J Clin 2005)
  2. For COVID, it is important to make patients and families aware that patients with significant comorbid illnesses or who have poor baseline functional or health status may decompensate rapidly and have very high mortality due to COVID-19.
  1. Discussing Goals of Care
  1. Key Skill: REMAP mnemonic (Childers et al. J Oncol Pract 2017)
  1. Reframe, Expect Emotion, Map Values, Align, Propose Plan
  2. The REMAP Framework
  1. Managing Uncertainty
  1. Key Skill: Pairing hope and worry (Jackson et al, JPM 2013)
  1. “I hope you will improve AND I am also worried because your oxygen level is getting worse.”

Documenting Important Conversations

  1. The Advance Care Planning (ACP) Module in Epic is the single BEST place to document serious illness conversations for patients with COVID-19 and their families. Where to find and how to use the ACP Module in Epic.
  2. In conscious patients, review or sign Health Care Proxy form.