Paul B. Bascom

Communication between physicians and surviving spouses following patient deaths

The authors evaluated the perceptions and adjustments of surviving spouses following patient deaths. Of 128 married patients dying in a university hospital in 1983, the surviving spouses of 105 (82%) were personally interviewed a year after the death. The physicians’ perspectives were recorded through chart review. Half of all spouses had had no subsequent contact with the physicians who had cared for the deceased, and 55% of spouses still had unanswered questions regarding the death a year later. Survivors of unexpected deaths were found to be at high risk for poor subsequent adjustment. Spouses with poorer adjustments consulted their own physicians more frequently, and used more alcohol and tranquilizers. The results identify areas where improvement is needed in communication with surviving spouses after patients’ deaths.

Educational agendas for interdisciplinary end-of-life curricula.

The importance of an interdisciplinary end-of-life curricula for the intensive care unit is now recognized. Educational agendas for interdisciplinary end-of-life curricula are being developed across the United States. However, the limited database on palliative care education precludes evidence-based recommendations. Through a case-based approach, the need for an interdisciplinary team is explored, including the definition of an interdisciplinary team and the step-wise incorporation of specific members, such as physicians, nurses, social workers, and the chaplain, as patient care evolves. Core competencies for end-of-life care are enumerated including the approaches to end-of-life care, ethical and legal constraints, symptom management, specific end-of-life syndromes/palliative crises, and development of communication skills for trusting relationships. Finally, four phases of ICU management of curative and comfort care are proposed: phase I, focus on checklist for transfer; phase II, focus on life-saving treatments; phase III, focus on the “whole” patient; and phase IV, focus on palliative care.

A hospital-based comfort care team: Consultation for seriously ill and dying patients

Access to hospice and palliative care services has been limited primarily to patients in the final stages of malignant terminal illness. Many have recognized the need to expand the scope of care to include other needy populations. This article describes the clinical activities of the Oregon Health Sciences University (OHSU) Comfort Care Team. This physician directed inter-disciplinary team provides consultation for any seriously ill patient with comfort care needs. There is no requirement that patients be in the final stages of a terminal illness, nor that they forego curative or life-prolonging treatments. The initial experience of this team supports the usefulness of a broader focus of care. The majority of patients referred for consultation would not have been served under a traditional palliative care model.

Clinical experiences of medical students in Oregon with dying patients.

BACKGROUND In Oregon only 31% of patients now die in acute care hospitals. This transformation carries profound implications for undergraduate medical education. METHODS Students graduating from Oregon Health Sciences University between 1996 and 1998 were surveyed regarding their direct clinical involvement in the care of dying patients. RESULTS Students had cared for substantial numbers of dying patients, and nearly all had participated in important advance planning discussions. However, student involvement had diminished markedly towards the latter stages of dying. Forty-five percent of the students had cared for two or fewer patients who died while still in the hospital. Even when patients died in the hospital, the students had rarely been present at the bedside at the time of patient death. Forty-two percent of the students had graduated having never witnessed a patient death. CONCLUSIONS The findings highlight the need to create opportunities for students to care for dying patients in settings outside the acute care hospital.

High-Dose Neuroleptics and Neuroleptic Rotation for Agitated Delirium Near the End of Life

Reason for the study: Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses. Main Findings: This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. Each patient experienced considerable sedation, though this was an acceptable side effect for the family. Each patient was transferred from the acute care hospital to a location of family preference. There they died within a week of transfer. Conclusions: Agitated delirium is a palliative care emergency. High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium. This remedy can provide the patient with a peaceful dying in a place of their choosing.

Dyspnea can be, and should be, effectively palliated with opioids.

