Quick Consults

Every year our Ask a Professional Team answers hundreds of questions from Canadian health care providers on a range of palliative care topics. Now you can read through a selection of these questions and answers to support your practice and enhance the quality of care you provide.

Personal information has been changed or removed to protect privacy.


     

    Index

    It is difficult to know how to respond to a child when he or she says, “I don’t want to die.”   Children often understand much more than we give them credit for. Children often say things to or ask questions of the people they trust and know will be honest with them. This child feels comfortable broaching this subject with you and has opened... read more...
    Talking about death and dying is difficult for many patients, families and health care providers. Death is not often talked about openly in society, so when faced with having to start that difficult discussion, many feel lost, worried and uncertain about how to begin. To complicate matters, all patients have their own coping and communication... read more...
    Racist comments can be both discouraging and hurtful for a caregiver. They shift the focus from the quality of the care you provide to who you are as a person in a way that dishonours both. One way of responding is to make a simple statement about how the comment makes you feel and then shift the attention back to the care the patient is receiving. read more...
    Communication between team members requires ongoing attention and effort to make it work in the best way possible. Any conflict can create barriers to effective communication. This affects the team as well patients and their families. A good place to start is with self-examination and reflection. Be aware of what you are thinking, how you... read more...
    Many professionals struggle with initiating conversations about end-of-life care. Some common barriers include finding the right moment, choosing words that will open the door, and being informative and empowering but not threatening to the person’s sense of hope. In our experience, people who are living with the diagnosis of a terminal condition... read more...
    People working in healthcare commonly find themselves providing care to someone they know. In some settings it may be possible to switch assignments. However, when the patient is known to staff, or the community is small, this won’t be an option. Depending on the relationship that former colleagues had with the patient, caring for her may... read more...
    The Canadian Virtual Hospice website has a wealth of information for those who provide palliative, end-of-life and bereavement care. In Topics , you will find an extensive selection of articles written by our Canadian Virtual Hospice clinical team on common palliative and end-of-life care issues. In Asked and Answered , you will find answers... read more...
    Perhaps the best resource for training people preparing for ministry is Developing Spiritual Care Capacity for Hospice Palliative Care : A Canadian Curricular Resource . This educational manual is designed to develop spiritual care capacity in those responding to end-of-life situations and needs. It is oriented particularly toward students,... read more...
    If hospice palliative care is a new career path for you, consider taking a volunteer education program specific to this field. These programs provide a solid foundation for palliative care, bereavement care and the interdisciplinary team approach to care. Volunteer education programs also give you work experience in the field and can help... read more...
    The Canadian Hospice Palliative Care Association has published Hospice Palliative Care Volunteers: A Training Program (Print version with CD ROM costs $35. 00). This manual contains nine learning modules specific to the volunteer's role in hospice palliative care, and a toolkit to guide the volunteer through the learning modules. It has been... read more...
    Teenagers are able to understand the abstract, and recognize that death is final and personal. Dealing with death can be difficult for adolescents and have an impact on all aspects of their daily lives. Their mood and overall coping can be profoundly affected. This can include alterations in their sleep pattern, how they interact with people... read more...
    A physician’s role in caring for family members is integral to providing care to the patient, and continues from diagnosis, through the disease trajectory, treatment, end-of-life care and bereavement. Understanding how family members grieve and what can help them is also important. During the illness, the physician plays a key role in connecting... read more...
    The illness or death of a student has a significant emotional impact on other students and teachers in the school or classroom. Providing opportunities to talk about the situation is part of the grieving and healing process for everyone. The information below provides some strategies for coping with a student’s illness or death. When a student... read more...
    We suggest that you start by reading Talking with Children and Youth About Serious Illness , in the Topics section of our website. This article, written by our clinical team, will give you basic information on how to reach out to children who have someone close to them who is ill or dying. Our Books, Links, and More section lists a number... read more...
    We suggest that you start by reading Talking with Children and Youth About Serious Illness , in the Topics section of our website. This article, written by our clinical team, will give you basic information on how to reach out to teenagers who have someone close to them who is ill and dying. Our Books, Links, and More section lists a number... read more...
    In palliative care the family is recognized as the ‘unit of care’ and bereavement care is believed to be an integral component of the care we provide. Therefore, our responsibility in developing a comprehensive palliative care program should include offering bereavement care to the family following the death. It is generally agreed that grief... read more...
    If health care providers are not part of a team where grief support services are provided, they can still engage in personal processes, such as journaling or connecting with others. The latter may involve debriefing with a trusted colleague or meeting privately with a counsellor on their own time. Many employment assistance programs across... read more...
    When the bereavement debriefing session is a response to a traumatic or difficult death, it’s essential to create a safe environment in which staff can ask questions, exchange information, and share thoughts and feelings. A traumatic death debriefing session often works best when the patient care manager arranges it and attends. Using an open-ended... read more...
