Nursing Standard of Practice Protocol: Palliative Care
Maria Gatto, MA, APRN, BC-PCM, NP, BC-AHN, HNP, DeAnne Zwicker, MS, APRN, BC
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
Palliative care: The World Health Organization’s (WHO) definition is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems (WHO, 2005).
Geriatric palliative care: the approach to care for the chronically ill and frail elderly. The focus is on quality of life, support for functional independence, and centrality of the patient's values and experiences in determining the goals of medical care (Morrison & Meier, 2003).
Geriatric palliative care is integrative using interdisciplinary delivery of care. The goal to relieve pain and suffering and improve quality of life for elderly patients and their families. The core principles are comprehensive patient/family unit centered that enhance functional independence and quality of life transitioning between levels of care (Morrison & Meier, 2003).
Symptom management: recognition and treatment of physical and nonphysical symptoms to prevent suffering and improve quality of life (Kazanowski, 2003).
Goal of Palliative Care
The goal of palliative care is "to prevent and relieve suffering and to support the best possible quality of life for patients and their families regardless of the stage of disease"(National Consensus Project for Quality Palliative Care, 2004).
Background of Geriatric Palliative Care
- Persons over age 80 have fewer interventions for symptom management (Evers, Meier, & Morrison, 2002).
- Older palliative care patients are more likely to suffer and die from chronic illnesses preceded by lengthy period of decline and functional impairment (Evers, Meier, & Morrison, 2002).
- Older persons are higher risk for developing multiple chronic, life-threatening diseases (cancer, stroke, heart disease, respiratory diseases). Alzheimer’s disease is the 4th leading cause of death in older adults; (Matzo, 2004); yet 80% of Medicare patients enrolled in hospice have cancer (Matzo, 2004). Only 3% have COPD and less than 3% of nation’s hospice census is comprised Alzheimer’s patients (Hoyert & Rosenberg, 1999).
- Patients over 80 referred for palliative care consultation have fewer interventions for pain, nausea, anxiety and other symptoms (Evers, Meier, & Morrison, 2002).
- Persons 65 and over often have under-treated or untreated pain and other symptoms.
Markers for Initiation of Palliative Care in Geriatrics
(Adapted from Morrison & Meier except as noted)
Core End-stage Indicators indicating terminal phase of chronic illness are physical decline, weight loss, multiple comorbidities, and a serum albumin of <2.5 g/dL. Dependence on assistance with most activities of daily living and a Karnofsky Performance score of less than 50% (Matzo, 2004).
Non-Disease Specific Indicators
Frailty – extreme vulnerability to morbidity and mortality due to progressive decline in function and physiological reserve. Frequent falls, disability, susceptibility to acute illness and reduced ability to recover are examples of frailty.
Functional dependence – dependence on others to perform activities of daily life (See Function Topic).
Cognitive impairment – changes in memory, attention, thinking, language, praxis, and executive function (See Dementia topic).
Family support needs – emotional support, information and educational support unique to each patient/family and/or caregivers.
Disease Specific Markers
- Symptomatic CHF
- Recurrent infections
- Degenerative joint disease causing functional impairment and chronic pain
Needs of the Geriatric Palliative Care Patient
- Continuity and coordination of care that responds to episodic and long-term chronic illnesses and transitioning between levels of care
- Management of multiple chronic illnesses
- Assistance in navigating a complex medical system
- Maintaining functional independence
- Decision making regarding care and treatment decisions
- Pain and symptom control
- Determining risk versus benefit of treatment
- Home support for family caregivers
- Community resource information and access assistance
General Assessment/Screening Tools
Edmonton Symptom Assessment Scale. (Victoria Hospice Society, 2001).http://www.palliative.org/PC/ClinicalInfo/
Palliative Performance Scale. Relevant to palliative care function. (Victoria Hospice Society, 2001). http://www.palliative.org/PC/ClinicalInfo/
Karnofsky Performance Scale. Allows patients to determine their own functional capacity. http://www.hospicepatients.org/karnofsky.html
Criteria for Hospice Eligibility for in Persons with Dementia
It is important for medical providers to be familiar with the criteria for Hospice eligibility. Hospice is often under-utilized in end stage dementia and often times not utilized until the last days or weeks of life. In fact, less than 3% of the nation's hospice census comprises patients with Alzheimer’s dementia (the most prevalent form of dementia), according to the Virginia-based National Hospice and Palliative Care Organization (NHPCO). (Miller, 2003; Schonwetter et al, 2003). View eligibility criteria at: http://www.aafp.org/afp/20031015/tips/2.html
General Assessment & Interventions
in Sympton Management by Specific Symptoms
Symptom Management in Palliative Care
Research indicates that persons near the end of life, those that are frail and those that have multiple chronic symptoms suffer symptoms of distress (Morrison & Meier, 2003; Kazanowski, 2003; National Consensus Project for Quality Palliative Care, 2004). Research also indicates that aging persons are often under-treated if treated at all for distressing symptoms. (Evers, Meier, & Morrison, 2002). Assessment and management of distressing symptoms is paramount for quality of life in aging persons.