Dear Editor: This journal recently published an article entitled ‘‘Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death?’’ My mentor and colleague, the late Dr. Miles Edwards, published an article covering similar ground back in 2005, entitled ‘‘Opioids and Benzodiazepines Appear Paradoxically to Delay Inevitable Death after Ventilator Withdrawal.’’ I was distressed to note that your recent article did not even honor Dr. Edwards with the respect of a citation, much less directly acknowledge his prior insights. Dr. Edwards was a man of singular humility and grace. I am quite certain he would have felt no distress at this oversight. At most, he might smile with avuncular understanding as a younger generation ignored the wisdom of their elders. Dr. Edwards had an extraordinary wisdom based on years spent in careful observation at the bedside. Yet, in his understated way, in his article he ventures only the following suggestion: ‘‘Palliative care physicians might consider as credible an alternative logic, that palliating dyspnea by carefully providing opioids and/or benzodiazepines should reduce work of breathing thereby protecting against premature death from fatigue.’’ The JPM article, on the other hand, speculates about the pathophysiology of dyspnea, using the ill-considered term ‘‘suffocation dyspnea.’’ This, in turn, appears to have led a journal reader to the horrifying suggestion that ‘‘perhaps from pathophysiologic inference, abandoning the practice of terminally extubating.is the most appropriate way of avoiding distress in patients who are prone to dyspnea. The avoidance of dyspnea.could outweigh the perceived benefit of treatment withdrawal to shorten the dying process and therefore the suffering.’’ In 1992 Dr. Edwards wrote of an experience with terminal extubation in a fully conscious patient. He reported that his fears of causing immediate ‘‘suffocation’’ and severe ‘‘visceral panic’’ were unfounded. He medicated the patient skillfully for dyspnea with opioids. He observed that the patient ‘‘exchanged smiles with his daughter, appeared comfortable and relaxed.and did not struggle further,’’ until inevitable death 45 minutes later. In this case report Dr. Edwards considered it ‘‘cruel’’ to delay his patient’s request to be extubated for even an additional five hours. Even as placid a man as Dr. Edwards might take umbrage at a clinical guideline that would condemn ventilated patients to a protracted cardiovascular death because of our mistaken fears of uncontrolled ‘‘suffocation dyspnea.’’ Dyspnea can be, and should be, effectively palliated with opioids. I remember Dr. Edwards’s grace and equanimity when yet another journal rejected his manuscript and his gratitude when it was finally accepted at a small journal. Dr. Edwards could have proclaimed his insights with the force of a zealot and perhaps attracted the attention of a major journal. But his humble spirit would only allow his text to read that his insights were ‘‘not new,’’ and that clinicians ‘‘might consider’’ changing their practice. Perhaps this explains why his contributions have been overlooked and ignored. Though he would be embarrassed to hear me say this, I will proclaim that Dr. Edwards’s seminal paper should be required reading for all palliative care clinicians.

Inadvertent Ophthalmic Administration of Atropine Drops in a Hospice Patient

This case report describes a patient who had atropine ophthalmic drops prescribed and dispensed by hospice to be administered sublingually as needed for control of secretions at the end of life. However, even as she stabilized and discharged from hospice, these remained on her medication list. At a subsequent hospitalization, this order was misinterpreted and the drops were ordered to be administered in both the eyes 3 times a day while in the hospital and were included in her discharge medication list. The patient experienced severe blurring of vision until the error was corrected. This case highlights the potential risks of the common practice in hospice of using alternate routes of administration for medications designed for another purpose.