    The nature and format of bereavement debriefing sessions will vary depending on who is involved, the purpose of the session, the event that precipitated it, and whether the session is a regularly scheduled review. Essential for an effective session is staff support. Be sure to involve people who can help create a safe environment in which... read more...
    Teenagers are able to understand the abstract, and recognize that death is final and personal. Dealing with death can be difficult for adolescents and have an impact on all aspects of their daily lives. Their mood and overall coping can be profoundly affected. This can include alterations in their sleep pattern, how they interact with people... read more...
    It is difficult to know how to respond to a child when he or she says, “I don’t want to die.”   Children often understand much more than we give them credit for. Children often say things to or ask questions of the people they trust and know will be honest with them. This child feels comfortable broaching this subject with you and has opened... read more...
    Caring for teenagers who are dying can be quite challenging. Your teenage patient is at the point where he is trying to exert his independence and gain some freedom. However, as his disease progresses, he will become more and more dependent on others. With his general decline, his relationships with friends and his family will be affected,... read more...
    The illness or death of a student has a significant emotional impact on other students and teachers in the school or classroom. Providing opportunities to talk about the situation is part of the grieving and healing process for everyone. The information below provides some strategies for coping with a student’s illness or death. When a student... read more...
    We suggest that you start by reading Talking with Children and Youth About Serious Illness , in the Topics section of our website. This article, written by our clinical team, will give you basic information on how to reach out to children who have someone close to them who is ill or dying. Our Books, Links, and More section lists a number... read more...
    We suggest that you start by reading Talking with Children and Youth About Serious Illness , in the Topics section of our website. This article, written by our clinical team, will give you basic information on how to reach out to teenagers who have someone close to them who is ill and dying. Our Books, Links, and More section lists a number... read more...
    Starting discussions about death with children can be very difficult, especially when children are quite young. This young mother is likely experiencing immense angst because of her disease and in addition to her own emotions, must also tell her children she is dying. The best way to help this young mother is to guide her through initial and... read more...
    You may find that with children, active treatment of the disease continues, even with the knowledge that there may not be a cure. The course of illness in children can be very hard to predict. Depending on the illness trajectory, the amount of involvement from a home care or palliative care perspective may be limited at times. Rural health... read more...
    Every family has their way of addressing stressful situations and how information is communicated. This family functioning will now change, with the death of their mother and wife Your health care team will need to keep in mind that each family and family member will deal with illness and grief in their own unique way. Being sensitive to these... read more...
    Many palliative care programs have an integrated approach to delivering care across settings. For example, the Calgary, Edmonton, Winnipeg and Fraser Health regions provide palliative care across settings - in the community, hospices, and in-patient palliative care units. This approach allows patients to transition from one setting to another,... read more...
    Often your initial step in this process is to pull together a group of staff who share a common interest in palliative care and are committed to improving the quality of care offered to the residents and families in your long-term care facility. It is best if this group includes representatives from the various disciplines or departments involved... read more...
    Your first step is to consider the population you hope to serve and how you will respond to its needs. Many hospice initiatives arise because of the focus of special interest groups. For example, a group may have a disease focus (such as HIV and ALS), a cultural focus or a geographical focus. Decide your focus and set up a working group. Be... read more...
    In palliative care the family is recognized as the ‘unit of care’ and bereavement care is believed to be an integral component of the care we provide. Therefore, our responsibility in developing a comprehensive palliative care program should include offering bereavement care to the family following the death. It is generally agreed that grief... read more...
    Moral distress is a significant ethical concern for both individuals and organizations. Some describe it as “moral compromise,” or the undermining of an individual’s integrity following participation in and/or failure to stop an event that the individual considers to be a harmful or undignified practice.   Moral distress can arise when members... read more...
    There are a number of opioid equianalgesic tables with variations in recommended conversion ratios. However, there are several problems with such tables: They do not consider incomplete cross-tolerance. Conversion charts are usually derived from single-dose studies in opioid-naive patients with well-defined pain problems such as post-surgery... read more...
    Information is limited regarding the long-term use of polyethylene glycol (PEG). Some of the information available suggests that it is the most effective for the first 14 days of treatment. However, geriatric resources produced by the American Society of Consultant Pharmacists suggest continuing the use of PEG if it still meets your therapeutic... read more...
    First, there is room to increase the Senokot dose to eight tablets daily at bedtime. If this is not effective, it is possible to introduce polyethylene glycol and decrease the daily Senokot dosage. Sennosides (such as Senokot) and osmotic laxatives (such as polyethylene glycol or Lactulose) have a different mechanism of action. If the response... read more...
