Aleve Hospice Care of Los Angeles, Inc

11/11/2021

“I don’t know what to do doc, I wish my father had told me his wishes before he got really sick. He is now in the ICU, can’t speak for himself, and I am here trying to make the right choices for him, and answering all of my family’s questions at the same time. What is the best treatment plan for him? Please HELP!”

Unfortunately, a very common scenario that inpatient palliative care providers see almost every day. But what can be done to somehow make this less stressful to family members, especially the ones responsible for making those difficult decisions?
Moreover, it is not uncommon to see family members fighting with each other due to differences in opinions, as their loved one is lying unconscious and intubated in the ICU.

This is why it is important to talk about written advance directives with all your patients. They may vary from state to state, however they are legal in every state.

Advance directive is the general “umbrella” term that refers to documents addressing future medical care. They include:
Healthcare agent/proxy/power of attorney - A surrogate decision maker for when the patient loses capacity to make decisions.
Living will - A written document that highlights certain medical treatments that the patient would want when loses capacity to make decisions.
POLST: Physician Orders for Life Sustaining Treatment, a PORTABLE document that has medical orders to healthcare providers, used during a medical crisis when the patient is unable to communicate them.

- It is important to note that living wills are a type of advance directives, but not all advance directives are living wills.

Many healthcare providers and patients inaccurately believe that having advance directives means having a “do not treat” order. This is wrong. In fact, having advanced directives is a good guide to treat the patient the way they would want to be treated.
So, it is very important to complete the advance directives as detailed as possible, to void any future misunderstandings between providers and family members.

If one desires a do not treat “DNR” order, then they need to complete a POLST (or the state’s equivalent) form.

It is never too early to complete advance directives as tragedy can occur at any age. These can be done in the outpatient setting also. Studies have shown that most patients actually want their doctors to discuss advance care planning with them before they become ill. So please have these discussions in your clinics, and no doubt someone somewhere someday will thank you for it.

AGAIN, these documents become active ONLY when a person loses decision making capacity.

Puzant Topaljekian MD, MBA
Hospice and Palliative Medicine
Aleve HCLA

References:
Myths About Advance Directives
Myths About Advance Directives Eric Warm MD Drew A Rosielle MD
https://www.mypcnow.org/fast-fact/myths-about-advance-directives/

11/04/2021

-Myths about morphine use in hospice patients-

“I’m worried that once you start giving my mom morphine she will die..”

Does morphine really hasten death?

76 year old female has been hospitalized for severe pain. She has a history of liver cancer, and now complains of severe abdominal pain. She is refusing any interventions including blocks, and is agreeable to opioid therapy. No prior history of renal disease. Morphine is recommended for pain relief.

To be fair, not only patients and their families get scared and hesitant when “morphine” is mentioned or offered, many physicians also are afraid to offer morphine especially to patients who are frail or nearing end of life. This rises from the inaccurate belief that using morphine in this patient population has unacceptable high risk of adverse events that may lead to death.
Studies (US National Hospice Outcomes Project) and systemic reviews from multiple countries about end of life opioid use have found “no difference in survival with absolute opioid dose or change in opioid dose.” (von Gunten)

Moreover, before the respiratory drive is significantly compromised, morphine related toxicity will be evident in various ways such as confusion, drowsiness, and loss of consciousness. These signs and symptoms will help the clinician to intervene appropriately before the patient stops breathing.

Double effect vs secondary unintended consequence:
Double effect - The physician gives a treatment or medication where the potential outcome is good, KNOWING that there will CERTAINLY be an undesired secondary effect (such as death). An example of this that von Gunten uses in his article is the separation of conjoined twins, knowing that one will live and the other will die.
This “double effect” is commonly inaccurately cited with morphine use, however it does not apply, as secondary adverse consequences are UNLIKELY.

So then is it ethical to use morphine in such frail patients?
It is the intent of the treatment offered that dictates whether or not it is ethical.
- if treatment is desirable/helpful to the patient with potential good outcome (pain relief), and the potential adverse effect such as death is undesired, then it’s considered ethical.
- if the intent is undesirable/will harm the patient, and the potential outcome is bad, then it is unethical.

It is important to note that almost all medical treatments have risks and benefits (chemotherapy, etc..).

Euthanasia and assisted su***de are not examples of “double effect” as the intent in offering the treatment is to end the patients life.

So in summary, if the intent in offering morphine in the above scenario with appropriate dosing is to relieve pain and suffering, and not to cause death, then the the treatment is considered ethical, adverse secondary effects are minimal, and the risk of respiratory depression is vastly over estimated.

Puzant Topaljekian MD, MBA
Hospice and Palliative Medicine
Aleve HCLA

-references:
Morphine and Hastened Death Charles F von Gunten MD Download PDF
https://www.mypcnow.org/fast-fact/morphine-and-hastened-death/

Visit mypcnow.org for more Palliative Medicine resources.

10/28/2021

“Please doctor... it’s my grandma… don’t you know? She has always been a second mother to me.. she has stopped eating, she refuses any food, we have to help her get better!” were the words of the concerned and grieving woman over the telephone.

Her precious grandmother had been battling melanoma for a few years, which now had metastasized to the brain and lower spine, causing memory issues and making her bed bound. She was refusing to eat most of the time and had lost significant amount of weight.

The cascade of events leading to the overall decline we see in cancer patients sometimes tend to happen rather quickly, in a matter of days to weeks, especially in more aggressive forms of malignancies.

This is understandably very difficult for patients and their families to witness.

In my experience, families usually tend to have the hardest time dealing with the fact that their loved is not eating anymore. After all, the way we show love and care to them is through feeding them, wiping their mouth, and so on.. and it’s true. This is very hard to see and understand. Who wants to see their loved one starve to death, right?!

However, in advanced/end stage illnesses such as cancers, the body shifts from metabolic to sort of a catabolic state, not relying much on outside calories, appetite decreases, and the person stops asking for food. It is important to mention that at this stage, the person is not starving - starvation is when someone wants food and we don’t feed them, or they can’t eat for any reason (can’t swallow, obstruction, etc.), however in this case, food is offered, but they refuse it. Moreover, sometimes feeding them forcibly can cause more harm than good, as it makes them uncomfortable, and the risk for aspiration increases.

The best way to care for these patients at this stage is to focus on comfort and quality of life, manage their symptoms proactively, and provide support to their family members.

P. Topaljekian MD
Hospice and Palliative Medicine
Aleve HCLA

02/11/2021

We provide the best care possible, in the comfort of your own home.

02/11/2021

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It is our job to to make the most out of the journey.

09/03/2019

You are brave!

08/27/2019

While Aleve Hospice Care continues to offer high quality, compassionate hospice care, we also offer so much more. Designed to meet you wherever you are in the process of living.

03/05/2019

Palliative Care vs. Hospice Care

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Our main goal.

01/15/2019

“Don’t count the days. Make the days count.” – Muhammad Ali

At Aleve Hospice Care of Los Angeles, our main focus is to provide quality care with compassionate hearts. We are committed to our patient's and their families. If you or a loved one is looking for Hospice care, please give us a call at 818-891-1000 for more information.