Fast Facts

# 253 Palliative Care Consultation in the ICU

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.

# 252 Borderline Personality Disorder in Palliative Care

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.

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# 002 Converting to/from Transdermal Fentanyl, 2nd ed

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.

# 004 Death Pronouncement in the Hospital, 2nd ed

This Fast Fact reviews key steps in the death pronouncement and notification process.

# 006 Delivering Bad News-Part 1, 2nd ed

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?

# 008 Morphine and Hastened Death, 2nd ed

Question: What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?

# 010 Tube Feed or Not Tube Feed?, 2nd ed

The Fast Fact reviews data on the use of tube feeding in advanced illness.

# 012 Myths About Advance Directives, 2nd ed

There are two general types of advance directives:

# 014 Palliative Chemotherapy, 2nd ed

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?

# 016 Moderating an End-of-Life Family Conference, 2nd ed

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.

# 018 Short-Acting Oral Opioid Dosing Intervals, 2nd ed

Understanding the pharmacological rational for dosing intervals is key to proper prescribing and patient counseling.

# 020 Opioid Dose Escalation, 2nd ed

A common question from trainees is how fast, and by how much, can opioids be safely dose escalated?

# 022 Writing a Condolence Letter, 2nd ed

One of the most meaningful acts of kindness you can do for a mourner is to write a letter of condolence.

# 024 Discussing DNR Orders-Part 2, 2nd ed

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?

# 026 The Explanatory Model, 2nd ed

Have you ever had this experience – you are talking with a patient about some care option and you just cannot come to an agreement?

# 028 Subcutaneous Opioid Infusions, 2nd ed

As death nears, the burden of maintaining intravenous (IV) access, especially in the home setting, can be enormous.

# 030 Prognostication, 2nd ed

Physicians tend to be overly optimistic when dealing with prognosis

# 032 Grief and Bereavement, 2nd ed

This Fast Fact provides an overview of grief and bereavement.

# 034 Symptom Control for Ventilator Withdrawal in the Dying Patient, 2nd ed

This is the second of a three-part series: Symptom Control for Ventilator Withdrawal in the Dying Patient

# 036 Calculating Opioid Dose Conversions, 2nd ed

Listed below are methods for common conversions using standard published conversion ratios.

# 038 Discussing Hospice, 2nd ed

Hospice discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach.

# 040 Pressure Ulcer Management: Prevention (Part 1), 2nd ed

This Fast Fact discusses the staging and prevention of pressure ulcers

# 042 Broaching the Topic of a Palliative Care Consultation with Patients and Families, 2nd ed

This Fast Fact provides tips for beginning a discussion leading to a visit by a palliative care consultation team.

# 044 Changing the Status Quo-Quality Improvement, 2nd ed

How do you change the status quo? What can you do when the system of care does not support best practice?

# 046 Malignant Wounds, 2nd ed

Few things can worsen a patient’s quality of life greater than an oozing, odorous, painful, and bleeding malignant skin wound.

# 048 Coding and Billing for Physician Services in Palliative Care, 2nd ed

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.

# 050 Disaster: Coping with Tragedy, 2nd ed

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.

# 052 Quality of Life

But what does ’quality of life’ (QOL) mean, and how should clinicians use this information in decision making?

# 054 Opioid Infusions in the Imminently Dying Patient, 2nd ed

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

# 056 What to do When a Patient Refuses Treatment, 2nd ed

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.

# 058 Neuroexcitatory Effects of Opioids: Treatment, 2nd ed

This Fast Fact discusses treatment.

# 060 Pharmacologic Management of Delirium; Update on Newer Agents, 2nd ed

Delirium is a common psychiatric disorder in the terminally ill

# 062 Preventing Neurologic Deficits: Early Diagnosis of Epidural Metastases, 2nd ed

Epidural metastases are very common in patients with advanced cancer.

# 064 Informing Significant Others of a Patient's Death, 2nd ed

This Fast Fact reviews the components of a sensitive notification of loved ones when a patient dies.

