Palliative Care: Back to Basics

Report
Palliative Care: Back to Basics
Dr Shirley H. Bush
Assistant Professor, Division of Palliative Care,
Department of Medicine
April 8, 2014
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[Back to Basics– Palliative Care – Dr. Shirley Bush]
Luke Fildes: The Doctor 1891
Oil on canvas, © Tate (tate.org.uk)
Overview of Session
•
•
•
•
Knowledge Quiz
In-class discussion of answers
Palliative Care overview
End of life (EOL) care
– For MCC objectives “The Dying Patient”
• Resources on One45
– Opioid Equivalency tables
• Don’t forget: The Pallium Palliative Pocketbook from Integration
Unit
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Objectives - I
• At the end of this session, students will be able to:
• Describe models of hospice palliative care and the principles on
which these are based.
• Discuss interprofessional collaboration in palliative and end-oflife care as a fundamental concept.
• Identify “total pain” incorporating the roles that psychological,
social, emotional and spiritual concerns, along with physical
symptoms, play in producing the pain experience.
• Identify the components of a holistic, interprofessional
assessment and plan of care for a terminally ill patient.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Objectives - II
•
•
•
•
Describe 3 illness trajectories.
Identify signs of approaching death.
Describe common signs of the natural dying process.
Describe preparing the patient, family and caregivers, when
death approaches.
• Complete a ‘worked example’ for prescribing opioids in an
opioid naïve patient
• Describe the pharmacological and non-pharmacological
management of patients at the end of life.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Palliative Care Knowledge Quiz
• Test your own knowledge:
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 1
• Mrs. X is taking Long-Acting Morphine tablets 30 mg by
mouth every 12 hours for her pain, which has been well
controlled.
• She is now dying, and unable to take anything by mouth.
• The appropriate change in medication should be:
–
–
–
–
(a) 10 mg subQ q4h
(b) 5 mg subQ q4h
(c) 5-10 mg subQ q4h prn only
(d) crush the tablets, dissolve them in water, and administer same
medications buccally
– (e) 30 mg subQ q12 hours
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 2
• The dose conversion ratio of morphine to oxycodone in the
setting of palliative care is:
(a) 10 mg po of morphine = approximately 5-7.5 mg po of oxycodone
(b) 10 mg po of morphine = approximately 15 mg po of oxycodone
(c) 10 mg po of morphine = approximately 20 mg po of oxycodone
(d) 10 mg po of morphine = approximately 10 mg po of oxycodone
(e) 10 mg po of morphine = approximately 1 mg po of oxycodone
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 3
• A 45-year-old, 60-kg cancer patient with severe pain (8/10)
related to metastatic bone disease is in need of a strong
opioid. You decide to initiate him on a morphine regimen. He
has not previously been on a strong opioid. What starting
dose would you use?
(a) Morphine (long acting formulation) 30 mg orally twice a day and
morphine (short-acting formulation) 5 mg orally every hour as needed (prn)
for breakthrough pain.
(b) Morphine (short-acting) 5-20 mg orally every 4 hours and morphine 5 mg
orally every hour as needed (prn) for breakthrough pain.
(c) Morphine (short-acting) 5 mg orally every 4 hours and 5 mg orally every
hour as needed (prn) for breakthrough pain
(d) Morphine (short-acting) 5 mg orally every hour as needed (prn) for pain.
(e) Morphine (short-acting) 5mg orally four times a day and 5mg orally as
needed (prn) for breakthrough pain.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 4
• Which one of the following opioids is not recommended for
chronic pain management in palliative patients?
(a) Meperidine (Demerol)
(b) Codeine
(c) Methadone
(d) Oxycodone
(e) Fentanyl
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 5
• A 67 year-old man with advanced lung cancer and bone metastases is
taking slow release morphine 90 mg orally q12h. In the last two days he
has complained of increased generalized pain and his family have noticed
that he has become agitated, developed generalized myoclonus (muscles
twitching) and has started “picking at the air”.
• Which one of the following is the most appropriate change to make to his
opioid regimen?
(a) Switch his morphine to short acting hydromorphone at a dose of 8 mg orally q4h
(b) Switch his morphine to short acting hydromorphone at a dose of 4 mg orally q4h
(c) Increase the morphine dose to 120mg orally twice a day.
(d) Switch his opioid to transdermal fentanyl at a dose of 25 micrograms/hr every 3
days.
(e) Continue the morphine at the current dose and add baclofen to control the muscle
twitches.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 6
• A 48 year-old man with advanced cancer presents with
delirium. He has cognitive impairment, mild agitation and
disturbing visual hallucinations. While searching for the
underlying causes, which one of the following treatments
would you initiate to control his delirium-related problems?
