Journal of palliative medicine
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By the year 2020, chronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally. While there have been consistent calls for increased palliative care involvement in the care of patients with advanced COPD, these calls should be based on empirical evidence that such an approach improves the symptom burden and poor quality of life associated with advanced COPD. Rather than reviewing the traditional treatments of airflow obstruction and palliative measures familiar to the palliative care community, we will focus on some novel approaches to the management of patients with advanced COPD from the perspective of clinicians involved in end of life care provision and research. By combining the clinical and research skills of pulmonologists and palliative medicine specialists we can advance the care of patients with this progressive and incurable disease.
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Conventional analgesic treatment involves the use of oral and transdermal formulations of drugs that require repetitive administration for sustained pain relief to be achieved. Along with the potential of analgesia, the risk of ongoing side effects consequent on the use of these analgesics also exists and this may have a detrimental effect on the patient's quality of life. In contrast, an intriguing body of evidence suggests that short-term administration of intravenous lidocaine may produce pain relief that far exceeds both the duration of infusion and the half-life of the drug. When pain relief is produced, concomitant analgesic medication can be reduced, side effects from pain relieving medication minimized with a potential for very real improvement in the quality of life of the patient. ⋯ While this form of therapy is not commonplace in the terminally ill patient, it could be argued that its use has much merit in that field and should be considered.
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Terminal restlessness is a term frequently used to refer to a clinical spectrum of unsettled behaviors in the last few days of life. Because there are many similarities between the clinical pictures observed in terminal restlessness and delirium, we postulate that at times what is referred to as terminal restlessness may actually be an acute delirium sometimes caused by medication used for symptom control. It is important therefore to consider the causes for this distressing clinical entity, treat it appropriately, and ensure the treatment provided does not increase its severity. ⋯ These include opioids, antisecretory agents, anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise awareness regarding the recognition and diagnosis of delirium and to highlight the fact that delirium may be reversible in up to half of all cases. Good management of delirium has the potential to significantly improve patient care at the end of life.
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The sublingual administration of opioid analgesics has been a mainstay in the pain management of homebound dying hospice patients who are no longer able to swallow. It is also a potentially useful route of administration in other situations in which the oral route is not available and other routes are impractical or inappropriate. Potential advantages of the sublingual route include rapid analgesic onset and avoidance of hepatic first-pass metabolism. ⋯ Other opioids have been less studied. Available data suggests limited sublingual availability of hydrophilic opioids (e.g., morphine, oxycodone, and hydromorphone) and superior absorption of the lipophilic opioids (e.g., methadone and the fentanils). Buprenorphine, a potent, lipophilic, partial mu-opioid receptor agonist, appears promising but awaits further study.
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Review Case Reports
Palliative sedation: when the family and consulting service see no alternative.