Palliative Care and Pain Management at the End of Life ___________________________________________
After the patient’s death, members of the palliative care team should encourage the family to talk about the patient, as this promotes acceptance of the death. Explaining that a wide range of emotions is normal during the mourning process can help family members understand that experiencing these emotions is a necessary aspect of grieving. Frequent contact with fam- ily members after the loved one’s death can ensure that the family is adjusting to the loss. Referrals for psychosocial and spiritual interventions should be made as early as possible to optimize their efficacy. Bereavement Bereavement support should begin immediately with a hand- written condolence note from the clinician. Such notes have been found to provide comfort to the family [444; 445]. The physician should emphasize the personal strengths of the family that will help them cope with the loss and should offer help with specific issues. Attendance at the patient’s funeral, if possible, is also appropriate. How bereavement services are provided through a hospice/pal- liative care program vary. Programs usually involve contacting the family at regular intervals to provide resources on grieving, coping strategies, professional services, and support groups [227; 310]. When notes are sent, family members should be invited to contact the physician or other members of the healthcare team with questions. Notes are especially beneficial at the time of the first holidays without the patient, significant days for the family (patient’s birthday, spouse’s birthday), and the anniversary of the patient’s death. Bereavement services should extend for at least one year after the patient’s death, but a longer period may be necessary [6; 227].
homes showed that between 1999 and 2006, the number of hospices providing care increased from 1,850 to 2,768, and rates of nursing home hospice use more than doubled (from 14% to 33%) [447]. The care of the frail elderly in the home is burdensome, as the long disease trajectory often requires an extended need for family caregivers. In addition, the primary caregiver may be a spouse who is older than 75 years of age and may have multiple health issues. For patients in nursing facilities, care may be fragmented, and staff often lack an appropriate under- standing of pharmacology, drug addiction and dependence, management of side effects, and effective nonpharmacologic therapies [448; 449; 450]. Also, family members often have grief symptoms before the death of the patient; the most frequent grief symptom is yearning (separation distress) [451]. Thus, early psychosocial support and bereavement services for family are important. Older patients, especially those with end-stage organ disease, often have substantial comorbidities and take multiple medi- cations, both of which add to the complexity of care [104; 412; 452]. One study of patients with heart failure found that approximately 33% had COPD, 40% had diabetes, and more than 50% had coronary heart disease or hypertension [453]. With respect to multiple medications, a study found that older patients took an average of 6.5 medications and that 29% of the patients were taking a medication that was considered to be “never appropriate” [454]. Polypharmacy increases the likelihood of drug interactions, and clinicians should review the medication list and eliminate those drugs that are not providing clear benefit [452]. Knowledge of pharmacokinetics, pharmacodynamics, and pathophysiology are needed in mak- ing decisions to stop or adjust drugs [455]. Consulting with a pharmacist can be valuable. As with the overall population of patients at the end of life, pain management is also inadequate for older patients, with pain experienced by more than 50% of patients at home and as many as 80% of patients in nursing facilities [456; 457; 458]. Studies have confirmed that older patients receive less pain medication at the end of life than younger patients and that pain management is inadequate for residents of nursing facilities [459; 460; 461; 462]. The American Geriatrics Society has issued guidelines for the management of chronic pain for older patients, and physicians and nursing facility staff should become familiar with this resource and other guidelines for pain [458]. Improvement is also needed in the treatment of patients who have psychosocial symptoms, such as depression, agitation, anxiety, and loneliness [463]. Perhaps the greatest issue is the need for better palliative care for patients with dementia [103; 448; 464]. The prevalence of dementia has been reported to be 40% to 50% among persons older than 80 years of age, and many persons with dementia spend the last weeks to months of life in a nursing home [465].
PALLIATIVE CARE FOR SPECIFIC POPULATIONS
The needs of some patient populations present unique chal- lenges to the delivery of high-quality palliative care. Among these populations are older patients, including those with dementia and/or debility; children and adolescents; and patients in the critical care setting. OLDER PATIENTS AND NURSING FACILITY RESIDENTS At present, the number of residents of nursing facilities in the United States is approaching 2 million, and that number is expected to double by 2030 [1]. Older persons comprise the largest percentage of patients who receive palliative care through hospice. In 2022, 49.4% of Medicare decedents 75 to 84 years of age and 61.8% of those 85 years of age and older used hospice [1]. The majority of older individuals receive hospice care at home, but up to 25% are residents at a nursing home or residential facility at the time of death [1; 446]. A study of Medicare beneficiaries dying in nursing
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MDCA1525
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