(a) Haloperidol 1mg orally q8hrs and haloperidol 1mg every hour if needed.
(b) Diazepam 5 mg to 10 mg orally twice a day and 5mg every hour if needed.
(c) Lorazepam 2mg orally or sublingually three times a day and 1mg every
hour if needed.
(d) Methotrimeprazine 12.5mg orally q12hrs and 12.5mg every hour if
needed.
(e) Midazolam: a bolus dose of 2.5mg subcutaneously followed by a
continuous infusion of 1mg to 4mg/hour titrated to control his agitation.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 7
• Joe D. is a 73 year old man who was prescribed an opioid for
severe pain, due to metastatic prostate cancer, 2 days ago.
The medication has made him feel very nauseated. The most
appropriate first-line antiemetic which has its main effect on
the chemoreceptor trigger zone is:
(a) Dimenhydrinate (Gravol)
(b) Metoclopramide (Maxeran)
(c) Ondansetron (Zofran)
(d) Cannibinoid derivative (Marinol or Cesamet)
(e) Prochlorprazine (Stemetil)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 8
• The presence of dyspnea in a terminally ill patient is best
determined by:
(a) A patient expressing that he is short of breath, without any other
objective measures.
(b) A patient expressing that he is short of breath, PLUS the use of accessory
breathing muscles.
(c) A patient expressing that he is short of breath, PLUS tachypnea
(d) A patient expressing that he is short of breath, PLUS hypoxia or
hypercarbia
(e) The presence of the use of accessory breathing muscles and tachypnea.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 9
• A 68 year old man with progressive amyotrophic lateral
sclerosis (ALS) presents with increasing weakness and
shortness of breath, even at rest. He has no symptoms or
signs to suggest a pneumonia. Which one of the following
would be the most appropriate first-line symptomatic
management of his dyspnea at this time?
(a) Morphine 5mg nebulized (via an airway mask) every 4 hrs and every hour
as needed (prn).
(b) Morphine 5mg orally every 4 hrs and 5mg orally every hour as needed for
dyspnea.
(c) Lorazepam 1mg orally or sublingually three times a day.
(d) Non-invasive airway support with BIPAP.
(e) Tracheostomy with artificial ventilation.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 10
• You have just written a prescription for hydromorphone
(Dilaudid) for a patient. You must also write a prescription for
a laxative. The best choice is:
(a) a stool softener, such as docusate sodium
(b) an enema, if needed
(c) a bowel stimulant e.g. senna derivatives or an osmotic agent
(d) a glycerine suppository
(e) methylnaltrexone
[Back to Basics– Palliative Care – Dr. Shirley Bush]
And now the Answers……
• These will be discussed in class
[Back to Basics– Palliative Care – Dr. Shirley Bush]
WHO Definition of Palliative Care - 2005
• “Palliative Care - an approach that improves QOL 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 problems, physical,
psychosocial and spiritual”.
• http://www.who.int/cancer/palliative/definition/en/
• (Page not available in French)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
• Effective palliative care requires a broad
multidisciplinary and interprofessional approach that
includes the family and makes use of available
community resources
• It can be successfully implemented even if resources
are limited
[Back to Basics– Palliative Care – Dr. Shirley Bush]
CHPCA Models of Palliative Care
(2002)
• Model
• Realistically
Bereavement
Care
Bereavement
Care
Therapy to cure or
control disease
Therapy to cure
or control
disease
Palliative
approach to care
Palliative
approach to care
Illness Trajectory
Illness trajectory
Dx
Death
Dx
Death
Aspects/Domains of Holistic Care
Physical, e.g.
-Disease management
-Pain & other symptoms
-Function
-Nutrition habits
-Physical activity
Social/Cultural, e.g.
-Finances
-Relationships
-Personal routines
-Recreation
-Vocation
-Rituals
-Legal issues
-Family caregiver support
-Practical
Psychological, e.g.
-Personality
-Psychological symptoms
-Emotions
-Control & dignity
-Coping responses
-Self image/ self esteem
-Loss & Grief
Spiritual, e.g.
-Meaning & values
-Existential issues
-Beliefs
-Spirituality
-Rites & rituals
-Symbols & icons
-Loss & Grief
-Life transitions
-Religions
Adapted from: “Domains of Issues Associated with Illness and Bereavement” in A Model to Guide Hospice Palliative
Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page 15.
Interprofessional (IP) Team Work
• Patients and families are experiencing a variety of needs representing the
different facets of their reality.
• In order to meet these needs which are often complex, the perspectives,
skills and resources of a variety of professionals are required.
– Physician collaborates with…….