At My Father's Deathbed

My sister and I sit at my father’s deathbed, as the clock ticks past midnight into yet another day of his inexorable slide into dementia. It is an easy time, unhurried, placid. We swap stories and laugh, remembering my father as he once was, not as he is now. Once upon a time he was the gentlest soul imaginable, never a harsh or cynical word, exceedingly patient, a generous listener, and a friend to all. Which made it all so bewildering when my gentle father grabbed a kitchen knife and threatened the caregiver we had hired to keep him from wandering out of his apartment at night. That midnight I raced frantically two hours down a deserted freeway to his bedside, wondering what strategy I might employ to keep him, and me, safe. I hid all the knives on a high shelf, and repeatedly coaxed him back to bed, using my credibility as his son. Inevitably he would again make a move toward the door, intent on getting somewhere else. At 4 AM, overcome with fatigue, I simply stacked furniture in front of the door, which thwarted him enough that he lost interest and returned to bed. We finally found a safe refuge for him here in this model eldercare residence. The enclosed garden and well-trained staff have allowed him to wander day or night to his heart’s content. It was the most expensive option, but I was confident that his savings would be sufficient. I knew even then that he would not have a protracted stay here. That was but eight months ago. This midnight is different. Now he has lost the capacity even to wander, betrayed by failing brain and body, unable to heed the imperative of his prodigious curiosity. This midnight when he gets restless and tries to crawl out of bed, the staff administers morphine, and he settles back to sleep. I have summoned my sister to share tonight’s vigil with me. I am saying my ‘‘goodbyes’’ now. Work beckons. Tomorrow, I will again be at the bedside of the dying, as a palliative medicine physician. This weekend I have a plane to catch, a much anticipated spring break trip to Maui with my three daughters. I am quite sure my father will not be alive when we return. My sister will stay near for the duration. My other siblings needed a few days to arrange work and travel. I assured them Dad would still be alive when they arrive. How do I know this? I am a palliative medicine physician. I have been honing my prognostic skills for 20 years. I have employed these skills repeatedly, with each difficult turn of events, as we navigated my father’s downward trajectory these last months. My ability to effectively guide these medical decisions for my father has validated my conviction that accuracy in prognostication is a fundamentally important skill for the physician. Back on that fateful midnight with the knife he was still physically strong. However, the virulence of his dementia (perhaps Lewy Body type) was apparent even then. I knew that he would not linger for years; many months, perhaps, but not years. Two months ago he could still walk, with an impulsive, shuffling gait. I took him on a walk down to a local taco stand. He moved along impatiently, eager to be free and independent again. In a moment’s inattention, I loosed my grasp of his arm and he veered off the sidewalk and tumbled into a shrub. I was able to get him to his feet with some effort. We barely made it back to the safer confines of his care home and professional caregivers. A few days later the care home sent him to the emergency room. He had seemed to favor one leg. The ER evaluation confirmed their suspicion: a nondisplaced hip fracture. I pondered the options. He had broken a hip before, a fracture sustained when he crashed his bicycle. (At age 87, less than a year before, he was still riding his bike!) Back then he still had the capacity to consent to surgery. His body recovered swiftly after surgery. His brain never did. In fact, his prior extremely aggressive behavior had its origins in a severe delirium induced from the anesthesia. I remembered the horrible bedside scene, in the immediate postoperative period, in which he struggled forcefully to climb out of bed, oblivious to all required hip precautions. We struggled to hold him down, on the verge of tying him down with restraints. To our relief, and chagrin, we discovered that all he wanted was the urinal at his bedside table. With his brain in a much diminished state, I could imagine the chaos of the postoperative care this time around. And I could see just how much function he was losing month to month. I knew that a life ending complication of his dementia would inevitably emerge before too long. The ER doctor asked me what I wanted to do. I chose to leave the hip unrepaired and had my father sent back to the care home. My siblings wondered whether they should travel out here then. But I recognized that his untreated broken hip did not mean imminent death. My father still had the strength and mental capacity to stand on his good leg and transfer to a wheelchair for meals and toileting. My demented 90-year-old grandmother lingered bedbound for three years with both

Four Essential Drugs: Differing Opinions or Heresy?

