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James condon blogJulie Bruno, AAHPM Director of Education, started the morning plenary session with a
reminder that “life happens” at preconference workshops just as it does in real life, so one
of the session speakers had to attend to a family health matter. The schedule was
therefore rearranged a bit to provide the two remaining faculty time to cover the
additional lectures. The speakers are experts and the presentation seamless.
So first off, Pat Schmidt gave her lecture on Communication, Psychosocial & Spiritual
Care. Everybody has a story to tell, and sometimes they need help, but we have to hear
and understand it for us to achieve our goal of allowing them to die with dignity and in
comfort. She listed the barriers to effective communication to help us avoid them, and
what we can do to make it better: body language, time, place, attitude. Different settings
(hospitals, SNFs, ALFs, and homes) have different cultures and ground rules to consider.
So do different patients. So do the different physicians who see each patient: the old yin-
yang symbol about how we interact as consultants is pertinent here. Communication is
not just about words; we listen not only to what is said, but how, and why – because we
want to recognize and validate emotions, and words are just not good enough.
The other IDT members can be invaluable here, because they have more training in
psychological, social, and experiential topics than physicians; Cecily Saunders was first a
social worker. The entire team is essential in helping the patient and the family deal with
the grief of illness, and death, and bereavement. Our tendency as healers is to want to fix,
to do something, but what we really need to do is just be present, listen, accept, validate,
and try to understand. It’s harder to take a spiritual history than a sexual history. Grieving
is helped y our presence, faith, noticing what’s needed, offering, doing, patience,
acceptance, and empathy – little of which we learned in medical school. The team
chaplain can be of immense help when there is spiritual pain – which may be relieved,
but sometimes worsened, by religion. Spiritual palliation is the goal; this requires
reflective listening. Communication is the foundation of our work, and all members of
the IDT play a role in the management of complex symptoms.
Next up was Lyra Sihra (yes, she told us, it rhymes) who talked about Medical, Ethical
and Legal Issues. Ethical practice follows with the four principles of autonomy,
beneficence, nonmaleficence, and justice (societal and distributive) – all discussed, as
was the principle of double effect, now being used more by courts and less by physicians,
and withdrawing treatment – on which the ethics and policy have changed; n.b.: in
medical ethics today there is no moral distinction between withholding treatment and
withdrawing it. Long discussion of Karen Quinlan, Nancy Cruzan, Terri Schiavo, and the
need for advance directives ensued.
Palliative sedation, and the new concept of “respite” palliative sedation, and whether they
are OK for existential distress, and the fine lines between this and euthanasia and
physician-assisted suicide concluded that at lease in the US, the Supreme Court has ruled
that this is a state, not a federal issue. So know your state’s law; it’s important to
understand what your courts say about what you do.
Next up was John Fullerton’s talk on Symptom Management – Part I – Nausea,
vomiting, & constipation. It was ably delivered by Lyra Sihra and used John’s slides.
Nausea plagues 40-70% of all hospice patients, and haldol is the cure unless it’s caused
by lazy stomach / autonomic dysfunction, in which case Reglan is logical; or bowel
obstruction in which case an anticholinergic to relieve the cramps is the best choice.
Treatment is targeted to the cause.
Back to Pat Schmidt, this time giving her lecture on Pain Management Part II –
Adjuvant treatments, and Methadone for Chronic Pain. Started with a Venn diagram
(three overlapping circles) of nonopioids, opioids, and adjuncts; where they all
overlapped in the center was where our patient should be, his pain benefitting from all
three. Adjuncts include antidepressants (especially tricyclics), anticonvulsants (most
effective in ‘nerve’ pain), steroids (inhibit the arachidonic cascade, reduce inflammation),
alpha-2 blockers, and NMDA antagonists (dextromethorphan, propoxyphene, methadone,
Second afternoon talk: Lyra Sihra; her own lecture this time, on Symptom Management
II – Dyspnea, Seizures, and Anorexia-cachexia. Seizures and massive hemorrhage are
the two most frightening things that families may experience when caring for the dying.
They can also do damage.
Anorexia-cachexia and the resulting fatigue and weakness is a major quality of life issue,
causing more suffering than pain or dyspnea. Etiology is unknown but is thought to be
systemic inflammation. Wasting of muscle always occurs, not always fat.
Finally, came John Fullerton’s lecture Symptomatic Management III – Delirium and
Behavioral Disorders, ably delivered by Pat Schmidt. Prevalence is very high at the end
of life: 98% of demented patients, and 85% of those who are not, have behavioral
symptoms which stress the caregiver, adding to grief, frustration, isolation, depression,
and conflicts in the caregiver’s other relationships. These behaviors are often the reason
for placing patients outside the home. Four major categories: behavioral dyscontrol
(disinhibition, euphoria, sleep and appetite disturbances); mood disorders (anxiety,
apathy, depression); psychosis (hallucinations, delusions); and agitation (aggression,
irritability, psychomotor hyperactivity). Hallucinations are usually visual and benign;
delusions may include persecution, misidentification of caregivers, perception of stealing
and abandonment, jealousy, and sexual infidelity.
Thassall, folks. It’s too late Wednesday night for me to reflect on the meaning of all this;
I’ll leave that up to you. Blog on.
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