# 066 Radiation for Palliation - Part 1, 2nd ed

This Fast Fact describes the physiology and methods of delivering radiation therapy

# 068 Is it Pain or Addiction?, 2nd ed

A very commonly requested educational topic by physicians, concerning pain, surrounds differentiating the patient in pain vs. the patient with a substance abuse disorder.

# 070 PRN Range Analgesic Orders, 2nd ed

It is critical that physicians, nurses, and pharmacists share a common understanding of how to properly write, interpret, and carry out PRN range orders.

# 072 Opioid Infusion Titration Orders, 2nd ed

This Fast Fact will discuss appropriate ways to write opioid infusion titration orders.

# 074 Oral Opioid Orders - Good and Bad Examples, 2nd ed

This Fast Fact will illustrate poorly written opioid orders and provide preferred alternatives.

# 076 Telephone Notification of Death - Part 1, 2nd ed

This Fast Fact offers some guidelines when telephone notification is unavoidable.

# 078 Cultural Aspects of Pain Management, 2nd ed

The meaning and expression of pain are influenced by people’s cultural background.

# 080 Controlled Release Oxycondone, 2nd ed

This Fast Fact reviews CRO usage in palliative care.

# 082 Medicare Hospice Benefit: Part 1 Eligibility and Treatment Plan, 2nd ed

In the United States, the Medicare Hospice Benefit (MHB) pays for 80% of all hospice care.

# 084 Swallow Studies, Tube Feeding and the Death Spiral, 2nd ed

The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming.

# 086 Methadone: Starting Dosing Information, 2nd ed

This Fast Fact will describe strategies for beginning methadone when the patient has not been taking a strong opioid.

# 088 Nightmares, 2nd ed

Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content.

# 090 Medicare Hospice Benefit Part III: Special Interventions, 2nd ed

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.

# 092 Patient Controlled Analgesia in Palliative Care, 2nd ed

PCA allows for more immediate relief of incident (breakthrough) pain and can provide patients with a greater sense of personal control over their pain.

# 094 Writing Discharge/Outpatient Opioid Prescriptions, 2nd ed

This Fast Fact will touch on some practical considerations in writing opioid prescriptions.

# 096 Diarrhea in Palliative Care, 2nd ed

Patients with uncontrolled diarrhea are at increased risk for dehydration, electrolyte imbalance, skin breakdown, and fatigue.

# 098 Intrathecal Drug Therapy for Pain, 2nd ed

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.

# 100 Megestrol Acetate for Cancer Anorexia/Cachexia

This Fast Fact discusses megestrol acetate, a synthetic progestin, which has been extensively studied as an appetite stimulant.

# 102 Highly Active Antiretroviral Therapy and Hospice

The following is a review of HAART benefits/burdens near the end-of- life.

# 104 Insomnia: Non-Pharmacologic Treatments

This Fast Fact addresses non-pharmacologic therapies for insomnia.

# 106 Controlled Sedation for Refractory Suffering - Part I

This Fast Fact reviews the medical decision-making surrounding these practices.

# 108 Music Therapy

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.

# 110 Urine Drug Testing for Opioids and Marijuana

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.

# 112 Implantable Cardioverter-Defibrillators at End-of-Life

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.

# 114 Myoclonus

This Fast Fact discusses its causes, evaluation, and therapy.

# 116 Radiopharmaceuticals for Painful Osseous Metastases

This Fast Fact reviews bone-seeking radiopharmaceuticals (radionuclides), which occupy a valuable niche in the palliation of painful bone metastases.

# 118 Near Death Awareness

Near death awareness (NDA) is a term to describe a dying person’s experiences of the dying process.

# 120 Physicians and Prayer Requests

The following options attempt to respect the integrity of the physician’s spiritual/religious beliefs and be supportive of the patient’s emotional needs.

# 122 Palliative Care and ICU Care: Pre-Admission Assessment

This Fast Fact will discuss the pre-ICU-admission assessment of patients with advanced illnesses.

