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Levorphano is similar to methadone with longer duration; an agonist at the mu, kappa, and delta opioids receptors, an NMDA antagonist, and a monoamine reuptake inhibitor of norepinephrine and serotonin; relatively high cost; suited for neuropathic pain.
Treatment goals for patients near the end-of-life are to avoid symptomatic hypo- and hyperglycemia and minimize the burdens of diabetes treatment, but not to prevent those long-term complications.
This Fast Fact introduces the use of rectal medications for patients in palliative care settings. The rectal route is an efficient and practical alternative in administering a broad array of palliative care medications to patients with a compromised oral route.
Many patients with advanced illness have tracheostomies, which require careful observation and specialized management. A working knowledge of the basic tracheostomy equipment and handling procedures can avoid complications and improve a patient’s comfort.
Carotid blowout is the rupture of the extracranial carotid arteries or their major branches. It is an uncommon but devastating complication of head and neck cancer. This Fast Fact will discuss the approach to patients with carotid blowout, including patients near the end of life whose care goals are focused on safety and comfort.
Borderline personality disorder (BPD) is identified by a pervasive pattern of instability of relationships, self-image, and mood, as well as marked impulsivity. This Fast Fact provides strategies for successful interactions with patients and patients’ caregivers with BPD.
The Intensive Care Unit (ICU) is the setting for high-intensity health care designed to resolve life-threatening illnesses and extend life. However, risks of mortality and severe morbidity remain high and virtually all ICU patients have palliative care needs. This Fast Fact reviews the role of palliative care consultations in the ICU along with options for more generalist palliative care services provided by ICU clinicians
About 10-20% of bereaved individuals experience a persistent, debilitating phenomenon referred to as complicated grief (CG). Complicated grief has also been referred to as prolonged, traumatic or pathological grief.
Capsaicin 0.075% cream demonstrated statistically significant benefit in post-herpetic neuralgia, post-surgical neuropathies, and diabetic neuropathy, compared to placebo.
Hyperthermia is an uncontrolled elevation in body temperature without a change in the thermoregulatory center. This Fast Fact reviews the key elements in assessment and treatment of fever in patients near the end-of-life.
Modafinil is a non-amphetamine psychostimulant approved for the treatment of excessive daytime somnolence associated with obstructive sleep apnea, narcolepsy, and shift work sleep disorder. This Fast Fact reviews use of modafinil for symptom management in the seriously ill.
This Fast Fact discusses the use of opioids in patients with liver failure.
Hot flashes are a common symptom which can negatively impact quality of life. Failure to assess and offer treatment for hot flashes is common. This Fast Fact is the first in a three part series reviewing hot flash assessment and treatment.
This Fast Fact will cover procedural and pharmacological treatment of hot flashes. Complementary and alternative therapies will be reviewed in Fast Fact #263.
Assessment and drug treatments of hot flashes (‘flushes’) were discussed in Fast Facts # 261-2; this Fast Fact reviews non-drug and complementary/alternative medicine (CAM) therapies.
Pulmonary artery hypertension (PAH) is a disease of the pulmonary vascular system characterized by elevated pulmonary vascular resistance. Patients with advanced PAH are often treated with prostacyclins. This Fast Fact reviews suggested guidelines for withdrawal of prostacyclin therapy in dying patients with PAH.
Understanding the pharmacological rational for dosing intervals is key to proper prescribing and patient counseling.
There are two general types of advance directives:
An easy way to remember the causes of vomiting is the VOMIT acronym. In the table below receptors involved in different types of nausea are highlighted using this acronym. Blockade of these receptors allows rational, focused therapy.
This trajectory is often referred to as “actively dying” or “imminent death”. Prompt recognition of this trajectory is key for clinicians to provide the most appropriate interventions for both the patient and family.
This Fast Fact reviews assessment and management issues in terminal delirium.
Quick—what dose of the transdermal fentanyl patch (DuragesicTM) is equianalgesic to a 3 mg/hr morphine continuous infusion? Conversions to and from fentanyl transdermal are notoriously tricky, requiring knowledge of the published conversion data, general opioid pharmacology, and a generous dose of common sense. See also Fast Fact #36 on opioid dose conversions.
This Fast Fact reviews key steps in the death pronouncement and notification process.
Case Scenario: You are caring for a previously healthy 52 year old man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. How do you prepare to discuss these test results with the patient?
Endicott has proposed substituting somatic criteria with affective criteria when evaluating depression in advanced cancer patients:
Question: What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?
The Fast Fact reviews data on the use of tube feeding in advanced illness.
Residents often feel strong emotions when they have to give bad news to a patient. As a preceptor, you will want to support the resident. Key teaching points:
One often hears the term palliative chemotherapy, but what exactly does it mean and how can a non-oncologist decide if it has potential value?
Four major components affect the production of a normal BM: solid waste, water, motility and lubrication.
Learning the process steps of a Family Conference are an important skill for physicians, nurses and others who are in a position to help patients and families reach consensus on end-of-life planning.
Patient-centered Interviewing - You can assess a patient’s illness experience by asking about 4 dimensions—Feelings, Ideas, Function and Expectations. The acronym FIFE can be a helpful reminder.
Taking a spiritual history is one way to support the patient in this exploration.
Hearing loss can lead to misunderstandings, which in the health care setting can literally have life-or-death implications.
This Fast Fact discusses the staging and prevention of pressure ulcers
This is the first part of a three-part series on withdrawing ventilators in patients expected to die
A common question from trainees is how fast, and by how much, can opioids be safely dose escalated?
This Fast Fact discusses the difficult balance between maintaining hope and truth telling, especially as it applies to giving bad news.
One of the most meaningful acts of kindness you can do for a mourner is to write a letter of condolence.
`Code status’ discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach. This Fast Fact introduces an approach to having these discussions.
The basic steps in the DNR discussion for seriously ill hospitalized patients were described In Fast Fact # 23. If you have followed those steps, what do you do if the patient or family/surrogate continues to want CPR and you think it is not in the patient's best interest?
Why do patients get nauseated and vomit after receiving an opioid?
Have you ever had this experience – you are talking with a patient about some care option and you just cannot come to an agreement?
This Fast Fact reviews key elements in the assessment and treatment of dyspnea near the end-of-life.
As death nears, the burden of maintaining intravenous (IV) access, especially in the home setting, can be enormous.
Here are eight tasks that guide you in responding to patient emotion:
Physicians tend to be overly optimistic when dealing with prognosis
Confronting our own mortality
This Fast Fact provides an overview of grief and bereavement.
This is the second of a three-part series: Symptom Control for Ventilator Withdrawal in the Dying Patient
This is Part 3 of a three-part series on withdrawing ventilator withdrawal.
Listed below are methods for common conversions using standard published conversion ratios.
Pruritus (itching) is a common and often distressing symptom near the end of life.
Hospice discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach.
Naloxone (Narcan®), a semisynthetic opioid antagonist, is indicated for the complete or partial reversal of life-threatening CNS/respiratory depression induced by opioids.
A common question asked by dying adults or their family members is What do I tell the children?
Review the library of Fast Fact documents.
This Fast Fact discusses the management, staging and prevention of pressure ulcers.
This Fast Fact provides tips for beginning a discussion leading to a visit by a palliative care consultation team.
This Fast Fact will review the definitions and clinical features that distinguish these conditions
How do you change the status quo? What can you do when the system of care does not support best practice?
Malignant bowel obstruction is a common oncologic complication; most common in ovarian and colon cancer.
Few things can worsen a patient’s quality of life greater than an oozing, odorous, painful, and bleeding malignant skin wound.
