Text 18 Palliative Care and Pain Managemet

The focus of palliative care is to improve symptoms and quality of life at any stage of illness. At the end of life, palliative care often becomes the only focus of care, but a palliative care approach is applicable throughout the course of both serious chronic and terminal illnesses.

Whether the goal is to cure disease or manage chronic illness, clinicians have a responsibility to help ameliorate patients’ suffering. “To cure sometimes, to relieve often, to comfort always” is the crux of palliative care.

The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Palliative care commonly involves management of pain, but treatment of all symptoms is pursued, including physical symptoms, such dyspnea, nausea and vomiting, constipation, and agitation; emotional distress, such as depression, anxiety, and interpersonal strain; and existential distress, such as spiritual crisis. While palliative care has been recognized formally as a medical specialty by the American Board of Medical Specialties, all clinicians should possess the basic skills to be able to manage pain, treat dyspnea, identify possible depression, communicate about important issues (such as prognosis and patient preferences for care), and help address spiritual distress. While palliative care experts are increasingly available in hospital and outpatient settings and while expert consultation may be helpful for many patients, recognizing the importance of symptom management and quality of life is a necessary step for all clinicians in helping patients face serious illness.

Symptoms that cause significant suffering can be considered a type of medical emergency and managed aggressively by frequent elicitation, continuous reassessment, and individualized treatment. While patients at the end of life may experience a host of distressing symptoms, pain, dyspnea, and delirium are reported to be among the most feared and burdensome. The principles of excellent palliative care dictate that comfort is the main focus of care and that properly informed patients or their surrogates may decide to pursue aggressive symptom relief even if, as a known but unintended consequence, the treatments preclude further curative interventions or even hasten death. That said, there is a growing awareness that scrupulous symptom control for patients with end-stage illness may actually prolong life.

Text 19 Community-Acquired Pneumonia Definition & Pathogenesis

Community-acquired pneumonia is diagnosed outside of the hospital or is diagnosed within 48 hours after admission to the hospital in a patient who has not been hospitalized in an acute care hospital for 2 or more days within 90 days of the infection; or has resided in a long-term care facility; or has received intravenous antimicrobial therapy, chemotherapy, or wound care within the 30 days prior to the current infection; or has attended a hospital or hemodialysis clinic.

Pulmonary defense mechanisms (cough reflex, mucociliary clearance system, immune responses) normally prevent the development of lower respiratory tract infections following aspiration of oropharyngeal secretions containing bacteria or inhalation of infected aerosols. Community-acquired pneumonia occurs when there is a defect in one or more of the normal host defense mechanisms or when a very large infectious inoculum or a highly virulent pathogen overwhelms the host.

Prospective studies have failed to identify the cause of community-acquired pneumonia in 40–60% of cases; two or more causes are identified in up to 5% of cases.

Bacteria are more commonly identified than viruses. The most common bacterial pathogen identified in most studies of community-acquired pneumonia is Spneumoniae, accounting for approximately two-thirds of bacterial isolates. Other common bacterial pathogens include H influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, S aureus, Neisseria meningitidis, M catarrhalis, Klebsiella pneumoniae, other gram-negative rods, and Legionella species. Common viral causes of community-acquired pneumonia include influenza virus, respiratory syncytial virus, adenovirus, and parainfluenza virus. A detailed assessment of epidemiologic risk factors may aid in diagnosing pneumonias due to the following causes: Chlamydia psittaci (psittacosis), Coxiella burnetii (Q fever), Francisella tularensis (tularemia), endemic fungi (Blastomyces, Coccidioides, Histoplasma), and sin nombre virus (hantavirus pulmonary syndrome).

Clinical Findings

A. Symptoms and Signs

Most patients with community-acquired pneumonia experience an acute or subacute onset of fever; cough with or without sputum production, and dyspnea. Other common symptoms include rigors, sweats, chills, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, headache, and abdominal pain.

Common physical findings include fever or hypothermia, tachypnea, tachycardia, and mild arterial oxygen desaturation. Many patients will appear acutely ill. Chest examination is often remarkable for altered breath sounds and rales. Dullness to percussion may be present if a parapneumonic pleural effusion is present.

The differential diagnosis of lower respiratory tract symptoms and signs is extensive and includes upper respiratory tract infections, reactive airway diseases, congestive heart failure, COP, lung cancer, pulmonary vasculitis, pulmonary thromboembolic disease, and atelectasis.

B. Laboratory Findings

Controversy surrounds the role of Gram stain and culture analysis of expectorated sputum in patients with community-acquired pneumonia. Most reports suggest that these tests have poor positive and negative predictive value in most patients. Some argue, however, that the tests should still be performed to try to identify etiologic organisms in the hope of reducing microbial resistance to drugs, unnecessary drug costs, and avoidable side effects of empiric antibiotic therapy. Expert panel guidelines suggest that sputum Gram stain should be attempted in all patients with community-acquired pneumonia and that sputum culture should be obtained for all patients who require hospitalization. Sputum should be obtained before antibiotics are initiated except in a case of suspected antibiotic failure. The specimen is obtained by deep cough and should be grossly purulent. Culture should be performed only if the specimen meets strict cytologic criteria, eg, more than

25 neutrophils and fewer than 10 squamous epithelial cells per low power field. These criteria do not apply to cultures of legionella or mycobacteria.

Additional testing is generally recommended for patients who require hospitalization: preantibiotic blood cultures (at least two sets with needle sticks at separate sites), arterial blood gases, complete blood count with differential, and a chemistry panel (including serum glucose, electrolytes, urea nitrogen, creatinine, bilirubin, and liver enzymes). The results of these tests help assess the severity of the disease and guide evaluation and therapy. HIV serology should be obtained from all hospitalized patients.