The following are common symptoms in geriatric palliative care. There is an abundance of information available on the web. Assessment tools and intervention strategies for each are provided, many via web links.
- Gastrointestinal symptoms: Constipation, anorexia, dysphagia
Dyspnea in Palliative Care
Definition: "Dyspnea is a subjective experience described as an uncomfortable awareness of breathing, breathlessness, or severe shortness of breath"(HPNA, 1996).
- One of the most common symptoms experienced by patients with all types of advanced lung disease, including cancer, interstitial lung disease, and particularly chronic obstructive pulmonary disease. Dyspnea is more common, and often more severe in the last few weeks before death. (WHO, 2005).
- Dyspnea, like pain, is a multidimensional experience with multiple layers of meaning: physiological, emotional, cognitive, behavioral dimensions. It is more prevalent in aging persons and does not only occur only in the end stages of life.
- Research indicates dyspnea is inadequately assessed at the end of life. (Sykes, 1997).
- Dyspnea is a highly prevalent symptom in older adults and increases with age regardless of the type of illness or community in which they live (Bednash & Ferrell, 2001).
Potential Causes of Dyspnea
(Adapted from Morrison & Meier, 2003 except as noted)
Debility with aging adult: Anemia, atelectasis, pulmonary embolism, pneumonia, emphysema, cachexia-anorexia syndrome, or weakness (asthenia).
Concurrent disease with increased age: COPD, asthma, CHF, acidosis, angina, respiratory infection.
Cancer complications: Pleural effusions, bronchial obstruction, metastasis, superior vena cava syndrome, tumor replacing normal lung tissue, lymphangitis carcinomatosis, mediastinal obstruction, pericardial effusion, massive ascites, or abdominal distention.
Complications of treatment of primary disease: Congestive heart failuresecondary to chemotherapy or constrictive pericarditis related to radiation therapy, radiation induced fibrosis, or anemia secondary to chemotherapy.
Psychological disorders: anxiety, depression, panic disorders (Dickerson, Benedetti, Davis et al., 2001).
Assessment of dyspnea
- Assessment should start with using the patient’s descriptor of how they are feeling, e.g. breathlessness, need to gasp or pant, unable to get enough air, feeling like suffocating (Morrison & Meier, 2003; Kazanowski, 2003) and asking the following regarding descriptor: (Morrison & Meier, 2003)
- Onset (days, weeks, hours) or acute vs. chronic
- What makes it better or worse
- What does it feel like – further assess descriptor
- Other symptoms occurring with it pain, chest tightness, palpitations, cough, fever, lightheadedness
- How severe is it (using a scale such as Visual Analog Scale 1-10)? How much does it interfere with daily life and function?
- When is it at its worst? Is it always present or does it come and go? Are there any temporal factors (night vs. daytime)?
- If patient unable to answer ask caregiver their observations of the above questions. Review of the past history for potential underlying causes of dyspnea, e.g., COPD, CHF, renal failure or lung cancer (Kazanowski, 2003) and review list of medications.
- Physical Exam:
- General appearance – mental status (is it different than normal?) Can patient speak a complete sentence without stopping?
- Count respiratory rate accurately, note use of accessory muscles or not
- Examine skin, cardiac (is there an S3 or murmur), respiratory status (are breath sound decreased, crackles or rhonchi/wheezing present?)and look for signs of infection or dehydration.
- Oxygen saturation resting and after walking (if able).
Management of Dyspnea
Goal of managing dyspnea in the palliative care patient is to ensure the best quality of life (Morrison & Meier, 2003).
Treatment and Interventions for Dyspnea
- Reduce the need for exertion and arrange for readily available help (e.g. access to call light, caregiver at bedside).
- Reposition, usually more upright position or with the compromised lung down.
- Improve circulation: provide draft-fans, open windows. Adjust humidity with humidifier or air conditioner.