Issues of coding and reimbursement are no different for palliative care than for any other medical specialty. That is, physicians code for each patient encounter in two parts: 1) a procedure/service code, and 2) a diagnosis code.
Gabapentin (Neurontin) is widely used for neuropathic pain.
While specific to a certain time and place, these reflections on living, working, and caring for patients in the immediate aftermath of horrific events are timeless.
This Fast Fact will review information for rationally choosing among the various products.
But what does ’quality of life’ (QOL) mean, and how should clinicians use this information in decision making?
The advantage of using SL morphine over intermittent IV boluses is a longer duration of action.
The following is a step by step approach to rational opioid infusion prescribing in the dying patient, and is most appropriate for morphine or hydromorphone infusions
In contrast, decision making capacity (‘decisionality’) refers to a physician’s determination, based on clinical examination, that a patient is able to make medical decisions for him- or herself.
A core aspect of American bioethics is that a competent adult patient has a right to refuse treatment, even when the physician believes that the treatment would be beneficial.
This Fast Fact will discuss risk factors and patient assessment of the neuroexcitatory opioid side effects, particularly myoclonus
This Fast Fact discusses treatment.
A guide to managing these situations is presented below.
This Fast Fact discusses megestrol acetate, a synthetic progestin, which has been extensively studied as an appetite stimulant.
This Fast Fact focuses on the assessment of insomnia; it is the first of a series of three Fast Facts about insomnia .
The following is a review of HAART benefits/burdens near the end-of- life.
This Fast Fact only discusses OTFC (Actiq).
This Fast Fact addresses non-pharmacologic therapies for insomnia.
This Fast Fact focuses on the pharmacological treatment of insomnia.
This Fast Fact reviews the medical decision-making surrounding these practices.
This Fast Fact will review sedation techniques.
Music therapy uses the properties of music – sounds, rhythm, and personal attachment and universality of songs – for psychosocial and spiritual support and to complement other palliative care treatments.
As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions.
Urine drug testing (UDT) is widely used for testing for opioids and illicit drugs. There are two types of UDT: a screening test and a confirmatory test.
This Fast Fact discusses management of cardiac pacemakers at life’s end.
However, near the end of life, decisions as to how best to use these devices can be the source of much anguish for patients, families and palliative care/hospice staff.
Bisphosphonates are used for the treatment or prophylaxis of cancer-related bone complications, including pain.
This Fast Fact discusses its causes, evaluation, and therapy.
This Fast Fact reviews the details of declaring death based on neurological criteria.
This Fast Fact reviews bone-seeking radiopharmaceuticals (radionuclides), which occupy a valuable niche in the palliation of painful bone metastases.
Research has shown that neonates may experience as much pain as older children and long-term consequences from exposure to repeated painful stimuli.
Near death awareness (NDA) is a term to describe a dying person’s experiences of the dying process.
Invasive treatment options should be considered for all patients except those who are actively dying.
The following options attempt to respect the integrity of the physician’s spiritual/religious beliefs and be supportive of the patient’s emotional needs.
This Fast Fact discusses the diagnosis and assessment of mucositis.
This Fast Fact will discuss the pre-ICU-admission assessment of patients with advanced illnesses.
An ICU daily care plan checklist can be used to promote palliative care, simultaneously with curative or life-prolonging therapies.
This Fast Fact reviews the Palliative Prognostic Score (PaP).
This Fast Fact reviews the Palliative Performance Scale.
The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control.
The spectrum of substance use disorders (SUDs) are characterized by increasing degrees of craving, compulsive use, loss of control, and continued use despite harm.
This Fast Fact will review the indications and contraindications for a swallowing study and the role of the speech pathologist.
This Fast Fact discusses the use of corticosteroids for painful bone metastases.
Delirium is a common psychiatric disorder in the terminally ill
More than 95% of patients experience fatigue near the end of life
Epidural metastases are very common in patients with advanced cancer.
It is well recognized that physician’s fear of regulatory scrutiny (DEA, state medical boards), is a major contributor to the problem of under treatment of pain.
This Fast Fact reviews the components of a sensitive notification of loved ones when a patient dies.
Doctor-patient discussions about end-of-life treatment are often framed as a choice between “medical treatment vs. treatment withdrawal.”
This Fast Fact describes the physiology and methods of delivering radiation therapy
This Fast Fact reviews the common indications for and outcomes of palliative XRT.
A very commonly requested educational topic by physicians, concerning pain, surrounds differentiating the patient in pain vs. the patient with a substance abuse disorder.
Put simply, pseudoaddiction is something that we do to patients, through our fears and mis-understanding of pain, pain treatment, and addiction.
It is critical that physicians, nurses, and pharmacists share a common understanding of how to properly write, interpret, and carry out PRN range orders.
This Fast Fact discusses the pharmacology of MP and concerns about its use as an analgesic.
This Fast Fact will discuss appropriate ways to write opioid infusion titration orders.
Respiratory failure is the most common cause of death from amyotrophic lateral sclerosis (ALS).
This Fast Fact will illustrate poorly written opioid orders and provide preferred alternatives.
This Fast Fact will introduce methadone’s pharmacology and clinical use as an analgesic.
This Fast Fact offers some guidelines when telephone notification is unavoidable.
This Fast Fact discusses the dilemma of whether to provide telephone information versus asking family members to first come to hospital before telling them that death has occurred.
The meaning and expression of pain are influenced by people’s cultural background.
The purpose of this Fast Fact is to review the issues surrounding organ, tissue, and cornea donation.
This Fast Fact reviews CRO usage in palliative care.
Hiccups (singultus) are distressing to patients and families; when chronic, they diminish quality of life.
In the United States, the Medicare Hospice Benefit (MHB) pays for 80% of all hospice care.
his Fast Fact discusses common reasons that patients do not take prescribed opioids, thus resulting in unnecessary pain and suffering.
The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming.
In palliative care, epidural analgesia may be appropriate for patients with regional pain (e.g. pelvic pain from cervical cancer) and/or patients who do not tolerate or obtain relief from oral/parenteral drugs and non-drug therapies.
This Fast Fact will describe strategies for beginning methadone when the patient has not been taking a strong opioid.
This Fast Fact will review where services are provided and the reimbursement system for hospice care.
Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content.
This Fast Fact will review simple strategies for improving pain management outcomes.
his Fast Fact will discuss the use of interventions in hospice care that can be controversial due to high cost and/or uncertainty whether they constitute ‘palliative’ interventions.
This Fact Fact reviews interventional approaches for upper GI obstructions, especially when further radiation, chemotherapy, medical management, or curative surgical options are longer helpful.
PCA allows for more immediate relief of incident (breakthrough) pain and can provide patients with a greater sense of personal control over their pain.
Recent scientific studies of cannabinoids for symptom management have focused on nausea/vomiting and appetite stimulation.
This Fast Fact will touch on some practical considerations in writing opioid prescriptions.
Physical dependence is a normal and predictable neurophysiological response to regular treatment with opioids for more than 1-2 weeks duration.
Patients with uncontrolled diarrhea are at increased risk for dehydration, electrolyte imbalance, skin breakdown, and fatigue.
In the palliative care setting, the most common indication for interrupting the sympathetic axis is to control pain arising from malignancies of the abdominal and pelvic viscera.
Intrathecal drug delivery can be an invaluable adjunct in the management of severe pain when meticulous application of conventional drug therapy proves ineffective or produces intolerable side effects.
The table below synthesizes data for several common cancers.
This Fast Fact focuses on prevention and general treatment of radiation (XRT) and chemotherapy-induced oral mucositis.
Caring for a dying patient who has a physician-family member provides challenges and opportunities.
This Fast Fact reviews the use of ketamine in palliative care as an analgesic.
