Community-based Palliative Care: Trends, Challenges, Examples and Collaborati...wwuextendeded
Community-based Palliative Care: Trends, Challenges, Examples and Collaboration with Payers - Eric Wall, MD, MPH
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
Community-based Palliative Care: Trends, Challenges, Examples and Collaborati...wwuextendeded
Community-based Palliative Care: Trends, Challenges, Examples and Collaboration with Payers - Eric Wall, MD, MPH
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
A Palliative Approach in Residential Care Settings (March 2014)Joan Trinh Pham
A basic presentation presentation on the topic of applying a palliative approach to residential care settings for elders + their families. It covers a review of palliative care + terminology then distinguishing between specialized palliative care + an a palliative approach. Emphasis is placed upon goals of care conversations as the primary means to integrate a palliative approach to care for elders.
Palliative care beyond cancer. Julia Addington-Hall. I Technical Conference about the Strategy in Palliative Care in The Nacional Health System of Spain. (Madrid, Ministry of Health and Consumer Affairs, 2008)
Table of TablesS. No.ContentsPage No.Table 5-1Name.docxdeanmtaylor1545
Table of Tables
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Contents
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Table 5-1
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Table 5-2
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Table 5-3
Name of the table
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Table 5-4
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Table 5-5
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Table 5-6
23
Table 5-7
24
Table 5-8
25
Table 5-9
25
Table 5-10
26
Table 5-11
26
List of Appendixes
No.
Contents
Page No.
Appendix A
Questionnaire
43
Appendix B
Consent Form
44
Appendix C
Declaration Form with your signature
List of Abbreviations
All of the following abbreviations are to be taken in context of the study
A
B
C
Palliative care
terminal illness
Abstract
Background: Palliative care clinical nurse specialists play an important role in specialist palliative care. Nurses perceive palliative care to be the most stressing facet of nursing. This is because it is emotionally draining to see a patient experience immense pain due to the inevitability of their death. Despite the view that palliative care is emotionally straining, it improves the quality of life of patients with terminal illnesses, such as cancer. This form of care also assists families of patients diagnosed with life-threatening ailments or organ failures. This is because palliative care involves early identification, and impeccable evaluation and curing of physical and emotional pain associated with chronic diseases.
Aim of the study: The purpose of this study was to assess nurses’ knowledge, attitude and practices about palliative care, determine the effect of the training program about palliative care on quality of nursing care and Identify factors affecting quality of nurses’ preparedness to practice palliative care in oncology units at King Abdullah specialized children hospital in Riyadh, Saudi Arabia
Subjects and methods: cross sectional study was used for conducting the study, A convenience sample nursing were included from five oncology units
Data collected through; demographic characteristic and PC knowledge and attitude .
Results:
Conclusion:
Chapter One
Introduction
Introduction
Everyone is mortal; hence, death is an inevitable phenomenon that affects every person across the globe. Nurses play a critical role in the beginning and ending of individuals’ lives as they are present at birth and dying moments. Many nurses play a vital role in caring for individuals who are in their final days on the world. As such, nurses perceive palliative care to be the most stressing facet of nursing. This is because it is emotionally draining to see a patient experience immense pain due to the inevitability of their death. Despite the view that palliative care is emotionally straining, it improves the quality of life of patients with terminal illnesses, such as cancer. This form of care also assists families of patients diagnosed with life-threatening ailments or organ failures. This is because palliative care involves early identification, and impeccable evaluation and curing of physical and emotional pain.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
A Palliative Approach in Residential Care Settings (March 2014)Joan Trinh Pham
A basic presentation presentation on the topic of applying a palliative approach to residential care settings for elders + their families. It covers a review of palliative care + terminology then distinguishing between specialized palliative care + an a palliative approach. Emphasis is placed upon goals of care conversations as the primary means to integrate a palliative approach to care for elders.
Palliative care beyond cancer. Julia Addington-Hall. I Technical Conference about the Strategy in Palliative Care in The Nacional Health System of Spain. (Madrid, Ministry of Health and Consumer Affairs, 2008)
Table of TablesS. No.ContentsPage No.Table 5-1Name.docxdeanmtaylor1545
Table of Tables
S. No.
Contents
Page No.
Table 5-1
Name of the table
18
Table 5-2
Name of the table
19
Table 5-3
Name of the table
20
Table 5-4
21
Table 5-5
22
Table 5-6
23
Table 5-7
24
Table 5-8
25
Table 5-9
25
Table 5-10
26
Table 5-11
26
List of Appendixes
No.
Contents
Page No.
Appendix A
Questionnaire
43
Appendix B
Consent Form
44
Appendix C
Declaration Form with your signature
List of Abbreviations
All of the following abbreviations are to be taken in context of the study
A
B
C
Palliative care
terminal illness
Abstract
Background: Palliative care clinical nurse specialists play an important role in specialist palliative care. Nurses perceive palliative care to be the most stressing facet of nursing. This is because it is emotionally draining to see a patient experience immense pain due to the inevitability of their death. Despite the view that palliative care is emotionally straining, it improves the quality of life of patients with terminal illnesses, such as cancer. This form of care also assists families of patients diagnosed with life-threatening ailments or organ failures. This is because palliative care involves early identification, and impeccable evaluation and curing of physical and emotional pain associated with chronic diseases.
Aim of the study: The purpose of this study was to assess nurses’ knowledge, attitude and practices about palliative care, determine the effect of the training program about palliative care on quality of nursing care and Identify factors affecting quality of nurses’ preparedness to practice palliative care in oncology units at King Abdullah specialized children hospital in Riyadh, Saudi Arabia
Subjects and methods: cross sectional study was used for conducting the study, A convenience sample nursing were included from five oncology units
Data collected through; demographic characteristic and PC knowledge and attitude .
Results:
Conclusion:
Chapter One
Introduction
Introduction
Everyone is mortal; hence, death is an inevitable phenomenon that affects every person across the globe. Nurses play a critical role in the beginning and ending of individuals’ lives as they are present at birth and dying moments. Many nurses play a vital role in caring for individuals who are in their final days on the world. As such, nurses perceive palliative care to be the most stressing facet of nursing. This is because it is emotionally draining to see a patient experience immense pain due to the inevitability of their death. Despite the view that palliative care is emotionally straining, it improves the quality of life of patients with terminal illnesses, such as cancer. This form of care also assists families of patients diagnosed with life-threatening ailments or organ failures. This is because palliative care involves early identification, and impeccable evaluation and curing of physical and emotional pain.
The course of death and dying has changed tremendously in the past.docxarnoldmeredith47041
The course of death and dying has changed tremendously in the past few decades because of social and technological advances. Increases in average life expectancy due to advances in medical science and technology (National Center for Health Statistics, 2010) have influenced our beliefs and attitudes about life and death. The course of illness and dying has changed; at one time, the onset of illness and subsequent death from certain illnesses was sudden and rapid, but now the typical death may be more prolonged. The place where death occurs has moved from the home or community to the hospital, nursing home, or institutional setting. These changes have posed enormous challenges in end-of-life and palliative care.