- Identify and address situational components that trigger dyspnea.
- Address anxiety (consider anti-anxiety agent) and provide reassurance.
- Discuss the meaning of symptoms and other patient and family concerns.
- Teach behavioral interventions such as relaxation, hypnosis.
- Discuss family concerns about use of opioids to relieve dyspnea.
- Provide oxygen, many will feel better with saturation > 90%.
- Facilitate circulation of air – electric fans or air-conditioning.
- Positioning patient to facilitate chest expansion – head of bed elevated with feet flat or down, upper body leaning forward supported with pillows.
- Oxygen therapy: O2 2-6L NP, reassess q2hr after each change of flow.
- Cooling off the body.
- Conservation of patient energy.
- Offer Foley catheter if dyspnea with voiding or patient on diuretics for dyspnea.
- Pursed lip breathing.
- Complementary therapies: imagery, massage, breathing exercises, therapeutic touch, music, aromatherapy, relaxation exercises.
Specific Causes and Treatment for Dyspnea
BREATH AIR mnemonic (Dickerson et al, 2001)
B: Bronchospasm: Corticosteriods, bronchodialators, nebulized albuterol, inhalers and/or oral steroids for COPD, asthma. CHF medications, i.e. digoxin, antiarrythmic’s, nitrates, doputamine. antitussives to help with cough.
R: Rales: If volume overload is present, reduce artificial feeding or stop intravenous fluid, diuretics, lasix, are occasionally needed. If pneumonia, decide whether ABT will be effective or prolong dying process. Patient and family participation in this process is essential.
E: Effusions: Thoracentesis, if reoccurs and patient is ambulatory, chest tube pleurodesism indwelling drainage catheter, paracentesis for severe ascites. If patient is close to death, palliative with opioids and benzodiazepines.
A: Airway obstruction: Make sure tracheostomy appliances are cleaned regularly. If aspirating food use pureed and thickened liquids. Instruct family on positioning patient during feeding and suctioning if necessary.
T: Thick secretions: If the cough reflex is still strong, use nebulized saline and expectorant as needed. If cough is weak, dry secretions with hycoscyamine, (Levison) 0.125 po or SL q 8hr, or transdermal Scopolamine 1-3 patches q3days, with the use of second patch PRN, or add glycopyrrolate 0.8-2.0 mg/d to a sc infusion or SC, or IV bolus 0.4 mg q 3hr prn.
H: Hemoglobin: A blood transfusion may improve energy and reduce dyspnea for a few weeks. Consider Erythropoietien (ProcritTM, EpogenTM) for patients likely to improve to a higher level of function. Hemorrhage or marrow failure is part of the dying process and is best palliated with opioids, benzodiazepines, and other symptomatic treatments.
A: Anxiety: Treat first with a short acting opioid, (morphine 5-10 mg po Q2-4/hr;morphine 2-4mg IV/SC q 2-4hr, 2.5-20mgq1 hour PRN, than try a short acting benzodiazepine if needed, lorazepam 0.5-2.0 mg PO/SL/IV or alprazolam 0.25-1mg PO q3-8hr PRN. Consider to lower dose of theophylline and adrenergic agents to reduce tremor/anxiety. If patient is already being treated with opioid, titrate dose by 25-50% above the existing dose. If dose is limited by drowsiness, reduce benzodiazepine and increase opioid. Antidepressants for depression related anxiety. Chlorpromazine, 12.5mg IV or 25 mg PR q4-6hr or phenergan.
I: Interpersonal issues: Social and financial problems contribute to dyspnea. Counseling with social workers and other IDT members of the team may bring relief. When family relationships exacerbate the problem, a few days in an inpatient unit as respite from family may help to relieve the patient symptoms.
R: Religious concerns: Some beliefs, such as "God is punishing me, or "God will heal me if I have enough faith", can precipitate or exacerbate symptoms. Take time to listen with full attention and have presence. Help ways patient can explore ways to reconnect with God, higher being, self, others. Coordinate spiritual advisement, chaplain, counselor, or other healthcare professionals and family members.
See also: EPERC Fast Fact #027: Dyspnea at End-of-Life: Weissman, DE(2005). 2nd Edition. End-of-Life Palliative Education Resource Center. Access at: http://www.eperc.mcw.edu/fastFact/ff_027.htm
Patient and Family Education
- Instruct family on nonpharmacological interventions.
- Instruct on signs and symptoms of impending exacerbations.
- Prioritize activities, minimize unnecessary activities.