This Fast Fact discusses medical decision-making about non-oral hydration in palliative care settings.
This Fast Fact reviews the technical aspects of providing non-oral hydration.
Neoplastic meningitis (NM) – also known as leptomeningeal metastases, meningeal carcinomatosis, or leukemic meningitis, is a common oncologic complication representing spread of tumor cells to the subarachnoid space (SAS).
This Fast Fact will discuss the current understanding of the term futility.
This Fast Fact will focus on managing the symptoms of CS.
This Fast Fact reviews key developmental concepts and describes strategies for addressing children’s grief.
This Fast Fact reviews key steps in the transition from the acute care hospital setting to home hospice care.
Because more than 95% of hospice care is in the form of routine home care, clinicians may not be aware that the MHB specifies four different levels of hospice services to meet the diverse needs of dying patients and their family.
This Fast Fact will review prognostication in patients with advanced COP
This Fast Fact reviews the clinical findings and treatment options
This Fast Fact reviews prognostication data in Heart Failure (HF).
This Fast Fact reviews domains of medical management common to most end-stage HF patients.
Separating “normal” death-related anxiety from pathological panic is an important palliative care skill.
This Fast Fact reviews that literature on depression screening tools.
Oropharyngeal candidiasis (thrush) occurs commonly in seriously ill and dying patients.
This Fast Fact reviews its mechanism of action, research data, and dosage information.
Family members look to the physician and nurse to help them know what to expect when a loved one is dying.
This Fast Fact reviews issues of prognostication in dementia.
Up to 30 percent of patients with cancer develop hypercalcemia.
Knowing the components of a military history can be a useful tool in bridging the silence that often surrounds the war experience and can act as a catalyst for discussions about end of life preferences.
This Fast Fact reviews assessment and management strategies for poor health literacy.
This Fast Fact reviews key issues when using interpreters in the palliative care setting.
This Fast Fact reviews key steps in the completion of a death certificate.
This Fast Fact provides guidance on how to evaluate and initially respond to a patient who raises the topic of a hastened death.
This Fast Fact reviews key facts regarding effusion management.
This Fast Fact reviews treatment options for managing distressing secretions.
This Fast Fact focuses on possible ways of responding to patients who continue to want a hastened death despite every effort to find appropriate palliative care alternatives.
Delirium can be hypoactive or hyperactive. Patients with hypoactive delirium are calm, but inattentive and manifest decreased mobility. Patients with hyperactive delirium are agitated and combative, and also lack the ability to maintain attention to complete tasks.
This Fast Fact reviews recommendations for opioid use in the setting of renal failure and in patients receiving chronic dialysis.
This Fast Fact reviews key concepts of the Advance Care Planning (ACP) process.
This Fast Fact reviews key concepts of the ACP process for CKD patients.
This Fast Fact reviews the legal basis for informed consent.
This Fast Fact discusses common myths about informed consent that arise in palliative care.
To prevent confusion due to similar generic names, this Fast Fact will use trade-names for Kadian and Avinza, and “ER-morphine” to describe extended-release formulations which are usually dosed q12 hours.
This Fast Fact will describe burnout and its risk factors, and review essential research regarding health professionals and burnout.
This Fast Fact will explore symptoms of burnout and its personal and professional consequences.
This Fast Fact will address strategies to avoid burnout while sustaining personal and professional health, integrity, and growth.
This Fast Fact will briefly describe assessment tools used in health professional research.
This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.
This Fast Fact reviews issues in health professional-patient boundaries in palliative care.
This Fast Fact reviews diagnostic and treatment approaches in the palliative care setting.
This Fast Fact will suggest guidelines for continued use or discontinuation in the hospice/palliative care setting.
This Fast Fact will review signs, symptoms, and management options of opioid allergies and pseudo-allergies.
This Fast Fact reviews the causes and diagnosis of malignant ascites.
This Fast Fact will review treatment approaches and the important role of determining the Serum Ascites-Albumin Gradient as a diagnostic and treatment aid.
This Fast Fact will review key elements of the POLST project.
This Fast Fact will review data on CPR outcomes in hospitalized patients.
This Fast Fact reviews the use of parenteral lidocaine for neuropathic pain.
This Fast Fact will review oral oxymorphone and its place in pain management.
This Fast Fact will review the causes and treatments of xerostomia.
This Fast Fact provides an alternative approach to conflict resolution based on understanding a patient’s or family’s story, attending to their emotions, and establishing shared goals.
Principled negotiation is an approach to resolving conflict that avoids power struggles and unwanted compromises.
This Fast Fact reviews the mechanism of action, research data, and dosing information on topically applied opioids.
This Fast Fact will discuss the causes and evaluation of anxiety.
This Fast Fact reviews the use of non-tricyclic antidepressants for neuropathic pain.
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome with a fluctuating course associated with end stage liver disease (ESLD).
This Fast Fact reviews prognosis in chronic liver failure, focusing on two validated prognostic indices.
This Fast Fact reviews the role of PN in advanced cancer patients.
This Fast Fact reviews the current data regarding prognostication in patients receiving chronic hemo- and peritoneal dialysis.
This Fast Fact will review special issues in the care of developmentally disabled people with life-limiting diseases.
This Fast Fact will address medical decision making for adults with developmental disabilities (DD) who are facing terminal or life-limiting diseases such as cancer, end-stage organ failure, or progressive debility.
This Fast Fact will address how to disclose error with a patient/family.
This Fast Fact will discuss responding to a colleague’s error.
Osteonecrosis of the jaw (ONJ) is a potentially devastating complication associated with bisphosphonate therapy.
This Fast Fact will review the clinical features and treatment of CAPN.
This Fast Fact will review US federal regulations regarding prescribing Schedule II drugs.
This Fast Fact will focus on the use of opioids for the symptomatic treatment of cough.
This Fast Fact will address peripherally-acting agents.
This Fast Fact will focus on supportive and terminal care for patients with HD and their families.
Vertebral compression fractures (VCFs) occur in up to 20% of patients above the age of 50, mostly due to osteoporosis.
This Fast Fact focuses on clinicians’ emotional responses to patient care.
This Fast Fact outlines research findings on differences in end-of-life care and values between African Americans and the population as a whole.
In 2002, the FDA approved the LVAD not only as “bridge therapy”, but also as an alternative to transplantation, or “destination therapy.”
Once patients die, however, their DNA is no longer readily available for this future testing. On the other hand, decisions about genetic testing are complex and can have profound emotional, familial, and financial impacts on those affected and should not be pursued hastily.
This Fast Fact reviews key issues pertaining to the decision to stop chronic dialysis; Fast Fact #208 will discuss the care of patients after it is stopped.
This Fast Fact addresses care of the patient around the time of dialysis discontinuation.
Malignant pericardial effusions (MPEs) are a rare complication of advanced cancer, but are associated with high morbidity and mortality. This Fast Fact discusses the diagnosis and management of MPEs.
This Fast Fact discusses evaluating and responding to suicidality in patients with life-limiting diseases.
Anxiety occurs in hospitalized patients for many reasons including fear of specific procedures, worry about the future, and lack of control. This Fast Fact will discuss guided imagery as an anxiety reduction technique.
Phantom limb pain (PLP) can be a painful and debilitating consequence of limb amputation from any cause including trauma, cancer, and vascular diseases. This Fast Fact will review the evaluation and management of PLP.
This Fast Fact discusses prognostication in patients who are suffering life-threatening complications related to HIV infection using data where cART was available.
This Fast Fact presents survival data for malignancies commonly arising in the setting of HIV / AIDS.