PALLIATIVE CARE
Palliative care is an interdisciplinary care model that focuses on the comprehensive management of physical, psychological, and existential distress. It is defined as “the active total care of patients whose disease is not responsive to curative treatment.” Control of pain and other symptoms and psychological, social, and spiritual problems is paramount. “The goal of palliative care is the achievement of the best possible quality of life for patients and their families” (World Health Organization [WHO], 1990, p. 7). Palliative care aims to improve the patient's quality of life by identifying physical, psychosocial, and spiritual issues while managing pain and other distressing symptoms. Palliative care “affirms life and regards dying as a normal process; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated” (WHO, 2004, p. 3).
The palliative care model applies throughout the entire course of illness and attempts to address the physical, psychosocial, and spiritual concerns that affect both the quality of life and the quality of dying for patients with life-limiting illnesses at any phase of the disease. It includes interventions that are intended to maintain the quality of life of the patient and family. Although the focus intensifies at the end of life, the priority to provide comfort and attend to the patient's and family's psychosocial concerns remains important throughout the course of the illness. In the model's ideal implementation, patient and family values and decisions are respected, practical needs are addressed, psychosocial and spiritual distress are managed, and comfort care is provided as the individual nears the end of life.
Palliative medicine is the medical specialty dedicated to excellence in palliative care. Palliative care specialists, including social workers, typically work on teams and are involved when patients’ disease is advanced, their life expectancy is limited, and medical and psychosocial concerns become complex and more urgent. In practice, these problems ofte.
The course of death and dying has changed tremendously in the past.docxrtodd643
The course of death and dying has changed tremendously in the past few decades because of social and technological advances. Increases in average life expectancy due to advances in medical science and technology (National Center for Health Statistics, 2010) have influenced our beliefs and attitudes about life and death. The course of illness and dying has changed; at one time, the onset of illness and subsequent death from certain illnesses was sudden and rapid, but now the typical death may be more prolonged. The place where death occurs has moved from the home or community to the hospital, nursing home, or institutional setting. These changes have posed enormous challenges in end-of-life and palliative care.
PALLIATIVE CARE
Palliative care is an interdisciplinary care model that focuses on the comprehensive management of physical, psychological, and existential distress. It is defined as “the active total care of patients whose disease is not responsive to curative treatment.” Control of pain and other symptoms and psychological, social, and spiritual problems is paramount. “The goal of palliative care is the achievement of the best possible quality of life for patients and their families” (World Health Organization [WHO], 1990, p. 7). Palliative care aims to improve the patient's quality of life by identifying physical, psychosocial, and spiritual issues while managing pain and other distressing symptoms. Palliative care “affirms life and regards dying as a normal process; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated” (WHO, 2004, p. 3).
The palliative care model applies throughout the entire course of illness and attempts to address the physical, psychosocial, and spiritual concerns that affect both the quality of life and the quality of dying for patients with life-limiting illnesses at any phase of the disease. It includes interventions that are intended to maintain the quality of life of the patient and family. Although the focus intensifies at the end of life, the priority to provide comfort and attend to the patient's and family's psychosocial concerns remains important throughout the course of the illness. In the model's ideal implementation, patient and family values and decisions are respected, practical needs are addressed, psychosocial and spiritual distress are managed, and comfort care is provided as the individual nears the end of life.
Palliative medicine is the medical specialty dedicated to excellence in palliative care. Palliative care specialists, including social workers, typically work on teams and are involved when patients’ disease is advanced, their life expectancy is limited, and medical and psychosocial concerns become complex and more urgent. In practice, these problems ofte.
Fears and Health Needs of Patients with Diabetes A Qualitative Re.docxmglenn3
Fears and Health Needs of Patients with Diabetes: A Qualitative Research in Rural Population
Maria Papaspurou,1 Vasiliki C. Laschou,2 Paraskevi Partsiopoulou,3 Evangelos C. Fradelos,4 Christos F. Kleisiaris,5 Malamati A. Kalota,6 Anna Neroliatsiou,7 and Ioanna V. Papathanasiou8
Author informationArticle notesCopyright and License informationDisclaimer
This article has been cited by other articles in PMC.
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Abstract
Introduction:
Insulin-dependent patients are individuals with chronic disease who are well adapted to living and dealing with any health needs and fears arising. An important aspect in the process of adaptation to chronic illness is the provision of nursing care in the early stages of the disease, because this contributes to its acceptance and the early identification and management of potential complications.
Purpose:
To investigate the health needs and self-management problems faced by patients with diabetes daily, especially those who use insulin. Furthermore, purpose of this study was to investigate the fears experienced by patients in the early stage of the disease, but also in its subsequent development and to study possible differences between sexes.
Methodology:
This is a qualitative study, using interpretative phenomenological approach. Fifteen (nine women and six men) insulin-dependent patients, recounted their personal fears and their needs, through semi-structured interviews, which took place in Central Greece. The method used for processing the results is the Mayering one.
Results:
The analysis of the narratives showed that patients have a variety of fears and needs associated with the diagnosis, treatment, expected consequences, prognosis and everyday life in the management of the disease. Most patients express the concept of need as desire. Care needs, psychological support and education to recognize and prevent hypoglycemia.
Conclusions:
Insulin-dependent patients express fears and needs in their daily lives. Nurses providing care aimed at enhancing the level of health, while putting self-care information and training them. Patients want the nurse next to them, so that information is continuous and permanent.
Keywords: diabetes mellitus, fears, health needs, self-care, nursing care
Go to:
1. INTRODUCTION
Patients with type II diabetes, especially insulin-dependent are usually suffering from diabetes several years before the initiation of insulin therapy. Treatment of diabetes has now as a central character, the patient himself who co-decides with the physician-nurse team. The primary concern is the patient’s acceptance of the disease in the early stages and his gradual familiarization with the treatment (1).
According to International Diabetes Federation, at least 285 million people worldwide have diabetes and this number is expected to increase to 438 million by 2030, with two-thirds of all cases living in low or middle income countries (2, 3).
Apart from pharmaceutical care, the nurse also pr.
Madridge Journal of AIDS (ISSN: 2638-1958); As a result of the increased availability of antiretroviral treatment, children infected with HIV can expect to live to adulthood and even to have long, productive lives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
1. Anesthesiology Clin N Am
24 (2006) 145 – 161
Palliative Care and Pediatrics
Doralina L. Anghelescu, MDa,T,
Linda Oakes, RN, MSN, CCNSb, Pamela S. Hinds, RN, PhDc
a
Pain Management Service, Division of Anesthesia, St. Jude Children’s Research Hospital,
332 North Lauderdale, Memphis, TN 38105-2794, USA
b
Department of Patient Care Service, St. Jude Children’s Research Hospital, 332 North Lauderdale,
Memphis, TN 38105-2794, USA
c
Nursing Research, St. Jude Children’s Research Hospital, 332 North Lauderdale, Memphis,
TN 38105-2794, USA
You matter because you are and you matter to the last moment of your life. We will
do all we can, not only to help you die peacefully, but also to live until you die.
Cicely Saunders [1]
Epidemiology of death in the pediatric setting
Death in childhood is unnatural and unexpected; nevertheless, it is an un-
questionable reality. More than 500,000 children live with complex chronic con-
ditions, and approximately 55,000 children ages 0 to 19 years old die annually in
the United States [2,3]. One third of pediatric deaths occur in the neonatal period,
half occur in the first year of life, and one fourth occurs among 15- to 19-year-old
adolescents [4]. The epidemiology of childhood death is significantly different
from that of adult death. The causes of pediatric death are remarkable for their
diversity. More than 30% of deaths are caused by injuries, whereas pediatric
cancer has been identified as the cause of death in only 4% of cases. Among 5- to
14-year-old children, cancer represents the second most frequent cause of death,
whereas in the 1- to 4-year-old group, cancer represents the third most common
cause of death [4]. Approximately 2200 children and adolescents die of cancer-
related deaths each year in the United States.