# 124 The Palliative Prognostic Score

This Fast Fact reviews the Palliative Prognostic Score (PaP).

# 126 Pain Assessment in the Cognitively Impaired

The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control.

# 128 The Speech Pathologist and Swallowing Studies

This Fast Fact will review the indications and contraindications for a swallowing study and the role of the speech pathologist.

# 130 Oral Mucositis: Prevention and Treatment

This Fast Fact focuses on prevention and general treatment of radiation (XRT) and chemotherapy-induced oral mucositis.

# 132 Ketamine Use in Palliative Care

This Fast Fact reviews the use of ketamine in palliative care as an analgesic.

# 134 Non-Oral Hydration Techniques in Palliative Care

This Fast Fact reviews the technical aspects of providing non-oral hydration.

# 136 Medical Futility

This Fast Fact will discuss the current understanding of the term futility.

# 138 Grief in Children and Developmental Concepts of Death

This Fast Fact reviews key developmental concepts and describes strategies for addressing children’s grief.

# 140 Medicare Hospice Benefit: Levels of 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.

# 142 Opioid-Induced Hyperalgesia

This Fast Fact reviews the clinical findings and treatment options

# 144 Palliative Care Issues in Heart Failure

This Fast Fact reviews domains of medical management common to most end-stage HF patients.

# 146 Screening for Depression in Palliative Care

This Fast Fact reviews that literature on depression screening tools.

# 148 The Lidocaine Patch

This Fast Fact reviews its mechanism of action, research data, and dosage information.

# 150 Prognostication in Dementia

This Fast Fact reviews issues of prognostication in dementia.

# 152 The Military History as a Vehicle for Exploring End-of-Life Care with Veterans

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.

# 154 Use of Interpreters in Palliative Care

This Fast Fact reviews key issues when using interpreters in the palliative care setting.

# 156 Evaluating Requests for Hastened Death

This Fast Fact provides guidance on how to evaluate and initially respond to a patient who raises the topic of a hastened death.

# 158 Respiratory Secretion Management

This Fast Fact reviews treatment options for managing distressing secretions.

# 160 Screening ICU Delirium

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.

# 162 Advance Care Planning in Chronic Illness

This Fast Fact reviews key concepts of the Advance Care Planning (ACP) process.

# 164 Informed Consent in Palliative Care - Part I

This Fast Fact reviews the legal basis for informed consent.

# 166 Once Daily Oral Morphine Formulations

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.

# 168 Health Professional Burnout - Part II

This Fast Fact will explore symptoms of burnout and its personal and professional consequences.

# 170 Health Professional Burnout - Part IV

This Fast Fact will briefly describe assessment tools used in health professional research.

# 172 Professional Patient Boundries in Palliative Care

This Fast Fact reviews issues in health professional-patient boundaries in palliative care.

# 174 Dementia Medications in Palliative Care

This Fast Fact will suggest guidelines for continued use or discontinuation in the hospice/palliative care setting.

# 176 Evaluation of Malignant Ascites

This Fast Fact reviews the causes and diagnosis of malignant ascites.

# 178 The National Polst Paradigm Initiative, 2nd Edition

This Fast Fact will review key elements of the POLST project.

# 180 Parenteral Lidocaine for Neuropathic Pain

This Fast Fact reviews the use of parenteral lidocaine for neuropathic pain.

# 182 Xerstomia, 2nd ed

This Fast Fact will review the causes and treatments of xerostomia.

# 184 Conflict Resolution II: Principled Negotiation

Principled negotiation is an approach to resolving conflict that avoids power struggles and unwanted compromises.

# 186 Anxiety in Palliative Care - Causes and Diagnosis

This Fast Fact will discuss the causes and evaluation of anxiety.

# 188 Hepatic Encephalopathy in ESLD

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome with a fluctuating course associated with end stage liver disease (ESLD).

# 190 Parenteral Nutrition in Advanced Cancer Patients

This Fast Fact reviews the role of PN in advanced cancer patients.