Relief of cancer pain from opioids is rarely all or nothing; most patients experience some degree of analgesia alongside opioid toxicities. While opioid poorly-responsive pain is not a discreet syndrome, it is a commonly encountered clinical scenario. This Fast Fact reviews key points in its assessment and management.
Patients’ cultural backgrounds profoundly influence their preferences and needs regarding discussing bad news, decision-making, and the dying experience. This Fast Fact offers a framework for taking a ‘cultural history’ to better understand a patient’s and family’s needs.
Restless Leg Syndrome (RLS) is a neurologic disorder characterized by unpleasant sensations in the legs causing an uncontrollable urge to move when at rest in an effort to relieve those feelings. RLS disrupts sleep, can lead to excessive daytime sleepiness, depression, and a decreased quality of life. This Fast Fact will review its evaluation and management.
This Fast Fact will discuss a practical approach to ameliorating wound odors.
This Fast Fact will introduce readers to a practical approach to responding to families who request non-disclosure to the patient.
This Fast Fact discusses subcutaneous fluid infusions, also known as hypodermoclysis (HDC).
Buprenorphine, a mixed opioid agonist/antagonist, available in the United States, is approved for treatment of opioid addiction in the US; such use is restricted to qualified physicians who have received training and a waiver to practice medication-assisted opioid addiction therapy.
A cornerstone procedure in Palliative Medicine is leadership of family meetings to establish goals of care, typically completed at a time of patient change in status, where the value of current treatments needs to be re-evaluated. As with any procedure, preparation is essential to ensure the best outcome. This Fast Fact reviews how to prepare for a Family Meeting.
This Fast Fact reviews the early steps of the actual meeting.
This Fast Fact provides a detailed approach to emotions that arise during family meetings.
This Fast Fact explores understanding the causes of conflict and how to plan an effective strategy to move beyond the conflict to meet the needs of the patient and surrogates.
This Fast Fact reviews an approach to help surrogates through the decision process when patients cannot participate in decision-making themselves.
This Fast Fact discusses an approach to goal setting when the expected length of life is short.
Tapentadol is a novel analgesic, with a 50 mg dose similar in efficacy to 10 mg of oxycodone.
The actual incidence of seizures in dying patients is unknown, and while likely uncommon, they can cause tremendous distress to patients and families. This Fast Fact reviews management strategies for seizures near the end of life.
Non-invasive positive pressure ventilation (NPPV, often called 'BiPAP') is commonly used in patients with respiratory failure from COPD, CHF, and other disorders. This Fast Fact discusses medical decision making around the use of NPPV at the end of life.
This Fast Fact discusses practical aspects of how using Non-Invasive Positive Pressure Ventilation (NPPV) can be used to palliate dyspnea in dying patients.
Allowing family presence during resuscitation (FPDR) has been proposed as a way to better support the emotional needs of family members and facilitate improved decision-making. This Fast Fact discusses the potential benefits and pitfalls of FPDR
The key components of a successful Family Presence During Resuscitation Protocol policy
Patients who intially survive cardiopulmonary resuscitation but remain comatose, demonstrating obvious impairments in neurologic function.
Common ICU prognostic models and their role in guiding patient care and communication
Venous thromboembolism (VTE) is a common complication of malignancy which carries a poor prognosis. This Fast Fact discusses the approach to VTE in patients with advanced cancer.
The clinical features and diagnosis of Spinal Cord Compression in adults
Metastatic spinal cord compression (SCC) is a medical emergency; early treatment is associated with less functional disability.
Discusses prognostication in severe Traumatic Brain Injury in adults
Patients enrolled in hospice programs will occasionally be transported to the Emergency Department (ED). Emergency medicine training focuses on life-prolonging measures and may fail to address hospice as a system of care. This Fast Fact provides information for clinicians practicing in EDs on management issues when a hospice patient arrives.
Patients with an end-stage illness often present to the Emergency Department (ED) with a crisis event (1). This Fast Fact provides information for ED providers on how to refer a patient to hospice care directly from the ED (2). Fast Fact #246 suggests strategies for caring for patients receiving hospice care who present to the ED.
Opioids have side effects which can limit their acceptability to patients.This Fast Fact gives expert opinion recommendations about patient counseling when initiating opioid therapy.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed drugs in the treatment of musculoskeletal pain. This Fast Fact reviews the pharmacology, clinical efficacy and adverse effects of topical NSAIDs for the treatment of musculoskeletal pain.
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Fast Facts
Review the library of Fast Fact documents.
This Fast Fact reviews assessment and management issues in terminal delirium.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Quick—what dose of the transdermal fentanyl patch (DuragesicTM) is equianalgesic to a 3 mg/hr morphine continuous infusion? Conversions to and from fentanyl transdermal are notoriously tricky, requiring knowledge of the published conversion data, general opioid pharmacology, and a generous dose of common sense. See also Fast Fact #36 on opioid dose conversions.
Fast Facts- Core Curriculum
- Pain - Opioids
This trajectory is often referred to as “actively dying” or “imminent death”. Prompt recognition of this trajectory is key for clinicians to provide the most appropriate interventions for both the patient and family.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
This Fast Fact reviews key steps in the death pronouncement and notification process.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
An easy way to remember the causes of vomiting is the VOMIT acronym. In the table below receptors involved in different types of nausea are highlighted using this acronym. Blockade of these receptors allows rational, focused therapy.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Case Scenario: You are caring for a previously healthy 52 year old man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. How do you prepare to discuss these test results with the patient?
Fast Facts- Communication
- Core Curriculum
Endicott has proposed substituting somatic criteria with affective criteria when evaluating depression in advanced cancer patients:
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Disease Categories- Cancer
- Psychiatric disorders
Question: What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
- Pain - Opioids
The Fast Fact reviews data on the use of tube feeding in advanced illness.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
Residents often feel strong emotions when they have to give bad news to a patient. As a preceptor, you will want to support the resident. Key teaching points:
Fast Facts- Communication
- Core Curriculum
There are two general types of advance directives:
Fast Facts- Communication
- Core Curriculum
- Ethics, Law, Policy, Health Systems
One often hears the term palliative chemotherapy, but what exactly does it mean and how can a non-oncologist decide if it has potential value?
Fast Facts- Communication
- Core Curriculum
Four major components affect the production of a normal BM: solid waste, water, motility and lubrication.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
Learning the process steps of a Family Conference are an important skill for physicians, nurses and others who are in a position to help patients and families reach consensus on end-of-life planning.
Patient-centered Interviewing - You can assess a patient’s illness experience by asking about 4 dimensions—Feelings, Ideas, Function and Expectations. The acronym FIFE can be a helpful reminder.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Understanding the pharmacological rational for dosing intervals is key to proper prescribing and patient counseling.
Fast Facts- Core Curriculum
- Pain - Opioids
Taking a spiritual history is one way to support the patient in this exploration.
Fast Facts- Communication
- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
A common question from trainees is how fast, and by how much, can opioids be safely dose escalated?
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact discusses the difficult balance between maintaining hope and truth telling, especially as it applies to giving bad news.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
One of the most meaningful acts of kindness you can do for a mourner is to write a letter of condolence.
`Code status’ discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach. This Fast Fact introduces an approach to having these discussions.
Fast Facts- Communication
- Core Curriculum
The basic steps in the DNR discussion for seriously ill hospitalized patients were described In Fast Fact # 23. If you have followed those steps, what do you do if the patient or family/surrogate continues to want CPR and you think it is not in the patient's best interest?
Fast Facts- Communication
- Core Curriculum
Why do patients get nauseated and vomit after receiving an opioid?
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
- Pain - Opioids
Have you ever had this experience – you are talking with a patient about some care option and you just cannot come to an agreement?