This work was supported in part by American Lebanese Syrian Associated Charities.
T Corresponding author.
E-mail address: doralina.anghelescu@stjude.org (D.L. Anghelescu).
0889-8537/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.atc.2005.11.001 anesthesiology.theclinics.com
2. 146 anghelescu et al
Palliative care should be considered for a variety of complex chronic con-
ditions, even when a cure remains a possibility. Approximately one fourth of all
childhood deaths result from complex chronic conditions, defined as medical
conditions in which at least 12 months of survival is expected and that involve
either one or several organ systems severely enough to require specialty pediatric
care [5]. Conditions in which patients may benefit from palliative care include
congenital anomalies incompatible with prolonged life, chromosomal disorders,
metabolic disorders, complex chronic heart conditions, and neuromuscular con-
ditions. Cancer and AIDS add to the list of medical conditions that prompt early
palliative care interventions. Although deaths related to many pediatric cancers
show a downward trend, the number of deaths caused by noncancerous complex
chronic conditions remains fairly constant over time [5]. Four patterns of disease
progression for which palliative care is indicated have been identified [2,6,7]:
conditions for which a potentially curative treatment has failed (cancer and severe
congenital or acquired heart disease); conditions in which intensive long-term
treatment may prolong and enhance life but premature death is expected (cystic
fibrosis, HIV infection, severe immune deficiencies, and muscular dystrophy);
progressive conditions in which treatment is almost exclusively palliative but
may extend over many years (neurodegenerative diseases); and nonprogressive
neurologic conditions that result in high susceptibility to complications and pre-
mature death (cerebral palsy, extreme prematurity, and hypoxic brain injury).
Palliative care: goals and focus
The World Health Organization’s definition of palliative care emphasizes the
concept of ‘‘active total care.’’ Palliative care is the active total care of patients
whose disease is not responsive to curative treatment. Control of pain, other
symptoms, and psychologic, social, and spiritual problems is paramount. The
goal of palliative care is the achievement of the best possible quality of life for
patients and their families, consistent with their values, regardless of the location
of the patient [8,9]. The ultimate goal of pediatric palliative care is to embrace the
unique needs of the suffering child and the family as well as those of the ‘‘family
of care-givers.’’ Ideally, palliative care is an early intervention instituted at the
time of diagnosis, which proceeds throughout the course of curative therapy. In
this sense, palliative care is ‘‘about living until you die,’’ as Cicely Saunders [1],
the founder of the palliative care movement, eloquently defined it. When the
disease process is not amenable to curative interventions and extending the du-
ration of life becomes a questionable goal, the focus of care shifts to maximizing
the quality of the time spent together by the child and the family, while mini-
mizing suffering and pain. Early palliative intervention should be considered for
all patients who have potentially life-threatening conditions. In caring for cancer
patients in particular, the relevant components of palliative care should be
introduced at the time of diagnosis. Importantly, the relationship between pal-
liative care and curative care is not one of mutual exclusion; palliative care is not
the philosophy of care that replaces curative or life-extending efforts. Instead,
3. palliative care and pediatrics 147
curative therapy and therapy aimed at maximizing comfort and quality of life
care should overlap as concurrent components of care.
Principles of pediatric palliative care
The principles of pediatric palliative care are modeled after those for adult
palliative care but are adapted for the pediatric age group [8]. The core ideals
are open communication, intensive symptom management, timely access to care,
flexibility in the implementation of interventions, ethical decision making, and
attention to the quality of life of the patient, the parents, and the siblings. The
interventions are child-focused and family oriented and can be modeled to fit
‘‘any place, any time,’’ in the hospital or the home, with home-care and hos-
pice support.
The integrated model for providing palliative care for children with life-
threatening or terminal conditions, as proposed by the American Academy of
Pediatrics [9], is based on five principles: (1) respect for the dignity of patients
and families; (2) access to competent and compassionate palliative care; (3) sup-
port for the caregivers; (4) improved professional and social support for pediat-
ric palliative care; and (5) continued advancement of pediatric palliative care
through research and education [9]. Palliative care interventions should be based
on respect for the child and family’s preferences about monitoring, testing, and
treatment. Open communication between the child, the family, and the health care
team is crucial because it provides the foundation for decision making. Family
support and bereavement care must be provided during the end of life and after
the death of a child as integrated components of palliative care. The palliative
care approach is based on the understanding that a person is an indivisible entity,
a physical and spiritual being. The interventions offered within the palliative care
structure address concerns at three levels: (1) physical concerns, such as symp-
toms (pain, fatigue, dyspnea, agitation, nausea, vomiting, and pruritus); (2) psy-
chosocial concerns, which include identifying and addressing the child and
family’s fears and concerns, coping and communication skills, previous experi-
ences and expectations, and sources of and needs for bereavement support; and
(3) spiritual concerns [2]. Respite care also should be considered throughout a
child’s illness as a support measure for the family.
Symptoms and suffering at the end of life
There are a limited number of evidence-based interventions aimed at de-
creasing physical symptoms and suffering at the end of life, reflecting the paucity
of research on this topic. Interviews of parents of children who have died of
cancer reveal that children experience substantial suffering during the last month
of life. According to parental reports, 89% of the children experienced substan-
tial suffering from at least one symptom; and the most common symptoms were
fatigue, pain, dyspnea, and poor appetite [10]. This study also found that treat-
ment was seldom successful: fewer than 30% of parents reported that pain
4. 148 anghelescu et al
treatment was successful, and only 10% of parents reported that nausea and
vomiting or constipation were controlled. Suffering may result in part from the
failure of the medical team to recognize it, as suggested by the discordance
between parental reports and physician assessments. Other studies also have
identified difficulties and limited success in managing pain for children with
various chronic conditions at the end of life [11,12].
Suffering among parents and siblings
During the end-of-life period and after the death of a child, palliative care
should include family support care and bereavement care. Psychologic and
physical distress is common among parents and siblings after the death of a
child. Psychologic distress, reported as depression, feelings of grief, guilt, or an-
xiety, is common, as are elements of physical suffering such as insomnia, head-
aches, and musculoskeletal pain. In one descriptive study [13], parents who
provided home care for their dying child reportedly experienced better psycho-
logic adjustment than parents whose child died in the hospital. Allowing families
to choose their preferred location of end-of-life care (home versus hospital) is
recommended. Components of psychosocial distress reported by siblings after
the death of a child include fears, sensations of isolation, school and social
difficulties, and behavioral problems. One fourth to one third of parents report
significant marital distress, and one third of siblings report adjustment problems.
Because parents of children who have died of cancer are themselves at risk for
premature death and the degree of suffering they perceive their child to experience
affects the parents’ ability to function, the death of a child or adolescent is an issue
of societal health.