    Dyspnea is a common symptom in end-stage heart failure, and, in addition to optimizing cardiac medications, opioids can be very effective in reducing the sensation of air hunger. However, there is often some reluctance to prescribe opioids in patients with respiratory compromise, and there is some conflicting information about the safety of... read more...
    Bisacodyl (Dulcolax) belongs to the same therapeutic class as sennosides (a stimulant laxative that acts on the intestinal wall to promote motility and bowel movement). The onset of action for bisacodyl tablets is approximately 10―12 hrs, and the bisacodyl suppository is approximately 15 minutes. If you are using the tablets, use a similar... read more...
    Polyethylene glycol (PEG) is an osmotic laxative . It acts by absorbing more moisture into the stool, increasing the fecal volume, and inducing a laxative effect. The typical onset of action for Miralax is 1―2 days for constipation and 1―3 days for fecal impaction . It is contraindicated in severe inflammatory intestinal conditions and intestinal... read more...
    Sennosides is a mixture of two naturally occurring plant glycosides (sennosides A and B). It works in the large intestine, acting directly on the submucosal plexus and the deeper myenteric plexus to stimulate propulsive waves. The typical onset of action for sennosides is 6―12 hours. Ideally, it should be taken at bedtime, with an expectation... read more...
    Docusate is a surface-wetting agent, more commonly known as a stool softener . If prescribed, it should always be combined with a stimulant like Senokot. Current published literature indicates that patients usually respond as well to sennosides alone as they do when sennosides are combined with docusate. One of the few times when docusate... read more...
    Many factors can contribute to poor patch adherence. Individual skin characteristics, such as skin oiliness or propensity to sweat, may interfere with adhesion. A particular brand of patch may not be suited to that individual, in which case, it may be worth trying a patch manufactured by another company. The following is a list of considerations... read more...
    This is not a straightforward issue, as the evidence supporting one opioid over another is often based on the experience and advice of experts rather than on solid data from prospective, randomized, double-blind trials. Both morphine and hydromorphone (Dilaudid) have active metabolites that are known to accumulate in the context of renal insufficiency. read more...
    Safety considerations when using opioids As health care providers taking care of palliative care patients, we need to educate patients and families about the safe use, handling and storage of opioids. This quick consult looks specifically at the safe handling of fentanyl.   For safety considerations when using opioids in general, please see:... read more...
    Background on the Opioid Crisis The opioid overdose crisis refers to the rise in opioid overdose deaths. The crisis has resulted in prominent media coverage and has become a major Canadian health concern. Unfortunately, for many health care providers, patients and families, this has impacted perceptions regarding the usefulness of opioids... read more...
    As your question suggests, some patients believe or intuitively sense that illness has a spiritual as well as a physical dimension. For them, receiving medical care is part of a bigger picture that involves their spirituality and/or religious faith. As they face the anxiety of a life-limiting illness, patients may turn to familiar spiritual... read more...
    No matter what your patient has done in her life, she can create a legacy. She can gain a place in the hearts and memories of people if she weaves love, gratitude and forgiveness into the last chapter of her life story. This is the simple, yet profound, wisdom that comes from Dr. Ira Byock’s identification of the four statements that matter... read more...
    Your patient is carrying a double burden – his health problems and his self-blame for not being healed. It may be that his sense of failure about not being healed is reinforced by members of his family or faith community who believe that prayers offered in deep faith will be answered. As his prayers for healing go unanswered, he may also feel... read more...
    Pain and symptom management are central to end-of-life care . When a patient does not allow us to do all we can to control symptoms, it can be very unsettling. We may feel frustrated in witnessing suffering that seems unnecessary and have difficulty understanding why the patient is not willing to receive what we have to offer. Often we use... read more...
    Death and dying often elicit a heightened awareness of the importance of spirituality in patients, families and health care professionals. Caring for dying people and their families may offer opportunities to help them find meaning, love, hope and peace in the midst of very difficult circumstances. With these opportunities comes the responsibility... read more...
    Your question indicates sensitivity and recognition of the important role the patient’s religion plays in her illness experience ― an essential component of spiritual care at the end of life, in and of itself. Your sense of inadequacy in addressing spiritual and religious issues is common among health care professionals, even among spiritual... read more...
    Attending to the spiritual struggles and needs of patients and families is part of palliative care philosophy and practice. Clearly, you have spirituality on your radar as you care for patients and have integrated it into your practice. Your comfort in opening up conversations with patients about their spiritual perspectives and religious... read more...
    Your patient clearly has a lot to live for and wants to live well in spite of her health issues. She does not see palliative care as an opportunity to improve her quality of life and physical comfort, but rather as a sign that she has given up and lost hope. She continues to cling to hope for a cure although this appears medically impossible. read more...