Fast Facts- Communication
- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews key elements in the assessment and treatment of dyspnea near the end-of-life.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
As death nears, the burden of maintaining intravenous (IV) access, especially in the home setting, can be enormous.
Fast Facts- Core Curriculum
- Pain - Opioids
Here are eight tasks that guide you in responding to patient emotion:
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Physicians tend to be overly optimistic when dealing with prognosis
Confronting our own mortality
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact provides an overview of grief and bereavement.
Fast Facts- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This is the first part of a three-part series on withdrawing ventilators in patients expected to die
This is the second of a three-part series: Symptom Control for Ventilator Withdrawal in the Dying Patient
This is Part 3 of a three-part series on withdrawing ventilator withdrawal.
Fast Facts- Communication
- Core Curriculum
Listed below are methods for common conversions using standard published conversion ratios.
Fast Facts- Core Curriculum
- Pain - Opioids
Pruritus (itching) is a common and often distressing symptom near the end of life.
Fast Facts- Non-Pain Symptoms and Syndromes
Hospice discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach.
Naloxone (Narcan®), a semisynthetic opioid antagonist, is indicated for the complete or partial reversal of life-threatening CNS/respiratory depression induced by opioids.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact discusses the staging and prevention of pressure ulcers
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact discusses the management, staging and prevention of pressure ulcers.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact provides tips for beginning a discussion leading to a visit by a palliative care consultation team.
This Fast Fact will review the definitions and clinical features that distinguish these conditions
Fast Facts- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
How do you change the status quo? What can you do when the system of care does not support best practice?
Fast Facts- Ethics, Law, Policy, Health Systems
Malignant bowel obstruction is a common oncologic complication; most common in ovarian and colon cancer.
Disease Categories- Cancer
- Gastrointestinal Diseases
Few things can worsen a patient’s quality of life greater than an oozing, odorous, painful, and bleeding malignant skin wound.
A common question asked by dying adults or their family members is What do I tell the children?
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Issues of coding and reimbursement are no different for palliative care than for any other medical specialty. That is, physicians code for each patient encounter in two parts: 1) a procedure/service code, and 2) a diagnosis code.
Fast Facts- Ethics, Law, Policy, Health Systems
Gabapentin (Neurontin) is widely used for neuropathic pain.
Fast Facts- Core Curriculum
- Pain - Non-Opioids
While specific to a certain time and place, these reflections on living, working, and caring for patients in the immediate aftermath of horrific events are timeless.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact will review information for rationally choosing among the various products.
But what does ’quality of life’ (QOL) mean, and how should clinicians use this information in decision making?
Fast Facts- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
The advantage of using SL morphine over intermittent IV boluses is a longer duration of action.
Fast Facts- Core Curriculum
- Pain - Opioids
The following is a step by step approach to rational opioid infusion prescribing in the dying patient, and is most appropriate for morphine or hydromorphone infusions
Fast Facts- Core Curriculum
- Pain - Opioids
In contrast, decision making capacity (‘decisionality’) refers to a physician’s determination, based on clinical examination, that a patient is able to make medical decisions for him- or herself.
Fast Facts- Communication
- Core Curriculum
- Ethics, Law, Policy, Health Systems
A core aspect of American bioethics is that a competent adult patient has a right to refuse treatment, even when the physician believes that the treatment would be beneficial.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact will discuss risk factors and patient assessment of the neuroexcitatory opioid side effects, particularly myoclonus
Fast Facts- Pain - Evaluation
- Pain - Opioids
This Fast Fact discusses treatment.
A guide to managing these situations is presented below.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Delirium is a common psychiatric disorder in the terminally ill
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
More than 95% of patients experience fatigue near the end of life
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Epidural metastases are very common in patients with advanced cancer.
Disease Categories- Cancer
- Other neurologic disorders
It is well recognized that physician’s fear of regulatory scrutiny (DEA, state medical boards), is a major contributor to the problem of under treatment of pain.
Fast Facts- Ethics, Law, Policy, Health Systems
- Pain - Evaluation
This Fast Fact reviews the components of a sensitive notification of loved ones when a patient dies.
Doctor-patient discussions about end-of-life treatment are often framed as a choice between “medical treatment vs. treatment withdrawal.”
This Fast Fact describes the physiology and methods of delivering radiation therapy
Fast Facts- Core Curriculum
- Pain - Non-Opioids
This Fast Fact reviews the common indications for and outcomes of palliative XRT.
Fast Facts- Core Curriculum
- Pain - Non-Opioids
A very commonly requested educational topic by physicians, concerning pain, surrounds differentiating the patient in pain vs. the patient with a substance abuse disorder.
Fast Facts- Core Curriculum
- Pain - Evaluation
Put simply, pseudoaddiction is something that we do to patients, through our fears and mis-understanding of pain, pain treatment, and addiction.
Fast Facts- Core Curriculum
- Pain - Evaluation
It is critical that physicians, nurses, and pharmacists share a common understanding of how to properly write, interpret, and carry out PRN range orders.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact discusses the pharmacology of MP and concerns about its use as an analgesic.
This Fast Fact will discuss appropriate ways to write opioid infusion titration orders.
Fast Facts- Core Curriculum
- Pain - Opioids
Respiratory failure is the most common cause of death from amyotrophic lateral sclerosis (ALS).
Disease Categories- Other neurologic disorders
This Fast Fact will illustrate poorly written opioid orders and provide preferred alternatives.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact will introduce methadone’s pharmacology and clinical use as an analgesic.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact offers some guidelines when telephone notification is unavoidable.
This Fast Fact discusses the dilemma of whether to provide telephone information versus asking family members to first come to hospital before telling them that death has occurred.
The meaning and expression of pain are influenced by people’s cultural background.
Fast Facts- Communication
- Pain - Evaluation
The purpose of this Fast Fact is to review the issues surrounding organ, tissue, and cornea donation.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact reviews CRO usage in palliative care.
Hiccups (singultus) are distressing to patients and families; when chronic, they diminish quality of life.
Fast Facts- Non-Pain Symptoms and Syndromes
In the United States, the Medicare Hospice Benefit (MHB) pays for 80% of all hospice care.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
his Fast Fact discusses common reasons that patients do not take prescribed opioids, thus resulting in unnecessary pain and suffering.
Fast Facts- Pain - Evaluation
- Pain - Opioids
The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Disease Categories- Dementia
- Gastrointestinal Diseases
- Other neurologic disorders
In palliative care, epidural analgesia may be appropriate for patients with regional pain (e.g. pelvic pain from cervical cancer) and/or patients who do not tolerate or obtain relief from oral/parenteral drugs and non-drug therapies.
Fast Facts- Pain - Non-Opioids
- Pain - Opioids
This Fast Fact will describe strategies for beginning methadone when the patient has not been taking a strong opioid.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact will review where services are provided and the reimbursement system for hospice care.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content.
Fast Facts- Ethics, Law, Policy, Health Systems
- Non-Pain Symptoms and Syndromes
This Fast Fact will review simple strategies for improving pain management outcomes.
his Fast Fact will discuss the use of interventions in hospice care that can be controversial due to high cost and/or uncertainty whether they constitute ‘palliative’ interventions.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
This Fact Fact reviews interventional approaches for upper GI obstructions, especially when further radiation, chemotherapy, medical management, or curative surgical options are longer helpful.
Disease Categories- Cancer
- Gastrointestinal Diseases
PCA allows for more immediate relief of incident (breakthrough) pain and can provide patients with a greater sense of personal control over their pain.
Fast Facts- Core Curriculum
- Pain - Opioids
Recent scientific studies of cannabinoids for symptom management have focused on nausea/vomiting and appetite stimulation.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will touch on some practical considerations in writing opioid prescriptions.