Caregiver suffering
For the health care professional, suffering for and with the sick and dying
child and the family is an integral part of caring [14]. Caregiver suffering has
a multitude of dimensions that must be addressed within the meaning and pur-
pose of palliative care. Human suffering results from a threat to the person’s
relationship with the physical and psychologic self, with others, and with a
transcendent source of meaning [15,16]. Suffering has its source in challenges
that threaten the intactness of the person as a complex physical, social, psycho-
logic, and spiritual being [15,17]. When the physical, emotional, and spiritual
demands of caregiving exceed the caregiver’s resources and suffering becomes a
threat to the caregiver’s sense of identity, integrity, and self-worth, the personal
well being of the caregiver and the quality of care will be endangered [18]. A
multitude of factors can threaten the caregiver’s integrity: powerlessness and
hopelessness in the face of suffering and death, competing demands, personal
value conflicts, misplaced guilt, a struggle to meet the expectations of being a
‘‘good’’ care provider, perceiving death as a failure to deliver ‘‘successful’’ care,
and the subsequent erosion of self-esteem. Symptoms of caregiver suffering can
5. palliative care and pediatrics 149
become manifest on a physical level (fatigue, weight changes, sleep disturbances,
and susceptibility to illness), an emotional level (fear, guilt, resentment, depres-
sion, anxiety, and feeling overwhelmed), a behavioral level (addictive behavior,
controlling behavior, avoidance, and erosion of relationships), and a spiritual
level (crisis of faith and a loss of self-worth) [14]. Strategies to address caregiver
suffering aim to preserve or recover self-integrity and to honor the integrity of
others. The first step toward healing is the acceptance and recognition of the
source and experience of suffering, which starts the dynamic process of shared
experiences and reflections. The opportunity to express oneself in discussion
forums (palliative care and ethics rounds and debriefing sessions after a child
dies) and to listen to others’ experiences of suffering help in the search for mean-
ing and significance in suffering and death.
Barriers to providing optimal pediatric palliative care
To ensure ‘‘competent, compassionate and consistent care to meet the chil-
dren’s and their families’ physical, emotional and spiritual needs,’’ the 2003 In-
stitute of Medicine Report ‘‘When Children Die’’ [4] called for the provision and
organization of family and child-centered care, the restructuring of care financ-
ing, policy reform, increased public awareness, enhanced education of health care
professionals, and research focused on palliative care. Significant barriers to the
optimal care of dying children range from the individual educational level to the
institutional and health care system level.
Pediatric care providers often lack experience in dealing with death. In a
survey of attitudes and practices regarding the care of dying children, pediatric
oncologists have reported a lack of formal education in pediatric palliative care;
only 10% of pediatric oncologists had taken formal courses in pediatric terminal
care. They also have reported a high reliance on trial and error in learning to
provide end-of-life care (91.9%), learning from colleagues in clinical practice
(85.4%), or learning from role models during their formative years [19]. Before
pediatric palliative care can evolve as a well-defined area of clinical expertise,
teaching, and research, pediatric palliative care specialists must be developed
who can take the lead as educators, clinical role models, and researchers and
who can expand educational programs to prepare all pediatric care providers
with basic competence in palliative, end-of-life, and bereavement care. The spe-
cialty of palliative care medicine is advanced by the opportunity to obtain
board certification in hospice and palliative care medicine by both physicians
and nurses.
At the institutional level, barriers to providing optimal palliative care can be
overcome by developing and implementing clinical practice guidelines, institu-
tional protocols, and procedures for palliative, end-of-life, and bereavement care.
Palliative care ideally should be provided by an interdisciplinary care team, which
could include palliative care physicians, advanced-practice nurses, social workers,
patient care coordinators, child life specialists, and chaplains. Such team inter-
ventions should promote the coordination and continuity of care.
6. 150 anghelescu et al
Other barriers to palliative care include financial and public policy limitations,
as reflected by the lack of universal health care coverage for children, the lack
of reimbursement for crucial services, and low daily reimbursement rates for
hospice care. Although two thirds of children are covered by employment-based
or other private health insurance and one fifth are covered by state Medicaid or
other public agencies, approximately 15% of children under the age of 19 have
no health insurance [4]. Patient access to palliative care and hospice care can
be hindered by factors such as eligibility restrictions (eg, a life expectancy of
6 months or less) and the family’s willingness to forgo further curative or life-
prolonging care. There are various recommendations to improve access to hos-
pice and palliative care, including enrollment criteria that are based on the
diagnosis and severity of illness, rather than on life expectancy, and reimburse-
ment for crucial services, such as palliative care consultations and counseling, as
well as bereavement services for the families.
Pain and symptom management
The importance of pain and symptom management at the end of life derives
from the high prevalence of symptoms and suffering [10,20] and the limited
success of therapeutic interventions [10]. During the last month of life, 89% of
children with cancer are reported to experience ‘‘a lot or a great deal’’ of suffering
from at least one symptom, and 51% of children suffer from three or more
symptoms. The most commonly treated symptoms are pain (76%) and dyspnea
(65%). However, pain was successfully controlled in only 27% of cases and
dyspnea in only 16% of cases [10]. These data, based on parental reports, contrast
sharply with the fact that 91% of pediatric oncologists report that they are
proficient at treating the pain of dying children [19]. Therefore, the dual nature of
our challenge is that symptom control at the end of life may be inadequate and
that providers may lack awareness of their limitations [21]. Intensive symptom
management is a priority of care and requires accurate symptom assessment,
aggressive intervention, frequent reevaluation, and flexibility in refining and
combining therapeutic modalities. Major advances have been made in the assess-
ment and control of pain in children. Misconceptions about the inability of chil-
dren to feel or remember pain, the risk of opioid addiction in children, and
the desirability of ‘‘saving the stronger medication for later’’ have been overcome
[22–24]. Several concepts and principles form the foundation of pediatric
pain management.
1. Use developmentally appropriate assessment tools to ensure the con-
sistency and accuracy of pain assessment. Behavioral pain scales are ap-
propriate for young, nonverbal, or developmentally delayed children.
Self-reporting is the gold standard for the older age group.
2. Follow a stepwise approach to the escalation of therapy, with an emphasis
on drug selection based on the intensity of pain, ranging from acet-
7. palliative care and pediatrics 151
aminophen and nonsteroidal anti-inflammatory drugs for mild pain to
opioids for moderate to severe pain.
3. Select the route of administration based on the criteria of simplicity, safety,
convenience, and effectiveness; the oral route is preferred.
4. Titrate the dose to attain pain control while minimizing side effects
and achieving a balance between satisfactory analgesia and acceptable
side effects.
5. Evaluate and treat the cause of pain concomitantly with symptomatic pain
management.
6. Determine the temporal characteristics of pain. Pain that is limited to
intermittent, brief episodes may be controlled with as-needed doses; on-
going pain is an indication for either an ‘‘around-the-clock’’ regimen or a
strategy of delivering a long-acting opioid for constant pain plus a short-
acting opioid for breakthrough episodes of pain.
7. Titrate the continuous hourly dose of opioid and the rescue doses for
breakthrough pain according to the principle that the rescue dose should
equal 50% to 200% of the hourly dose, or 5% to 10% of the total daily
opioid requirement, and therefore both parameters should be adjusted
proportionally [24,25].
8. Select specific pharmacologic interventions based on the suspected
pathophysiology of pain (eg, nociceptive pain versus neuropathic pain,
inflammatory pain, or bone pain).