- Maximize usefulness of medications.
- Do not leave patients in distress alone.
- Monitor self care activities and need for additional assistance.
- Evaluate understanding, compliance and effectiveness of medications for dyspneic episodes.
- Evaluate improvement in management and control of dyspneic episodes.
- Evaluate for progression of disease related to uncontrolled dyspnea.
Depression in Palliative Care
The overlap of physical illness symptoms with signs and symptoms of depression complicates reliable diagnosis during illness. Incidence increases with higher levels of disability, advanced illness and pain (Morrison & Meier, 2003). Persistent feelings of helplessness, hopelessness, inadequacy, depression and suicidal ideation are not normal at the end of life or in aging and should be aggressively evaluated and treated (Morrison & Meier, 2003).
Prevalence of Depression (Morrison & Meier, 2003)
- In hospitalized geriatric patients:
- 10-20% for major depression
- 30% for minor depression
- Depression in elderly communities:
- 1-15%, 10-20% in Alzheimer’s patients
- 33% with Dementia
- 36% in rehabilitation facilities
- Nursing Homes:
- 60% of nursing home residents
- Cancer and Terminally ill:
- 20% to 25% of patients with cancer
- 25% to 77% of terminally ill
- Palliative care patients have a higher risk due to chronic deteriorating medical illness with perceived poor health, recent diagnosis of life threatening illness. Presence of chronic or life threatening illness may cause increased dependence, helplessness, uncertainty, negative self-critical view.(HPNA, 1996).
Assessment/Screening Tools for Depression
EPERC Fast Fact: Is it Grief or Depression?
Periyakoil, VJ. Fast Facts and Concepts #43: Is it grief or depression? August 2005, 2nd edition. End-of-Life Physician Education Resource Centerwww.eperc.mcw.edu
Geriatric Depression Scale
Assess for Depression Risk Factors (Dickerson, Benedetti, Davis et al., 2001)
- Uncontrolled pain
- Multiple co-morbid issues and associated deficits: inability to walk, loss of bowel and bladder control, amputation, inability to eat or swallow, sensory loss, exhaustion.
- Medical co morbidity: Cancer patients at highest risk are those diagnosed with oral, pharyngeal, or lung
- Recent conflict or a loss of significant relationship
- Familiar history, prior episodes of depression, suicide attempt
- Lack of social support
- Feelings of being burden to family
For further Assessment and Interventions for Depression in Aging persons see ConsultGeriRn Depression Topic.
Depression in Advanced Cancer
Warm, E, and Weissman, DE. (July, 2005). Depression in Advanced Cancer. Fast Facts and Concepts #7; 2nd Edition End-of-Life Physician Education Resource Center www.eperc.mcw.edu. http://www.eperc.mcw.edu/fastFact/ff_007.htm
Fatigue in Palliative Care
Fatigue: "an overwhelming, sustained sense of exhaustion and decreased capacity for physical or emotional work"(Tiesinag,Dassen & Halfens, 1996). Described by patients as worn out, exhausted sleepiness, tired, low energy and care providers as lethargy or malaise (Morrison & Meier, 2003).
There has been no consensus on the definition of fatigue in palliative care; however the following criteria was delineated by Dean & Anderson: (Dean & Anderson, 2001).
- A subjective perception
- Alteration in neuromuscular and metabolic processes
- Decrease in physical performance
- Deterioration in mental and physical activities
Background (Morrison & Meier, 2003)
- Fatigue is often erroneously seen as inevitable as a normal consequence of aging by patients and care providers alike.
- It often reported to medical providers due to this belief.
- Occurs in diseases that commonly afflict the older adult: ESRD, CAD, and CHF.
- Often difficult to ascertain in fatigue is due to treatment or chronic disease processes such as CHF, depression.
- Occurs in older age associated with advanced disease and combined therapies.
- Over half of palliative care patients reported fatigue in a W.H.O. study of 1840 persons.
- Many causes of fatigue can be treated and improve quality of life by teaching coping mechanisms and lifestyle changes.
Gastrointestinal Symptoms in Palliatve Care
Constipation in Palliative Care
Background (Morrison & Meier, 2003)
- Common in those requiring palliative care and increases in prevalence with advancing years.
- 63% of elderly in hospitals compared to 22% of elderly in the home.
- 95% of persons taking opioids.
