From the Guidelines
Alternative symptom management strategies for long-term care patients who refuse investigations should prioritize a comprehensive approach focused on comfort and dignity, incorporating non-pharmacological interventions and careful medication management, as outlined in recent guidelines 1.
Key Considerations
- Begin with non-pharmacological interventions such as repositioning, massage, music therapy, aromatherapy, and heat or cold therapy to address pain and discomfort.
- For pain management, consider acetaminophen (500-1000mg every 6 hours, maximum 4g daily) as a first-line medication, followed by NSAIDs like ibuprofen (400-600mg every 6-8 hours) for inflammatory pain if kidney function permits.
- For moderate to severe pain, opioids such as morphine (2.5-5mg orally every 4 hours as needed, titrating carefully) or hydromorphone may be necessary.
- Manage respiratory symptoms with positioning, oxygen therapy, and medications like morphine (2.5mg every 4 hours) for dyspnea, as suggested by palliative care guidelines 1.
- For gastrointestinal issues, use metoclopramide (10mg three times daily) for nausea and haloperidol (0.5-1mg every 8 hours) for persistent vomiting.
- Treat constipation proactively with sennosides (8.6-17.2mg daily) and docusate sodium (100mg twice daily).
Patient-Centered Approach
- Regular assessment using validated tools like the Pain Assessment in Advanced Dementia (PAINAD) scale helps monitor symptom burden, especially in non-verbal patients.
- Incorporate family members in symptom management, as they can assist in evaluating patients’ responses to procedures and report observations to the care team 1.
- Consider the patient's goals and intensity of care, and simplify regimens when possible, especially in palliative care settings 1.
Recent Guidelines
- The most recent guidelines from 2022 emphasize the importance of overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity in diabetes management at the end of life 1.
- These guidelines suggest that strict glucose and blood pressure control may not be necessary, and simplification of regimens can be considered.
- The decision process should involve the patient, family, and caregivers, leading to a care plan that is both convenient and effective for the goals of care.
From the Research
Alternative Symptom Management Strategies
For long-term care patients who refuse investigations, several alternative symptom management strategies can be employed to ensure comfort. These include:
- Non-pharmacological measures such as:
- Aromotherapy
- Distraction
- Guided Imagery
- Laughter
- Massage
- Music
- Reiki
- Heat or Cold
- Meditation
- Reflexology
- Reposition
- Transcutaneous Electrical Nerve Stimulation 2
- Utilizing a comfort measures only checklist to facilitate interdisciplinary conversations and improve structure and consistency in transitioning patients to comfort measures only 3
- Implementing a multidimensional intervention by primary care providers, consisting of cognitive-behavioral, pharmacological, and other treatment modalities 4
- Prescribing sustained-release opioid preparations, such as morphine, oxycodone, or transdermal fentanyl, to manage pain and constipation severity 5
Patient-Centered Approach
It is essential to adopt a patient-centered approach, taking into account the patient's goals, strategies, and evaluation criteria in managing chronic illness 6. This approach can help clinicians better understand the patient's perspective and develop effective symptom management strategies that cater to their individual needs.
Interdisciplinary Collaboration
Interdisciplinary collaboration and communication are crucial in ensuring that patients receive comprehensive care. By working together, healthcare providers can develop a personalized care plan that addresses the patient's physical, emotional, and social needs, ultimately improving their overall comfort and quality of life 3.