9. Follow a continuum of frequent pain reassessment, intervention adjust-
ment, and assessment and treatment of side effects.
10. Multimodal interventions include nonpharmacologic modalities to com-
plement and enhance the pharmacologic tools and the use of different
classes of medications to target various pathophysiologic pathways.
11. Consider invasive treatment modalities for pain that is difficult to treat
(epidural and intrathecal catheters and neurolytic nerve blocks).
A number of factors may concur to limit the adequacy of pain control at the
end of life. Parents’ misconceptions about the risk of respiratory depression,
sedation, or addiction and practitioners’ underdosing of opioids are possible
scenarios that cause the undertreatment of pain. The distinction between the
opioid-naRve and the opioid-tolerant patient is of paramount importance when
refining pain management interventions. The recommended starting doses of
opioids are weight-based and are applicable to the opioid-naRve child, as indicated
in Table 1 [24,26–29]. This approach must be modified for the opioid-tolerant
child at the end of life. Titration to effect becomes a key strategy at the end of
life because the dosage required to achieve pain control may escalate tremen-
dously. As in adults, there is no maximum acceptable dose of opioid; the
appropriate dose is the dose that controls the child’s pain with the least side
effects. The opioid response increases linearly with the log of the dose [30]. Thus,
strategies for opioid titration recommend a dose increment of 30% to 50% to
improve analgesia significantly for patients in moderate to severe pain [24,25].
8. 152 anghelescu et al
Table 1
Analgesics for children
Drug classification Medication Route and dosagea Comment
Opioids Morphine PO: 0.15–0.3 mg/kg q 4 h Initial doses for opioid-
Intermittent IV: 0.1 mg/kg q naRve children; titration to
3–4 h effect is often required for
Continuous IV infusion: any opioid
0.03–0.06 mg/kg/h with an
initial bolus of 0.05 mg/kg
Hydromorphone Intermittent IV bolus:
0.015 mg/kg q 4–6 h
Fentanyl Intermittent IV bolus:
1–2 mg/kg
Continuous IV infusion:
1–3 mg/kg/hr
Oxycodone PO: 0.1 mg/kg q 4 h
NSAIDs Acetaminophen PO: 15 mg/kg q 4 h Limited anti-inflammatory
(maximum 1000 mg/dose); effect
maximum of 90 mg/kg/d in
older children, 60 mg/kg/d
in younger children
(or 4000 mg/d)
Naproxen PO: 5 mg/kg q 8–12 h; Side effects: anti-platelet,
maximum dose of gastritis, renal toxicity
500 mg/dose or 1000 mg/d
Ibuprofen PO: 5–10 mg/kg q 6–8 h;
maximum dose of 800 mg/
dose or 3200 mg/d
Ketorolac IV: 0. 5 mg q 6 h; limit to
48–72 h
Neuropathic Gabapentin PO: 5 mg/kg or 100–300 mg Side effects: dizziness,
co-analgesics up to 70 mg/kg/d or 1200 mg ataxia, somnolence,
TID fatigue
Amitriptyline PO: 0.1 mg/kg up to Side effects: dizziness,
1 mg/kg/d once per day somnolence, dry mouth,
at bedtime cardiac dysrhythmias
Abbreviations: IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug; PO, oral; TID, three
times per day.
a
Doses are for children older than 6 months of age.
Experts report the need for high doses of opioids in pediatric palliative care
[24,31,32], with doses of morphine as high as 500 mg/kg/h for children with
terminal cancer [33].
The selection of pharmacologic interventions for pain is dictated by the in-
tensity of pain, with consideration of the pathophysiologic mechanisms involved
in the specific clinical situation and the child’s comorbidities and opioid history
(side effects and preferred route). For mild pain, acetaminophen or nonsteroidal
anti-inflammatory drugs are used as the first line of therapy. Acetaminophen
has the advantage of not causing gastrointestinal, renal, or platelet function side
9. palliative care and pediatrics 153
effects, but its antipyretic action may mask fever in neutropenic patients. Non-
steroidal anti-inflammatory drugs should be considered the agents of choice for
bone pain (primary or metastatic bone tumors and leukemic infiltrates); however,
they are contraindicated in children with thrombocytopenia, and their use may be
limited by pharmacologic interactions with chemotherapeutic agents. Although
selective cyclooxygenase-2 inhibitors have a better side-effect profile, they have
not been studied sufficiently in the pediatric population [21]. If codeine is used
for mild pain, the practitioner must consider that 10% of whites lack the enzyme
that metabolizes codeine to its active form, morphine, and therefore these patients
will not experience the analgesic effect [34]; furthermore, the incidence of nau-
sea, vomiting, and constipation may be higher than that caused by oxycodone or
hydrocodone [21,35].
Morphine is an effective opioid for the treatment of moderate to severe noci-
ceptive pain and is the gold standard with which all other opioids are compared.
Pharmacokinetics studies suggest that younger children, when given an equiv-
alent weight-based dose, are likely to have significantly lower plasma levels of
morphine and its metabolites; therefore, a starting dose of oral morphine of 1.5 to
2 mg/kg/d and a regimen of sustained-release oral morphine at 8-hour intervals,
rather than the traditional twice-per-day regimen, is recommended for children
[27,36]. The recommended pediatric dose for intravenous morphine is 0.02 to
0.03 mg/kg/h. However, for infants in the first 3 months of life, morphine doses
should be reduced by 25% to 30% because of the delayed clearance of opioids in
this age group. [27]. For the child who has a pattern of continuous pain with
intermittent exacerbation, morphine offers the advantage of several sustained-
release preparations, some of which are available in capsules that can be opened
and sprinkled on food or administered through a feeding tube. The immediate-
release morphine solution can be concentrated to a maximum of 20 mg/mL,
which makes it convenient for administration as sublingual drops for the child
who is unable to swallow at the end of life [21].
If unacceptable side effects (pruritus, dysphoria, or myoclonus) occur with
morphine, an alternative opioid may be given using equianalgesic doses (Table 2)
[30,37]. A hydromorphone-to-morphine equianalgesic ratio of 6 to 1 has been
determined in a population of bone marrow transplant patients who had muco-
sitis and were receiving patient-controlled analgesia [38]. In the palliative care
setting, hydromorphone has the advantage that it can be administered subcuta-
Table 2
Opioid equianalgesic doses
Equianalgesic dose (mg)
Drug IV or IM PO
Morphine 10 30
Hydromorphone 1.5 7.5
Fentanyl 0.1–0.2 Not available
Oxycodone Not available 15–30
Abbreviations: IM, intramuscular; IV, intravenous; PO, oral.
10. 154 anghelescu et al
neously because of its high potency and high aqueous solubility. Fentanyl is an
attractive alternative opioid for pain control at the end of life because it has
unique routes of administration, in addition to the traditional intravenous route.