Physical dependence is a normal and predictable neurophysiological response to regular treatment with opioids for more than 1-2 weeks duration.
Fast Facts- Core Curriculum
- Pain - Opioids
Patients with uncontrolled diarrhea are at increased risk for dehydration, electrolyte imbalance, skin breakdown, and fatigue.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
In the palliative care setting, the most common indication for interrupting the sympathetic axis is to control pain arising from malignancies of the abdominal and pelvic viscera.
Fast Facts- Core Curriculum
- Pain - Non-Opioids
Intrathecal drug delivery can be an invaluable adjunct in the management of severe pain when meticulous application of conventional drug therapy proves ineffective or produces intolerable side effects.
The table below synthesizes data for several common cancers.
This Fast Fact discusses megestrol acetate, a synthetic progestin, which has been extensively studied as an appetite stimulant.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
This Fast Fact focuses on the assessment of insomnia; it is the first of a series of three Fast Facts about insomnia .
Fast Facts- Non-Pain Symptoms and Syndromes
The following is a review of HAART benefits/burdens near the end-of- life.
Fast Facts- Ethics, Law, Policy, Health Systems
This Fast Fact only discusses OTFC (Actiq).
This Fast Fact addresses non-pharmacologic therapies for insomnia.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact focuses on the pharmacological treatment of insomnia.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews the medical decision-making surrounding these practices.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
- Non-Pain Symptoms and Syndromes
This Fast Fact will review sedation techniques.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Music therapy uses the properties of music – sounds, rhythm, and personal attachment and universality of songs – for psychosocial and spiritual support and to complement other palliative care treatments.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions.
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Urine drug testing (UDT) is widely used for testing for opioids and illicit drugs. There are two types of UDT: a screening test and a confirmatory test.
This Fast Fact discusses management of cardiac pacemakers at life’s end.
Fast Facts- Ethics, Law, Policy, Health Systems
Disease Categories- Cardiac diseases and heart failure
However, near the end of life, decisions as to how best to use these devices can be the source of much anguish for patients, families and palliative care/hospice staff.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
Disease Categories- Cardiac diseases and heart failure
Bisphosphonates are used for the treatment or prophylaxis of cancer-related bone complications, including pain.
This Fast Fact discusses its causes, evaluation, and therapy.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Other neurologic disorders
This Fast Fact reviews the details of declaring death based on neurological criteria.
Fast Facts- Ethics, Law, Policy, Health Systems
Disease Categories- Other neurologic disorders
This Fast Fact reviews bone-seeking radiopharmaceuticals (radionuclides), which occupy a valuable niche in the palliation of painful bone metastases.
Research has shown that neonates may experience as much pain as older children and long-term consequences from exposure to repeated painful stimuli.
Near death awareness (NDA) is a term to describe a dying person’s experiences of the dying process.
Fast Facts- Non-Pain Symptoms and Syndromes
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Invasive treatment options should be considered for all patients except those who are actively dying.
Disease Categories- Cancer
- Gastrointestinal Diseases
The following options attempt to respect the integrity of the physician’s spiritual/religious beliefs and be supportive of the patient’s emotional needs.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact discusses the diagnosis and assessment of mucositis.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will discuss the pre-ICU-admission assessment of patients with advanced illnesses.
An ICU daily care plan checklist can be used to promote palliative care, simultaneously with curative or life-prolonging therapies.
This Fast Fact reviews the Palliative Prognostic Score (PaP).
This Fast Fact reviews the Palliative Performance Scale.
The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control.
The spectrum of substance use disorders (SUDs) are characterized by increasing degrees of craving, compulsive use, loss of control, and continued use despite harm.
This Fast Fact will review the indications and contraindications for a swallowing study and the role of the speech pathologist.
Fast Facts- Communication
- Non-Pain Symptoms and Syndromes
Disease Categories- Dementia
- Gastrointestinal Diseases
- Other neurologic disorders
This Fast Fact discusses the use of corticosteroids for painful bone metastases.
This Fast Fact focuses on prevention and general treatment of radiation (XRT) and chemotherapy-induced oral mucositis.
Fast Facts- Non-Pain Symptoms and Syndromes
Caring for a dying patient who has a physician-family member provides challenges and opportunities.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews the use of ketamine in palliative care as an analgesic.
This Fast Fact discusses medical decision-making about non-oral hydration in palliative care settings.
Fast Facts- Ethics, Law, Policy, Health Systems
- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
This Fast Fact reviews the technical aspects of providing non-oral hydration.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
Neoplastic meningitis (NM) – also known as leptomeningeal metastases, meningeal carcinomatosis, or leukemic meningitis, is a common oncologic complication representing spread of tumor cells to the subarachnoid space (SAS).
Disease Categories- Cancer
- Other neurologic disorders
This Fast Fact will discuss the current understanding of the term futility.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
This Fast Fact will focus on managing the symptoms of CS.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews key developmental concepts and describes strategies for addressing children’s grief.
Fast Facts- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews key steps in the transition from the acute care hospital setting to home hospice care.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
Because more than 95% of hospice care is in the form of routine home care, clinicians may not be aware that the MHB specifies four different levels of hospice services to meet the diverse needs of dying patients and their family.
Fast Facts- Core Curriculum
- Ethics, Law, Policy, Health Systems
This Fast Fact will review prognostication in patients with advanced COP
Disease Categories- Chronic pulmonary diseases
This Fast Fact reviews the clinical findings and treatment options
This Fast Fact reviews prognostication data in Heart Failure (HF).
Disease Categories- Cardiac diseases and heart failure
This Fast Fact reviews domains of medical management common to most end-stage HF patients.
Disease Categories- Cardiac diseases and heart failure
Separating “normal” death-related anxiety from pathological panic is an important palliative care skill.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews that literature on depression screening tools.
Oropharyngeal candidiasis (thrush) occurs commonly in seriously ill and dying patients.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews its mechanism of action, research data, and dosage information.
Family members look to the physician and nurse to help them know what to expect when a loved one is dying.
Fast Facts- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews issues of prognostication in dementia.
Up to 30 percent of patients with cancer develop hypercalcemia.
Knowing the components of a military history can be a useful tool in bridging the silence that often surrounds the war experience and can act as a catalyst for discussions about end of life preferences.
This Fast Fact reviews assessment and management strategies for poor health literacy.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact reviews key issues when using interpreters in the palliative care setting.
Fast Facts- Communication
- Core Curriculum
This Fast Fact reviews key steps in the completion of a death certificate.
Fast Facts- Ethics, Law, Policy, Health Systems
This Fast Fact provides guidance on how to evaluate and initially respond to a patient who raises the topic of a hastened death.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews key facts regarding effusion management.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews treatment options for managing distressing secretions.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact focuses on possible ways of responding to patients who continue to want a hastened death despite every effort to find appropriate palliative care alternatives.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
Delirium can be hypoactive or hyperactive. Patients with hypoactive delirium are calm, but inattentive and manifest decreased mobility. Patients with hyperactive delirium are agitated and combative, and also lack the ability to maintain attention to complete tasks.
This Fast Fact reviews recommendations for opioid use in the setting of renal failure and in patients receiving chronic dialysis.
Fast Facts- Core Curriculum
- Pain - Opioids
Disease Categories- Renal diseases and dialysis
This Fast Fact reviews key concepts of the Advance Care Planning (ACP) process.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact reviews key concepts of the ACP process for CKD patients.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Disease Categories- Renal diseases and dialysis
This Fast Fact reviews the legal basis for informed consent.