# 192 Palliative Care for Adults with Developmental Disabilities

This Fast Fact will review special issues in the care of developmentally disabled people with life-limiting diseases.

# 194 Disclosing Medical Error

This Fast Fact will address how to disclose error with a patient/family.

# 196 Bisphosphonates and Osteonecrosis of the Jaw

Osteonecrosis of the jaw (ONJ) is a potentially devastating complication associated with bisphosphonate therapy.

# 198 Regulatory Issues for Prescribing Schedule II Opioids at the End-of-Life

This Fast Fact will review US federal regulations regarding prescribing Schedule II drugs.

# 200 Non-Opioid Anti-Tussives

This Fast Fact will address peripherally-acting agents.

# 202 Vertebroplasty and Kyphoplasty for Vertebral Compression Fractures

Vertebral compression fractures (VCFs) occur in up to 20% of patients above the age of 50, mostly due to osteoporosis.

# 204 African Americans and End-of Life 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.

# 206 Genetic Screening and DNA Banking at the End-of-Life

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.

# 208 Clinical Care Following Withdrawal of Dialysis

This Fast Fact addresses care of the patient around the time of discontinuation.

# 210 Suicidal Attempts in the Terminally Ill

This Fast Fact discusses evaluating and responding to suicidality in patients with life-limiting diseases.

# 212 Phantom Limb Pain

This Fast Fact will review the evaluation and management of PLP.

# 214 Prognosis in HIV Associated Malignancies

This Fast Fact presents survival data for malignancies commonly arising in the setting of HIV / AIDS.

# 216 Asking about Cultural Beliefs in Palliative Care

This Fast Fact offers a framework for taking a ‘cultural history’ to better understand a patient’s and family’s needs.

# 218 Managing Wound Odor

# 220 Hypodermoclysis

This Fast Fact discusses subcutaneous fluid infusions, also known as hypodermoclysis (HDC).

# 222 Preparing for the Family Meeting

Careful preparation for the family meeting is essential to ensure the best outcome.

# 224 Responding to Emotion in Family Meetings

This Fast Fact provides a detailed approach to emotions that arise during family meetings.

# 226 Helping Surrogates Make Decisions

This Fast Fact reviews an approach to help surrogates through the decision process when patients cannot participate in decision-making themselves.

# 228 Tapentadol

Tapentadol is a novel analgesic, with a 50 mg dose similar in efficacy to 10 mg of oxycodone.

# 230 Using Non-Invasive Ventilation at the End of Life

This Fast Fact discusses medical decision making around the use of NPPV at the end of life.

# 232 Family Presence During Resuscitation

This Fast Fact discusses the potential benefits and pitfalls of FPDR.

# 234 Prognosis of Anoxic-Ischemic Encephalopathy

Patients who intially survive cardiopulmonary resuscitation but remain comatose, demonstrating obvious impairments in neurologic function.

# 236 Pharmacologic Treatment of Acute Venous Thromboembolism in Patients with Advanced Cancer

# 238 Management of Spinal Cord Compression

Metastatic spinal cord compression (SCC) is a medical emergency; early treatment is associated with less functional disability.

# 240 Levorphanol

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.

# 242 Organ Donation after Cardiac Death

Appropriate patients are generally comatose patients between the ages of 0 and 60 for whom a decision has been made to discontinue life-sustaining treatments with the expectation of imminent death.

# 244 Screening for Opioid Misuse and Abuse

Opioid analgesics are effective in relieving both cancer and chronic non-malignant pain but can be misused and abused by patients and others (1, 2). Clinicians need to identify patients at risk of misusing prescribed opioids in order to prescribe and monitor opioid therapy safely. This Fast Fact discusses how clinicians can screen for risk of misuse.

# 246 Emergency Department Management of Hospice Patients

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.

# 248 Counseling Patients on Side Effects and Driving When Starting Opioids

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.

# 250 Tracheostomy Care

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.

# 252 Borderline Personality Disorder in Palliative Care

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.