Oral transmucosal fentanyl has established indications in adult cancer palliative
care for control of breakthrough pain [39]. The risks of hypoventilation, oxygen
desaturation, and nausea and vomiting may limit the safety of its use in the
pediatric population. Transdermal fentanyl has been evaluated for its usefulness,
feasibility, and tolerability in a small study of children with cancer pain [40]. This
modality of opioid delivery is advantageous for treating stable levels of chronic
pain at the end of life, and it offers the convenience of application only once
every 72 hours. Nevertheless, it lacks flexibility and titratability because of the
12- to 16-hour interval necessary to reach steady-state plasma concentrations
and the delayed dissipation of effect after removal of the patch because of con-
tinued absorption from the subcutaneous reservoir. It can be useful for back-
ground opioid delivery, while the need for rescue doses is met by using short-acting
oral opioids.
Opioid rotation is used to gain some analgesic benefit by taking advantage
of the incomplete cross-tolerance between opioids. The indications for opioid
rotation are dose-limiting toxicity (delivery of adequate analgesia is limited by
side effects) or the development of tolerance that prevents adequate pain control
by dose escalation. The administration of 100% of the equianalgesic dose is
unnecessary when rotating opioids and may lead to unacceptable side effects or
overdose [30,37]. For opioids with short half-lives, the conversion dose may be
approximately 50%, whereas for conversion to methadone, the required dose may
be only 10% to 20% of the equianalgesic dose of the opioid used previously [41].
It is essential to anticipate and control opioid-related side effects to avoid
adding to the patient’s discomfort and suffering. Interventions to control such
symptoms are presented in Table 3 [28,37,42,43]. Patients may develop some
degree of tolerance to sedation, pruritus, nausea, and vomiting; however, children
do not develop tolerance to constipation. A bowel regimen should be initiated at
the time of treatment with opioids, usually with a stool softener such as sodium
docusate in combination with a stimulant such as senna. Additional factors such
as immobility and poor fluid and dietary intake may contribute to constipation,
and interventions to attenuate them should be considered, if possible [21,44].
Pruritus may be treated with antihistaminic drugs or low-dose naloxone infusion
or by changing to another opioid. Sedation and somnolence can be bothersome
side effects of opioids and are controllable with both dextroamphetamine and
methylphenidate [21]. Multimodal approaches that combine opioids with other
analgesics (nonsteroidal anti-inflammatory drugs, anticonvulsants, and anti-
depressants) and with nonpharmacologic interventions (Box 1) should be con-
sidered in providing optimal pain relief with fewer side effects.
Several principles guide the therapeutic approach to nausea and vomiting:
(1) therapy should be mechanism-oriented; (2) the dose regimen of the first-line
drug should be optimized as tolerated; (3) combination therapy offers the benefit
of different modes of action [24]; and (4) nonpharmacologic approaches should
11. palliative care and pediatrics 155
Table 3
Pharmacologic management of symptoms other than pain
Symptom Medication Route and dosage
Dyspnea Glycopyrrolate PO: 40–100 mg/kg/dose TID or QID
IV: 4–10 mg/kg/dose q 3–4 h
Opioids See Table 1
Anxiety, agitation, Lorazepam PO or IV: 0.03–0.2 mg/kg q 4–6 h up to 2 mg/dose
or delirium Midazolam IV: 0.025–0.05 mg/kg q 2–4 h
Pentobarbital IV: 0.5–1 mg/kg, repeated q 5–10 min until desired
effect
Opioids See Table 1
Nausea Ondansetron PO: 0.2 mg/kg q 8 h up to 8 mg/dose
IV: 0.10–0.45 mg/kg q 8 h up to 8 mg/dose
Lorazepam See anxiety above
Promethazine PO or IV: 0.25–0.5 mg/kg q 4–6 h, with maximum
50 mg/dose
Dexamethasone PO or IV: 0.1–0.2 mg/kg initially; then up to
1–1.5 mg/kg/day divided into doses q 6 h
Metoclopramide PO or IV: 0.1 mg/kg up to 1–2 mg/kg q 6 h, with
maximum 50 mg/dose
Diphenhydramine PO or IV: 0.5–1 mg/kg q 4–6 h, with maximum
50 mg/dose
Hydroxyzine PO: 0.5–1 mg/kg q 4–6 h
Pruritus Diphenhydramine See nausea above
Hydroxyzine See nausea above
Naloxone IV continuous infusion: 0.25 mg/kg/h; titrate up to
1 mg/kg/h
Constipation Senna PO: 10–20 mg/kg or BID
Docusate PO: 5 mg/dose (3–12y old) or 5–15 mg/dose ( N 12y old)
BID or TID
Bisacodyl PO: 5–10 mg/day (3–12y), 5–15 mg/day ( z12y)
Naloxone PO: 1–3 mg TID, titrated to a maximum of 12 mg BID
Excessive sedation Methylphenidate PO: 0.3 mg/kg or 10–20 mg prior to breakfast and
lunch; increase the dose up to 2 mg/kg/d
Abbreviations: BID, twice per day; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug;
PO, oral; QID, four times per day; TID, three times per day.
be included in the multimodal intervention [21]. Nausea and vomiting have
multiple causes and contributing factors in the child receiving palliative care.
Therapeutic interventions should be selected on the basis of the corresponding
mechanism of action, and should target more than symptomatic relief, if possi-
ble. Nausea and vomiting can be result from intestinal obstruction caused by
tumor invasion or by impaction and chronic constipation. Opioid treatment,
chemotherapy, and radiation therapy contribute to nausea and vomiting. For
symptoms that are an expression of increased intracranial pressure, dexametha-
sone may be beneficial. If triggered by movement, symptoms may respond to an
anticholinergic-like scopolamine. Nausea and vomiting related to gastric stasis
may respond to prokinetic agents such as metoclopramide. Anticipatory vomiting
and anxiety-induced emesis are best treated with a benzodiazepine (eg, lor-
azepam). Ondansetron and other 5-hydroxytryptamine antagonists are effective
12. 156 anghelescu et al
Box 1. Nonpharmacologic approaches to pain management
Physical comfort measures
Acupuncture
Heat and cold
Massage
Pacifier
Rocking
Transcutaneous nerve stimulators
Other
Meditation and prayer
Music and art therapy
Behavioral and cognitive techniques
Art and play therapy
Biofeedback
Controlled breathing, eg, blowing bubbles
Desensitization
Distraction
Guided imagery
Hypnotherapy
Modeling
Relaxation
Thought stopping
for nausea and vomiting in patients who have advanced cancer. Antihistamines
and phenothiazines are additional options.
Anxiety and depression are prevalent among children at the end of life [10].
Anxiety should be addressed by offering a caring, openly supportive environ-
ment. Agitation and delirium require the consideration of potentially reversible
causes, including pain, renal and hepatic failure, drug toxicity, sepsis, hypoxia,
and brain metastases. The prolonged administration of benzodiazepines may
be associated with a decrease in anxiolytic effect and cumulative psychomotor
impairment; therefore, the recommendation is for short-term or intermittent use
[21,45]. In the context of terminal restlessness and agitation at the end of life,
the option of terminal sedation may be considered, with the intent to ensure com-
fort [21,24].
Dyspnea or ‘‘air hunger’’ is a common source of suffering at the end of life
[10] and is intensely distressing to the child and the parents. A thorough eval-
13. palliative care and pediatrics 157
uation of the underlying mechanism should direct the therapeutic interventions.
The most frequent cause of respiratory distress in pediatric cancer patients is
pulmonary metastases. Contributory reversible factors such as pneumonia, pleu-
ral effusion, or volume overload should be considered and addressed with anti-
biotics, thoracentesis, or diuresis, respectively. Beneficial supportive treatments
include supplemental humidified oxygen for comfort and either systemic or in-
haled opioids [46,47].