Causes of Constipation
(Dickerson, Benedetti, Davis, et al., 2001)
Directly related to tumor site: bowel cancers, secondary bowel cancers, pelvic cancers, hypercalcemia, and surgical interruption of bowel integrity, inactivity, weakness and/or inability to reach toilet, poor nutrition, and dehydration related to nausea and vomiting, polyuria, or fever.
Hypercalcemia: low calcium causes decreased absorption leading to constipation.
Concurrent disease related (Morrison & Meier, 2003)
Diabetes, hypothyroidism, hypokalemia, diverticular disease, hemorrhoids, colitis, or chronic neurological diseases.
Opioids, anticholinergic effects, tricyclic antidepressants, antiparkinson medications, antihypertensives, antihistamines, antacids, diuretics, vinca alkaloids, NSAIDs, or anticholinergics.
Screening Tool: Constipation Scale
|Box 1. Constipation Scale|
Perform: Plain, Supine x-ray of abdomen, divided into 4 quadrants. Evaluate for constipation:
- Four quadrants represent ascending, transverse, descending and rectosigmoid colon
- Each quadrant assessed for amount of stool present
- Scored 0 -3; O = absent of stool, 3 = complete stool impaction
- Scores for each quadrant are added together
- Maximum score 12 out of 12
- A score of more than 7 indicates more aggressive constipation management is needed.
|Adapted from McMillian and Williams, 1989
Nonpharmacologic Interventions for Constipation
- Increase dietary fiber
- Improve mobility as much as tolerated
- Encourage fluids
- Eliminate constipating drugs as feasible
Suggestions for Treatment for Constipation (Sykes, 1997)
- Many studies do not recommend one specific treatment over another.
Combinations of stimulant and softening laxatives have shown fewer adverse effects. For a bowel protocol see the following link: http://www.palliative.org
- Click on Clinical information
- Clinical Practice Guidelines
- Bowel Care in Palliative Care
Anorexia/Cachexia in Palliative Care
The loss of appetite is common in end stages of illness. However, it needs to be sorted out from potential reversible causes such as medication induced constipation. Reversible causes should be evaluated in aging persons prior to adding further medications. Anorexia accompanies physical deterioration and frequently causes significant concern in patients and families (Morrison & Meier, 2003). It also contributes to the cachexia syndrome (which is not due to inadequate food intake – see resources below). Weight loss often ensues before anorexia and the only treatment is to reverse the underlying cause(Morrison & Meier, 2003).
Potential Reversible Causes of Anorexia (Morrison & Meier, 2003)
- Poor oral hygiene, mucositis or other oral problems
- Dysphagia where treatment is beneficial and desired
- Depression and/or anxiety
- Dietary choices and consistency are what patient desires/likes
- Treatment of underlying disease
Interventions/Treatment for Anorexia
Consider treatment for anorexia only after reversible causes are ruled out.
See the topic Oral Health
Cancer Anorexia/Cachexia: Palliative Care Tips
Program, Edmonton Alberta. (April, 2005). Access at:http://www.palliative.org/PC/ClinicalInfo/PCareTips/
ABCs of Palliative Care: Anorexia, Cachexia, and Nutrition. Access free journal article at: http://bmj.bmjjournals.com
Courtesy of Blackwell Publishing. www.blackwellpublishing.com
Dysphagia in Palliative Care
Dysphagia affects 12% of one study of 800 palliative care patients (Sykes, Baines, Carter, 1988). 30% of these were not confirmed by assessment and attributed to possible anxiety and poor appetite (Sykes, Baines, Carter, 1988). Dry mouth or inadequate chewing in edentulous patients can also cause dysphagia when no obstruction or neuro deficit exits(Morrison & Meier, 2003).
Oral Health Problems in Palliatve Care
Mouth problems left untreated can lead to further problems: difficulties with nutritional intake, infections, pain, and difficulty communicating. These problems may include dry mouth, infections or mucositis (due to chemotherapy). See Oral Healthcare Topic for management of general aging mouth problems.
Assessment, Interventions and Treatment of Mouth Problems
ConsultGeriRn Oral HealthCare and Nutrition topics
Fast Facts: Oral Mucositis Prevention and Treatment
Henson DF and Arnold R.( September 2004). Fast Facts and Concepts #121: Oral Mucositis: Diagnosis and Assessment. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.