Fast Facts- Communication
- Core Curriculum
- Ethics, Law, Policy, Health Systems
This Fast Fact discusses common myths about informed consent that arise in palliative care.
Fast Facts- Communication
- Core Curriculum
- Ethics, Law, Policy, Health Systems
To prevent confusion due to similar generic names, this Fast Fact will use trade-names for Kadian and Avinza, and “ER-morphine” to describe extended-release formulations which are usually dosed q12 hours.
This Fast Fact will describe burnout and its risk factors, and review essential research regarding health professionals and burnout.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact will explore symptoms of burnout and its personal and professional consequences.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact will address strategies to avoid burnout while sustaining personal and professional health, integrity, and growth.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact will briefly describe assessment tools used in health professional research.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.
This Fast Fact reviews issues in health professional-patient boundaries in palliative care.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact reviews diagnostic and treatment approaches in the palliative care setting.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will suggest guidelines for continued use or discontinuation in the hospice/palliative care setting.
This Fast Fact will review signs, symptoms, and management options of opioid allergies and pseudo-allergies.
Fast Facts- Core Curriculum
- Pain - Opioids
This Fast Fact reviews the causes and diagnosis of malignant ascites.
Disease Categories- Cancer
- Gastrointestinal Diseases
This Fast Fact will review treatment approaches and the important role of determining the Serum Ascites-Albumin Gradient as a diagnostic and treatment aid.
Disease Categories- Cancer
- Gastrointestinal Diseases
This Fast Fact will review key elements of the POLST project.
Fast Facts- Ethics, Law, Policy, Health Systems
This Fast Fact will review data on CPR outcomes in hospitalized patients.
This Fast Fact reviews the use of parenteral lidocaine for neuropathic pain.
This Fast Fact will review oral oxymorphone and its place in pain management.
This Fast Fact will review the causes and treatments of xerostomia.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact provides an alternative approach to conflict resolution based on understanding a patient’s or family’s story, attending to their emotions, and establishing shared goals.
Fast Facts- Communication
- Core Curriculum
Principled negotiation is an approach to resolving conflict that avoids power struggles and unwanted compromises.
Fast Facts- Communication
- Core Curriculum
This Fast Fact reviews the mechanism of action, research data, and dosing information on topically applied opioids.
This Fast Fact will discuss the causes and evaluation of anxiety.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact reviews the use of non-tricyclic antidepressants for neuropathic pain.
Fast Facts- Core Curriculum
- Pain - Non-Opioids
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome with a fluctuating course associated with end stage liver disease (ESLD).
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
This Fast Fact reviews prognosis in chronic liver failure, focusing on two validated prognostic indices.
Disease Categories- Gastrointestinal Diseases
This Fast Fact reviews the role of PN in advanced cancer patients.
Disease Categories- Cancer
- Gastrointestinal Diseases
This Fast Fact reviews the current data regarding prognostication in patients receiving chronic hemo- and peritoneal dialysis.
Disease Categories- Renal diseases and dialysis
This Fast Fact will review special issues in the care of developmentally disabled people with life-limiting diseases.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Other neurologic disorders
This Fast Fact will address medical decision making for adults with developmental disabilities (DD) who are facing terminal or life-limiting diseases such as cancer, end-stage organ failure, or progressive debility.
Fast Facts- Communication
- Non-Pain Symptoms and Syndromes
Disease Categories- Other neurologic disorders
This Fast Fact will address how to disclose error with a patient/family.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact will discuss responding to a colleague’s error.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
Osteonecrosis of the jaw (ONJ) is a potentially devastating complication associated with bisphosphonate therapy.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will review the clinical features and treatment of CAPN.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will review US federal regulations regarding prescribing Schedule II drugs.
Fast Facts- Ethics, Law, Policy, Health Systems
- Pain - Opioids
This Fast Fact will focus on the use of opioids for the symptomatic treatment of cough.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will address peripherally-acting agents.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will focus on supportive and terminal care for patients with HD and their families.
Disease Categories- Other neurologic disorders
Vertebral compression fractures (VCFs) occur in up to 20% of patients above the age of 50, mostly due to osteoporosis.
This Fast Fact focuses on clinicians’ emotional responses to patient care.
Fast Facts- Communication
- Core Curriculum
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
This Fast Fact outlines research findings on differences in end-of-life care and values between African Americans and the population as a whole.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
In 2002, the FDA approved the LVAD not only as “bridge therapy”, but also as an alternative to transplantation, or “destination therapy.”
Disease Categories- Cardiac diseases and heart failure
Once patients die, however, their DNA is no longer readily available for this future testing. On the other hand, decisions about genetic testing are complex and can have profound emotional, familial, and financial impacts on those affected and should not be pursued hastily.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
This Fast Fact reviews key issues pertaining to the decision to stop chronic dialysis; Fast Fact #208 will discuss the care of patients after it is stopped.
Disease Categories- Renal diseases and dialysis
This Fast Fact addresses care of the patient around the time of dialysis discontinuation.
Disease Categories- Renal diseases and dialysis
Malignant pericardial effusions (MPEs) are a rare complication of advanced cancer, but are associated with high morbidity and mortality. This Fast Fact discusses the diagnosis and management of MPEs.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Cancer
- Cardiac diseases and heart failure
This Fast Fact discusses evaluating and responding to suicidality in patients with life-limiting diseases.
Fast Facts- Ethics, Law, Policy, Health Systems
Anxiety occurs in hospitalized patients for many reasons including fear of specific procedures, worry about the future, and lack of control. This Fast Fact will discuss guided imagery as an anxiety reduction technique.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Cancer
- Psychiatric disorders
Phantom limb pain (PLP) can be a painful and debilitating consequence of limb amputation from any cause including trauma, cancer, and vascular diseases. This Fast Fact will review the evaluation and management of PLP.
Disease Categories- Other neurologic disorders
This Fast Fact discusses prognostication in patients who are suffering life-threatening complications related to HIV infection using data where cART was available.
This Fast Fact presents survival data for malignancies commonly arising in the setting of HIV / AIDS.
Relief of cancer pain from opioids is rarely all or nothing; most patients experience some degree of analgesia alongside opioid toxicities. While opioid poorly-responsive pain is not a discreet syndrome, it is a commonly encountered clinical scenario. This Fast Fact reviews key points in its assessment and management.
Fast Facts- Pain - Evaluation
- Pain - Opioids
Patients’ cultural backgrounds profoundly influence their preferences and needs regarding discussing bad news, decision-making, and the dying experience. This Fast Fact offers a framework for taking a ‘cultural history’ to better understand a patient’s and family’s needs.
Restless Leg Syndrome (RLS) is a neurologic disorder characterized by unpleasant sensations in the legs causing an uncontrollable urge to move when at rest in an effort to relieve those feelings. RLS disrupts sleep, can lead to excessive daytime sleepiness, depression, and a decreased quality of life. This Fast Fact will review its evaluation and management.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Other neurologic disorders
This Fast Fact will discuss a practical approach to ameliorating wound odors.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will introduce readers to a practical approach to responding to families who request non-disclosure to the patient.
This Fast Fact discusses subcutaneous fluid infusions, also known as hypodermoclysis (HDC).
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Gastrointestinal Diseases
Buprenorphine, a mixed opioid agonist/antagonist, available in the United States, is approved for treatment of opioid addiction in the US; such use is restricted to qualified physicians who have received training and a waiver to practice medication-assisted opioid addiction therapy.
A cornerstone procedure in Palliative Medicine is leadership of family meetings to establish goals of care, typically completed at a time of patient change in status, where the value of current treatments needs to be re-evaluated. As with any procedure, preparation is essential to ensure the best outcome. This Fast Fact reviews how to prepare for a Family Meeting.