Fatigue is the most common symptom experienced by children and adoles-
cents dying of cancer [10,48]. Treatment should be targeted toward the correction
of underlying causes, such as anemia, infection, pain, malnutrition, metabolic
abnormalities, cardiac, renal, or hepatic compromise, or disrupted sleep [49,50].
Prioritizing the activities of daily living, avoiding nonessential activities, and
careful planning for social interactions are useful strategies for families and health
care providers when attempting to conserve the child’s energy. It also is helpful
for family members to learn that fatigue can be an emotional or mental tiredness,
rendering the dying child or adolescent unable to interact in a social situation,
respond with expected emotions, or retain new information [49,51]. Altered sleep
patterns (such as prolonged naps or disrupted sleep) often accompany fatigue as
do negative thoughts, sadness, or even depression [52].
Multiple distressing and burdensome symptoms that occur together are ref-
erred to as symptom clusters. Sleep deprivation, pain, and anxiety tend to be
present simultaneously in pediatric oncology patients and constitute a symptom
cluster. Diminishing one symptom in the cluster may effectively diminish other
symptoms in the same cluster [53]. The symptom management plan of care
should be individualized, acceptable to the child’s family, flexible, based on the
most current research and evidence, and include both pharmacologic and non-
pharmacologic interventions. Specific nonpharmacologic interventions should
be selected for children according to the type of symptom, the child’s age or
cognitive level, and whether the intervention is focused on modifying the child’s
sensory perception, behavior, or thoughts and coping abilities.
Communication at the end of life
Useful, effective and sensitive communication involving the terminally ill
child and family and health care providers regarding the child’s prognosis, care
options, and potential end-of-life experiences is critical for maintaining trusting
relationships that will be essential for preventing or diminishing the child and
family’s suffering. In several reports, parents of terminally ill children describe
their perceptions of uncaring and insufficient communication from health care
professionals and link that communication with their own lingering regrets and
emotional distress [11,54–56].
Parents of terminally ill children tend to maintain hope for their child’s sur-
vival, even when they have been told by trusted professionals that their child’s
death is certain. When this need to maintain hope is respected by the health care
professionals, parents tend to be more willing to participate in end-of-life care
14. 158 anghelescu et al
decision making and to report higher satisfaction with end-of-life care [54]. Cli-
nicians experienced with pediatric end-of-life care generally recommend that
terminally ill children be informed about their prognosis because open com-
munication can help to diminish certain fears [2,57–60]. Children differ in the
amount and detail of information that they desire and a careful assessment of
what information is preferred needs to be ongoing. Effective, compassionate
communication with the terminally ill child and the family may be the most
significant contribution that a health care professional can make to facilitate a
family’s adjustment to living without their child [9,55].
Summary
Such a systematic approach to symptoms and suffering, described step by
step in a problem-based approach, is insufficient and less than ideal, even when
it is based on good clinical evidence and sound science. It can only become
meaningful and effective through a process of reintegration in which the patient’s
goals for care and ‘‘the big picture’’ are constantly reevaluated. Goal-oriented
care directs decision making toward integrated therapies and interventions that
keep the child in the center as a whole human being, rather than the isolated
symptoms. In this respect, pediatric palliative care involves conceptually a pro-
cess of deconstruction into a series of discrete problems, only to reconstruct a
holistic approach by which all dimensions, physical, psychosocial, and spiritual,
are integrated in an attempt to relieve suffering and to preserve dignity, meaning,
and value of life until the last moment.
References
[1] Saunders C. Care of the dying: 1. the problem of euthanasia. Nurs Times 1976;72(26):1003 – 5.
[2] Himelstein BP, Hilden JM, Boldt AM, et al. Pediatric palliative care. N Engl J Med 2004;
350(17):1752 – 62.
[3] Arias E, MacDorman MF, Strobino DM, et al. Annual summary of vital statistics–2002.
Pediatrics 2003;112(6 Pt 1):1215 – 30.
[4] Field M, Behrman R. When children die: improving palliative care and end-of-life care for
children and their families. Washington (DC)7 National Academies Press; 2003.
[5] Feudtner C, Hays RM, Haynes G, et al. Deaths attributed to pediatric complex chronic
conditions: national trends and implications for supportive care services. Pediatrics 2001;
107(6):E99 – 103.
[6] Hynson JL, Sawyer SM. Paediatric palliative care: distinctive needs and emerging issues.
J Paediatr Child Health 2001;37(4):323 – 5.
[7] Goldman A. ABC of palliative care: special problems of children. BMJ 1998;316(7124):49 – 52.
[8] Levetown M. Compendium of pediatric palliative care: Children’s International Project on
Palliative/Hospice Services (ChIPPS). Alexandria (VA)7 National Hospice and Palliative Care
Organization; 2000.
[9] American Academy of Pediatrics Committee on Bioethics and Committee on Hospital Care.
Palliative care for children. Pediatrics 2000;106(Pt 1):351 – 7.
15. palliative care and pediatrics 159
[10] Wolfe J, Grier HE, Klar N, et al. Symptoms and suffering at the end of life in children with
cancer. N Engl J Med 2000;342(5):326 – 33.
[11] Contro N, Larson J, Scofield S, et al. Family perspectives on the quality of pediatric palliative
care. Arch Pediatr Adolesc Med 2002;156(1):14 – 9.
[12] Hunt AM. A survey of signs, symptoms and symptom control in 30 terminally ill children.
Dev Med Child Neurol 1990;32(4):341 – 6.
[13] Mulhern RK, Lauer ME, Hoffmann RG. Death of a child at home or in the hospital: subsequent
psychological adjustment of the family. Pediatrics 1983;71(5):743 – 7.
[14] Rushton C. The other side of caring: caregiver suffering. In: Carter B, Levetown M, editors.
Palliative care for infants, children, and adolescents. Baltimore (MD)7 The Johns Hopkins Uni-
versity Press; 2004. p. 220 – 46.
[15] Kane JR, Hellsten MB, Coldsmith A. Human suffering: the need for relationship-based re-
search in pediatric end-of-life care. J Pediatr Oncol Nurs 2004;21(3):180 – 5.
[16] Brenneis JM. Spirituality and suffering. In: Parris WC, editor. Cancer pain management. Boston7
Butterworth-Heinemann; 1997. p. 551.
[17] Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982;306(11):
639 – 45.
[18] Rushton CH. The baby K case: ethical challenges of preserving professional integrity. Pediatr
Nurs 1995;21(4):367 – 72.
[19] Hilden JM, Emanuel EJ, Fairclough DL, et al. Attitudes and practices among pediatric on-
cologists regarding end-of-life care: results of the 1998 American Society of Clinical Oncology
survey. J Clin Oncol 2001;19(1):205 – 12.
[20] Collins JJ, Byrnes ME, Dunkel IJ, et al. The measurement of symptoms in children with cancer.
J Pain Symptom Manage 2000;19(5):363 – 77.
[21] Wolfe J, Friebert S, Hilden J. Caring for children with advanced cancer integrating pallia-
tive care. Pediatr Clin North Am 2002;49(5):1043 – 62.
[22] Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia
and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326(1):1 – 9.