Henson CF and Arnold R. (January 2005). Fast Facts and Concepts #130: Oral mucositis: Prevention and treatment. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.http://www.eperc.mcw.edu/fastFact/ff_130.htm
Pain in Palliative Care
Pain is the most distressing and feared symptom near the end of life (Morrison & Meier, 2003). Older persons tend to under-report pain and are often under-treated for pain(Evers, Meier, & Morrison, 2002). In addition, ageing persons often have complications from treatment however can pain be relieved in aging persons if managed appropriately (Morrison & Meier, 2003). Medical personnel have a moral obligation to provide effective pain relief and prevent unnecessary suffering, particularly in those at the end of life (AGS Ethics Committee, 2003).
Assessment, Interventions, Treatment and Family Education for Pain
Relieving Pain, Pain Algorithms, Pain in Nursing Homes and other information. Innovations in End of Life Care on–line (2002) athttp://www2.edc.org/lastacts/pain.asp
See also ConsultGeriRN Pain Topic
Other Interventions and Treatment Resources
Symptom Management: Treatment Approaches
Reproduced with permission of Promoting Excellence in End-of-Life Care, a national program of The Robert Wood Johnson Foundation. Access at:http://www.promotingexcellence.org/index.html
Treatment Tables for Specific Symptoms at: American Academy of Hospice and Palliative Medicine. Access at: http://www.aahpm.org
Guidelines for Health Workers Supporting Families in the Community
Includes symptom specific algorithms, interventions and education of families providing care at home. (European approach). World Health Organization. (2004). Palliative Care, Symptom Management and End of Life Care: Interim Guidelines for first-Level Facility Health Workers.http://ftp.who.int/htm/IMAI/Modules/IMAI_palliative.pdf
Geriatric Palliative Care. Morrison, RS and Meier, DE (eds.). (2003) order athttp://www.oup.com/us/catalog/general/subject/
AGS Ethics Committee. (2003). The care of dying patients: a position statement.Journal of American Geriatrics Society, 43, 577-578.
Alzheimer’s Association. (2005). Original Medicare: An outline of benefits. Accessed Jan 31, 2006 athttp://www.alz.org/Resources/FactSheets/FSMedicareOutline.pdf
- Bednash G. & Ferrell B. (2001). End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing.
Dean, G.E. & Anderson, P.R. (2001). Fatigue. In Ferrel, BR & Coyle, N (Eds). The Textbook of Palliative Nursing. New York: Oxford University Press, 91-100.
Dickerson, D., Benedetti C., Davis, M., Graur, P., Santa-Emma, P., et al. (2001).Palliative Care Pocket Consultant. Kendall-Hunt Publishing Company.
Evers, M.M., Meier, D.E. Morrison, R.S. (2002). Assessing differences in care needs and service utilization in geriatric palliative care patients. Journal of Pain and Symptom Management, 23 (5), 424-32.
Hospice and Palliative Nurses Association (HPNA). (1996). Clinical practice protocol: Dyspnea. Pittsburgh, PA: HPNA.
Kazanowski, M.K. Symptoms management in palliative care. (2003). In Mazo, ML & Sherman, DW. Palliative Care Nursing: Quality Care to the End of Life, 327-361. Springer Publishing Company: New York.
Matzo, ML. (2004). Palliative care: Prognostication and the chronically ill.American Journal of Nursing, 104 (9), 40-49.
Miller, K.E. (2003). News & Publications: Predicting life expectancy in patients with dementia. American Family Physician, 68 (8), 1613.
Morrison, R.S. & Meier, D.E. (eds). (2003). Geriatric Palliative Care. Oxford University Press: NY.
National Consensus Project for Quality Palliative Carea. (2004). American Academy of Hospice and Palliative Medicine & Hospice and Palliative Nursing Association Task Force. Clinical Practice Guideline for Quality palliative Care. Accessed 10/29/2005 at: http://www.nationalconsensusproject.org/
- Schonwetter, R.S., Han, B., Small, B.J., Martin B., Tope, K., Haley, W.E. (2003). Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliative Care; 20:105-13.:
Sykes, N.P. (1997). A volunteer model for the comparison of laxatives in opioid-induces constipation. Journal of Pain and Symptom Management, 11, 363-69.
Sykes, N.P., Baines, M., Carter, R.L. (1988). Clinical and pathological study of dysphagia conservatively managed in patients with advanced malignant disease.Lancet, ii, 726-28.
Tiesinag, L.J., Dassen T.W., Halfens, R.J. (1996). Fatigue: A summary of the definitions, dimensions and indicators. Nursing Diagnosis 7, 51-56.
World Health Organization (WHO). (2005). Definition of Palliative Care. Accessed 10/27/05 at http://www.who.int/cancer/palliative/definition/en/
Last updated - January 2013