Dear Editor: Though I risk being branded a Counter-Reformer, Spanish Inquisitor, or worse, an apostate, I would like to venture some differing opinions regarding the Four Essential Drugs Needed for Quality Care of the Dying. The four drugs deemed essential by our European colleagues were morphine, midazolam, haloperidol, and an antimuscarinic drug. Some of my differing opinions may be simply personal preference or may reflect the reality of what is available and acceptable on this side of the Atlantic. Some could be examples of heresy, renouncing treatments that ‘‘everyone knows to be effective.’’ It is undisputable that an opiate should be available to dying patients. However, the choice of morphine may be based on affinity rather than on pharmacologic superiority. As a stigmatized, scorned, and misunderstood drug, morphine has much in common with palliative care. That affinity likely leads us to mistakenly invest morphine with virtues beyond those of its less stigmatized cousins, hydromorphone and oxycodone. However, the venerable Cochrane Collaborative concluded, ‘‘The current limited evidence available suggests that there is little difference between morphine and hydromorphone in terms of analgesic efficacy, adverse effect profile and patient preference.’’ Morphine is distinguished as the first opiate and is 100% natural as well. Yet we routinely cast aside other first, 100% natural drugs, such as atropine and digitalis, in favor of their pharmacologically altered, and potentially improved, cousins. I gravitate towards hydromorphone as my first choice of opiate. Hydromorphone has the virtue of potency, which helps overcome cultural barriers to aggressive opiate dosing. Nurses who might hesitate to administer 12 mg of IV morphine or 40 mg of oral morphine rarely blanch when I order 2 mg of IV hydromorphone. The choice of midazolam reflects the widespread use in Europe of continuous subcutaneous infusions by syringe driver. This method of administration is not widely available in the United States. In my hospital, midazolam is only permitted in monitored settings such as ICUs and procedural units. Lorazepam is my benzodiazepine of choice. Sublingual lorazepam is 94% bioavailable, and thus equivalent to subcutaneous administration. The choice of haloperidol may be based on its shared affinity with morphine as a stigmatized, scorned, and misunderstood drug. Chlorpromazine, the first neuroleptic, was just as effective as haloperidol in one of the few comparative studies of the pharmacologic treatment of delirium. Haloperidol is a high potency neuroleptic, and should be less sedating than chlorpromazine. Yet at the end of life, sedation may be acceptable, even desirable. Haloperidol would be expected to carry a higher risk of extrapyramidal side effects (EPS). Indeed, in one study, haloperidol was associated with EPS in 19% of delirious patients, compared to 0% in patients who received a newer, atypical antipsychotic drug. Thus, haloperidol may not be the optimal pharmacologic agent for the treatment of delirium at the end of life. At my hospital, quetiapine is less stigmatized than haloperidol, and given the lower risk of EPS and similar cost, has become my first choice for the treatment of delirium. Regarding the antimuscarinic drugs, the Cochrane Collaboration concluded that, ‘‘There is currently no evidence to show that any intervention, be it pharmacological or nonpharmacological, is superior to placebo in the treatment of death rattle. We acknowledge that in the face of heightened emotions when death is imminent, it is difficult for staff not to intervene. It is therefore likely that the current therapeutic options will continue to be used. However, patients need to be closely monitored for lack of therapeutic benefit and adverse effects.’’ Indeed, dry mouth is a prevalent and troublesome symptom afflicting the dying, which antimuscarinic drugs would only exacerbate. Given the questionable benefit and high likelihood of adverse effect, I prefer to employ calm presence when confronted with a dying patient’s noisy breathing. The consensus recommendation of an antimuscarinic drug despite a lack of evidence is an apt example of what our editor highlights as the risks of the ‘‘energy of zealotry.’’ Zealotry was an adaptive and necessary trait as we labored in the inhospitable vineyards of yesteryear, without a scientific base to guide us. Now that palliative care is broadly accepted, and there is an accumulating evidence base, it is time to recognize when mainstream medical institutions like the Cochrane Collaboration have something to teach us.

Withdrawal of Mechanical Ventilation in Neurosurgical Critical Care

Withdrawal of mechanical ventilation in the Neuro ICU should proceed in a careful, coordinated fashion. The trajectory of each individual patient will depend upon their ventilatory capacity and respiratory drive, and the likelihood of upper airway obstruction upon extubation. Patients with near apnea will die within minutes. Those with good ventilatory capacity will sustain their breathing without mechanical ventilation, prompting a subsequent discussion about maintaining life through artificial feeding. Those with impaired ventilation will require aggressive, proactive use of medication to blunt dyspnea. Opioids are the drug of choice and should be administered in anticipation of expected dyspnea. Attention to family preferences and clinician presence at the bedside are paramount.