[23] Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during
subsequent routine vaccination. Lancet 1997;349(9052):599 – 603.
[24] Frager G. Palliative care and terminal care of children. Child Adolesc Psychiatr Clin N Am
1997;6(4):889 – 909.
[25] Cherny NI, Portenoy RK. Cancer pain management. Current strategy. Cancer 1993;72(Suppl 11):
3393 – 415.
[26] McGrath P. Pain control. In: Doyle D, Hanks G, McDonald N, editors. Oxford textbook of
palliative medicine. 2nd edition. Oxford (UK)7 Oxford University Press; 1998. p. 1013 – 28.
[27] Collins J. Palliative care and the child with cancer. Hematol Oncol Clin North Am 2002;16:
657 – 70.
[28] Weisman S. Supportive care in children with cancer. In: Berger A, Portenoy RK, Weissman DE,
editors. Principles and practices of supportive oncology. Philadelphia7 Lippincott-Raven; 1998.
p. 845 – 52.
[29] Anghelescu D, Oakes L. Working toward better cancer pain management for children. Cancer
Pract 2002;10(Suppl 1):S52–7.
[30] Yaster M. Clinical pharmacology. In: Schechter N, Berde CB, Yaster M, editors. Pain in infants,
children, and adolescents. 2nd edition. Philadephia7 Lippincott, Williams Wilkins; 2003.
p. 71 – 83.
[31] Hooke C, Hellsten MB, Stutzer C, et al. Pain management for the child with cancer in end-of-life
care: APON position paper. J Pediatr Oncol Nurs 2002;19(2):43 – 7.
[32] Siden H, Nalewajek BS. High dose opioids in pediatric palliative care. J Pain Symptom Manage
2003;25(5):397 – 9.
[33] Collins JJ, Grier HE, Kinney HC, et al. Control of severe pain in children with terminal
malignancy. J Pediatr 1995;126(4):653 – 7.
[34] Caraco Y, Sheller J, Wood AJ. Pharmacogenetic determination of the effects of codeine and
prediction of drug interactions. J Pharmacol Exp Ther 1996;278(3):1165 – 74.
16. 160 anghelescu et al
[35] Schecter N, Weisman SJ. Management of pain in childhood cancer. In: Patt R, editor. Cancer
pain. Philadelphia7 JB Lippincott; 1993. p. 509.
[36] Hunt A, Joel S, Dick G, et al. Population pharmacokinetics of oral morphine and its glucuro-
nides in children receiving morphine as immediate-release liquid or sustained-release tablets for
cancer pain. J Pediatr 1999;135(1):47 – 55.
[37] Galloway KS, Yaster M. Pain and symptom control in terminally ill children. Pediatr Clin
North Am 2000;47(3):711 – 46.
[38] Collins JJ, Geake J, Grier HE, et al. Patient-controlled analgesia for mucositis pain in children:
a three-period crossover study comparing morphine and hydromorphone. J Pediatr 1996;129(5):
722 – 8.
[39] Payne R, Coluzzi P, Hart L, et al. Long-term safety of oral transmucosal fentanyl citrate for
breakthrough cancer pain. J Pain Symptom Manage 2001;22(1):575 – 83.
[40] Collins JJ, Dunkel IJ, Gupta SK, et al. Transdermal fentanyl in children with cancer pain:
feasibility, tolerability, and pharmacokinetic correlates. J Pediatr 1999;134(3):319 – 23.
[41] Portenoy RK. Opioid tolerance and responsiveness: research findings and clinical observations.
In: Gebhart GF, Hammond DJ, Jensen TS, editors. Progress in pain research and management.
Seattle (WA)7 JASP Press; 1994. p. 615 – 9.
[42] Berde CB, Collins JJ. Cancer pain and palliative care in children. In: Wall P, Melzack R, editors.
Textbook of pain. Edinburgh (UK)7 Churchill Livingstone; 1999. p. 967 – 89.
[43] Levetown M. Treatment of symptoms other than pain in pediatric palliative care. In: Portenoy
R, Bruera E, editors. Topics in palliative care. New York7 Oxford University Press; 1998.
p. 51 – 69.
[44] Fallon M, O’Neill B. ABC of palliative care: constipation and diarrhoea. BMJ 1997;315(7118):
1293 – 6.
[45] Barraclough J. ABC of palliative care: depression, anxiety, and confusion. BMJ 1997;315(7119):
1365 – 8.
[46] Bruera E, MacEachern T, Ripamonti C, et al. Subcutaneous morphine for dyspnea in cancer
patients. Ann Intern Med 1993;119(9):906 – 7.
[47] Bruera E, Schoeller T, MacEachern T. Symptomatic benefit of supplemental oxygen in
hypoxemic patients with terminal cancer: the use of the N of 1 randomized controlled trial.
J Pain Symptom Manage 1992;7(6):365 – 8.
[48] Kutner JS, Kassner CT, Nowels DE. Symptom burden at the end of life: hospice providers’
perceptions. J Pain Symptom Manage 2001;21(6):473 – 80.
[49] Hinds PS, Hockenberry-Eaton M, Gilger E, et al. Comparing patient, parent, and staff
descriptions of fatigue in pediatric oncology patients. Cancer Nurs 1999;22(4):277 – 88 [quiz:
288–9].
[50] National Comprehensive Cancer Network. Clinical practice guidelines in oncology v.2.2005.
Cancer related fatigue. Available at: http://www.nccn.org. Accessed January 5, 2006.
[51] Hinds PS, Hockenberry-Eaton M, Quargnenti A, et al. Fatigue in 7- to 12-year-old patients
with cancer from the staff perspective: an exploratory study. Oncol Nurs Forum 1999;26(1):
37 – 45.
[52] Hockenberry MJ, Hinds PS, Barrera P, et al. Three instruments to assess fatigue in children with
cancer: the child, parent and staff perspectives. J Pain Symptom Manage 2003;25(4):319 – 28.
[53] Hinds PS, Oakes LL, Hicks J, et al. End-of-life care for children and adolescents. Semin Oncol
Nurs 2005;21(1):53 – 62.
[54] Wolfe J, Klar N, Grier HE, et al. Understanding of prognosis among parents of children who
died of cancer: impact on treatment goals and integration of palliative care. JAMA 2000;284(19):
2469 – 75.
[55] De Graves SD, Aranda S. Exploring documentation of end-of-life care of children with cancer.
Int J Palliat Nurs 2002;8(9):435 – 43.
[56] Meyer EC, Burns JP, Griffith JL, et al. Parental perspectives on end-of-life care in pediatric
intensive care unit. Crit Care Med 2002;30(1):226 – 31.
[57] A statement from the Work Group on Palliative Care for Children of the International Work
17. palliative care and pediatrics 161
Group on Death, Dying, and Bereavement: Children, adolescents, and death; myths, realities,
and challenges. Death Stud 1999;23(5):443 – 63.
[58] Faulkner KW. Talking about death with a dying child. Am J Nurs 1997;97(6):64, 6, 8, 9.
[59] Freyer DR. Care of the dying adolescent: special considerations. Pediatrics 2004;113(2):381 – 8.
[60] Nitschke R, Meyer WH, Sexauer CL, et al. Care of terminally ill children with cancer. Med
Pediatr Oncol 2000;34(4):268 – 70.