    When patients are uncomfortable or in distress, even though their physical symptoms are well controlled, they may be experiencing spiritual pain . Spiritual pain is often experienced in the midst of a life-limiting illness and is “a great mimicker, often presenting as physical pain, anxiety or depression , anorexia , insomnia or shortness... read more...
    Assessing and responding to the spiritual needs of patients and families are important aspects of person-centred, comprehensive palliative care. However, hospice palliative care programs and settings vary widely in their spiritual care resources. Ideally, every palliative care team should include a certified spiritual care provider (i. e.,... read more...
    When weighing end-of-life interventions in progressive life-limiting illness, it is usually helpful to consider the hoped-for goals and whether the intervention is expected to achieve them. With feeding, there are various goals people might seek, such as: Preventing hunger. Preventing malnutrition―Malnutrition is a physiological term and does... read more...
    Refractory edema in advanced metastatic cancer is one of the more challenging clinical problems. Diuretic therapy tends not to be particularly effective. Occasionally, there may be contributing factors that can be fully or partially addressed. There may be inferior or superior vena cava obstruction by clot (for which anticoagulation may be... read more...
    Odour from wounds results from bacteria that reside in necrotic wound tissue. Odour associated with malignant fungating wounds can be upsetting and may contribute to the suffering of the patient and the family. Fungating wounds also present challenging management issues for health care providers.   Based on clinical practice and a review of... read more...
    There are no specific best practice guidelines on the use of oxygen at the end of life. The first distinction that must be made is between the use of oxygen in unconscious and conscious patients. Frequently, oxygen is continued in patients who are deeply unconscious and in their final hours of life. As with all interventions, it is important... read more...
    Constipation is a very common symptom in patients with advanced disease of any kind, including cancer. Patients at the end of life have many reasons for becoming constipated, including immobility, reduced fluid intake, and the use of a number of medications. Patients frequently need to have bowel movements in inconvenient and unfamiliar places,... read more...
    Information is limited regarding the long-term use of polyethylene glycol (PEG). Some of the information available suggests that it is the most effective for the first 14 days of treatment. However, geriatric resources produced by the American Society of Consultant Pharmacists suggest continuing the use of PEG if it still meets your therapeutic... read more...
    First, there is room to increase the Senokot dose to eight tablets daily at bedtime. If this is not effective, it is possible to introduce polyethylene glycol and decrease the daily Senokot dosage. Sennosides (such as Senokot) and osmotic laxatives (such as polyethylene glycol or Lactulose) have a different mechanism of action. If the response... read more...
    Dyspnea is a common symptom in end-stage heart failure, and, in addition to optimizing cardiac medications, opioids can be very effective in reducing the sensation of air hunger. However, there is often some reluctance to prescribe opioids in patients with respiratory compromise, and there is some conflicting information about the safety of... read more...
    Bisacodyl (Dulcolax) belongs to the same therapeutic class as sennosides (a stimulant laxative that acts on the intestinal wall to promote motility and bowel movement). The onset of action for bisacodyl tablets is approximately 10―12 hrs, and the bisacodyl suppository is approximately 15 minutes. If you are using the tablets, use a similar... read more...
    Polyethylene glycol (PEG) is an osmotic laxative . It acts by absorbing more moisture into the stool, increasing the fecal volume, and inducing a laxative effect. The typical onset of action for Miralax is 1―2 days for constipation and 1―3 days for fecal impaction . It is contraindicated in severe inflammatory intestinal conditions and intestinal... read more...
    Sennosides is a mixture of two naturally occurring plant glycosides (sennosides A and B). It works in the large intestine, acting directly on the submucosal plexus and the deeper myenteric plexus to stimulate propulsive waves. The typical onset of action for sennosides is 6―12 hours. Ideally, it should be taken at bedtime, with an expectation... read more...
    Docusate is a surface-wetting agent, more commonly known as a stool softener . If prescribed, it should always be combined with a stimulant like Senokot. Current published literature indicates that patients usually respond as well to sennosides alone as they do when sennosides are combined with docusate. One of the few times when docusate... read more...
    Fever is a common symptom at the end of life. It can mean there is an infection, which often indicates an end-of-life pneumonia. But fever may also be associated with other causes, such as a cytokine-induced fever produced by a cancer, which is referred to as “tumour fever.” The investigation and/or treatment of fever is based on life expectancy... read more...
    If reversible issues may be causing or contributing to nausea, these will need to be addressed if possible and appropriate. These may include the following: medication side effects (consider switching from hydromorphone to a fentanyl patch); severe constipation (consider an abdominal X-ray if one has not been done); metabolic abnormalities... read more...
    End-stage secretions (commonly referred to as “death rattle”) is known to occur in between 12 and 92 percent of patients, with the median time from onset of death rattle until death between 11 and 28 hours. A question around secretions is whether they originate from the throat and salivary glands, or from the lower respiratory tract, possibly... read more...