This Fast Fact reviews the early steps of the actual meeting.
This Fast Fact provides a detailed approach to emotions that arise during family meetings.
This Fast Fact explores understanding the causes of conflict and how to plan an effective strategy to move beyond the conflict to meet the needs of the patient and surrogates.
This Fast Fact reviews an approach to help surrogates through the decision process when patients cannot participate in decision-making themselves.
This Fast Fact discusses an approach to goal setting when the expected length of life is short.
Tapentadol is a novel analgesic, with a 50 mg dose similar in efficacy to 10 mg of oxycodone.
The actual incidence of seizures in dying patients is unknown, and while likely uncommon, they can cause tremendous distress to patients and families. This Fast Fact reviews management strategies for seizures near the end of life.
Non-invasive positive pressure ventilation (NPPV, often called 'BiPAP') is commonly used in patients with respiratory failure from COPD, CHF, and other disorders. This Fast Fact discusses medical decision making around the use of NPPV at the end of life.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Chronic pulmonary diseases
This Fast Fact discusses practical aspects of how using Non-Invasive Positive Pressure Ventilation (NPPV) can be used to palliate dyspnea in dying patients.
Fast Facts- Non-Pain Symptoms and Syndromes
Disease Categories- Chronic pulmonary diseases
Allowing family presence during resuscitation (FPDR) has been proposed as a way to better support the emotional needs of family members and facilitate improved decision-making. This Fast Fact discusses the potential benefits and pitfalls of FPDR
Fast Facts- Ethics, Law, Policy, Health Systems
The key components of a successful Family Presence During Resuscitation Protocol policy
Fast Facts- Ethics, Law, Policy, Health Systems
Patients who intially survive cardiopulmonary resuscitation but remain comatose, demonstrating obvious impairments in neurologic function.
Disease Categories- ICU
- Other neurologic disorders
Common ICU prognostic models and their role in guiding patient care and communication
Venous thromboembolism (VTE) is a common complication of malignancy which carries a poor prognosis. This Fast Fact discusses the approach to VTE in patients with advanced cancer.
Fast Facts- Non-Pain Symptoms and Syndromes
The clinical features and diagnosis of Spinal Cord Compression in adults
Disease Categories- Cancer
- Other neurologic disorders
Metastatic spinal cord compression (SCC) is a medical emergency; early treatment is associated with less functional disability.
Disease Categories- Cancer
- Other neurologic disorders
Discusses prognostication in severe Traumatic Brain Injury in adults
Fast Facts- Core Curriculum
- Non-Pain Symptoms and Syndromes
Levorphano is similar to methadone with longer duration; an agonist at the mu, kappa, and delta opioids receptors, an NMDA antagonist, and a monoamine reuptake inhibitor of norepinephrine and serotonin; relatively high cost; suited for neuropathic pain.
Hearing loss can lead to misunderstandings, which in the health care setting can literally have life-or-death implications.
Fast Facts- Communication
- Non-Pain Symptoms and Syndromes
Fast Facts- Ethics, Law, Policy, Health Systems
Fast Facts- Ethics, Law, Policy, Health Systems
Patients enrolled in hospice programs will occasionally be transported to the Emergency Department (ED). Emergency medicine training focuses on life-prolonging measures and may fail to address hospice as a system of care. This Fast Fact provides information for clinicians practicing in EDs on management issues when a hospice patient arrives.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Patients with an end-stage illness often present to the Emergency Department (ED) with a crisis event (1). This Fast Fact provides information for ED providers on how to refer a patient to hospice care directly from the ED (2). Fast Fact #246 suggests strategies for caring for patients receiving hospice care who present to the ED.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
Opioids have side effects which can limit their acceptability to patients.This Fast Fact gives expert opinion recommendations about patient counseling when initiating opioid therapy.
Fast Facts- Communication
- Ethics, Law, Policy, Health Systems
- Pain - Opioids
Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed drugs in the treatment of musculoskeletal pain. This Fast Fact reviews the pharmacology, clinical efficacy and adverse effects of topical NSAIDs for the treatment of musculoskeletal pain.
Many patients with advanced illness have tracheostomies, which require careful observation and specialized management. A working knowledge of the basic tracheostomy equipment and handling procedures can avoid complications and improve a patient’s comfort.
Carotid blowout is the rupture of the extracranial carotid arteries or their major branches. It is an uncommon but devastating complication of head and neck cancer. This Fast Fact will discuss the approach to patients with carotid blowout, including patients near the end of life whose care goals are focused on safety and comfort.
Fast Facts- Communication
- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Borderline personality disorder (BPD) is identified by a pervasive pattern of instability of relationships, self-image, and mood, as well as marked impulsivity. This Fast Fact provides strategies for successful interactions with patients and patients’ caregivers with BPD.
The Intensive Care Unit (ICU) is the setting for high-intensity health care designed to resolve life-threatening illnesses and extend life. However, risks of mortality and severe morbidity remain high and virtually all ICU patients have palliative care needs. This Fast Fact reviews the role of palliative care consultations in the ICU along with options for more generalist palliative care services provided by ICU clinicians
About 10-20% of bereaved individuals experience a persistent, debilitating phenomenon referred to as complicated grief (CG). Complicated grief has also been referred to as prolonged, traumatic or pathological grief.
Fast Facts- Psychosocial and Spiritual Experience: Patients, Families, and Clinicians
Capsaicin 0.075% cream demonstrated statistically significant benefit in post-herpetic neuralgia, post-surgical neuropathies, and diabetic neuropathy, compared to placebo.
Hyperthermia is an uncontrolled elevation in body temperature without a change in the thermoregulatory center. This Fast Fact reviews the key elements in assessment and treatment of fever in patients near the end-of-life.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact introduces the use of rectal medications for patients in palliative care settings. The rectal route is an efficient and practical alternative in administering a broad array of palliative care medications to patients with a compromised oral route.
Fast Facts- Non-Pain Symptoms and Syndromes
- Pain - Opioids
Treatment goals for patients near the end-of-life are to avoid symptomatic hypo- and hyperglycemia and minimize the burdens of diabetes treatment, but not to prevent those long-term complications.
Fast Facts- Communication
- Geriatrics
- Non-Pain Symptoms and Syndromes
Disease Categories- Other
- Renal diseases and dialysis
Modafinil is a non-amphetamine psychostimulant approved for the treatment of excessive daytime somnolence associated with obstructive sleep apnea, narcolepsy, and shift work sleep disorder. This Fast Fact reviews use of modafinil for symptom management in the seriously ill.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact discusses the use of opioids in patients with liver failure.
Disease Categories- Gastrointestinal Diseases
Hot flashes are a common symptom which can negatively impact quality of life. Failure to assess and offer treatment for hot flashes is common. This Fast Fact is the first in a three part series reviewing hot flash assessment and treatment.
Fast Facts- Non-Pain Symptoms and Syndromes
This Fast Fact will cover procedural and pharmacological treatment of hot flashes. Complementary and alternative therapies will be reviewed in Fast Fact #263.
Fast Facts- Non-Pain Symptoms and Syndromes
Assessment and drug treatments of hot flashes (‘flushes’) were discussed in Fast Facts # 261-2; this Fast Fact reviews non-drug and complementary/alternative medicine (CAM) therapies.
Pulmonary artery hypertension (PAH) is a disease of the pulmonary vascular system characterized by elevated pulmonary vascular resistance. Patients with advanced PAH are often treated with prostacyclins. This Fast Fact reviews suggested guidelines for withdrawal of prostacyclin therapy in dying patients with PAH.
Disease Categories- Cardiac diseases and heart failure
- Chronic pulmonary diseases