•
•
•
•
•
•
•
•
•
•
Nurse (RN, RPN, APN, PCA – Personal Care Assistant)
Dietician/ Speech Language Pathologist (SLP)
Pharmacist
Physiotherapist/ Occupational therapist (PT/OT)
Psychologist
Recreation therapist
Social worker
Spiritual care professional/ Chaplain
Volunteer
Patient and family
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Medical Care of the Dying, 4th ed. Victoria Hospice Society; 2006
Conceptual Model of level of need within the population of
patients with a life limiting illness
A Guide to Palliative Care Service Development: a population based
approach . PCA 2005. Available at: http://www.palliativecare.org.au
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Episode of Care scenarios to meet Palliative Care needs
A Guide to Palliative Care Service Development: a population
based approach . Palliative Care Australia (PCA) 2005.
Available at: http://www.palliativecare.org.au
[Back to Basics– Palliative Care – Dr. Shirley Bush]
W.H.O. 3-step Analgesic Ladder
Opioid for
moderate to
severe pain
Non-opioid
e.g. paracetamol,
NSAIDs
+/– Adjuvant
STEP 1
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Opioid for mild
to moderate
pain
+/– Non-opioid
+/– Adjuvant
+/– Non-opioid
+/– Adjuvant
STEP 3
STEP 2
Pain persisting or increasing
W.H.O. Analgesic “Ladder”
• Promoted 3 important concepts world-wide:
• By Mouth
• By the Clock
• By the Ladder
• N.B. not designed for use in isolation
• Is there still a role for Step 2?
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Initiating Opioids: “Worked example”
• Bernard is a 65 year old retired policeman who was diagnosed
with colon cancer 18 months ago.
• After surgery, his disease initially responded to
chemotherapy, but has now recurred with metastases to the
liver and peritoneum.
• He is experiencing increasing abdominal pain.
• He rates the pain as 6/10.
• He has been taking extra strength acetaminophen (1 to 2
tablets 3 to 4 times a day) with minimal effect.
• Q: Bernard has moderate to severe pain: What opioid would
you choose, and why? What starting dose?
[Back to Basics– Palliative Care – Dr. Shirley Bush]
“Worked example”: Answers
• Bernard is opioid naïve.
• Suggested starting doses:
– Morphine (IR) 5mg po q4hrs straight + 2.5 or 5mg po q1-2hr prn as
‘rescue’ dose/for breakthrough pain
– Hydromorphone (IR) 1mg po q4hrs straight + 0.5 or 1mg po q1-2hr
prn
• For ‘rescue’ dose:
– Generally, it is 10% of total daily dose.
– It should be titrated, so could be anything between 5-20% of total
daily dose if needed.
– If patient needs 3 or more ‘rescue’ doses/24 hours, the regular
opioid dose should be increased (assuming opioid-responsive
pain)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Commencing Opioids
Common starting dose
Starting dose in frail, weak
patients or patients with
severe COPD
Morphine
5 – 10mg PO q4H straight
2.5 – 5mg PO q4H straight
Hydromorphone
1– 2mg PO q4H straight
0.5 – 1mg PO q4H straight
Oxycodone
2.5 – 5mg PO q4H straight 1 – 2.5mg PO q4H straight
(1) Discuss Opioid fears and misapprehension with patient: ‘Morphine Myths’
(2) Do also prescribe a ‘Rescue ‘ dose of IR (Immediate release) opioid for
‘breakthrough’ or ‘episodic’ pain: 10% of total daily dose
(3) Also see OPIOID EQUIVALENCY tables: on One45
[Back to Basics– Palliative Care – Dr. Shirley Bush]
When Commencing Opioids: Manage Potential
Side Effects
• Discuss potential side effects and strategies with patients
• Constipation: occurs in majority of patients and does not
resolve spontaneously
– Regular laxative e.g. senna, lactulose
• Nausea: in up to 2/3 of patients, but usually subsides within
3-7 days
– Antiemetic e.g. metoclopramide, haloperidol
• Somnolence/ Sedation: usually temporary for a few days
– Advise patient not to drive following opioid initiation, opioid
switch, significant dose increase for at least 5-7 days,
or if uncontrolled pain
• Respiratory depression (RR less than 8/min):
• Extremely low risk if appropriate starting dose and appropriate
titration
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• Q: How would you titrate the opioid dose up, if Bernard’s pain
remains poorly controlled?
• Method 1: Increase the dose by 20-30%
• Method 2:
– Add up the # of ‘rescue’ doses used in previous 24 hours
– Add these to the total dose of regularly scheduled doses over
last 24 hour period
– Now divide this total by 6 to get the new 4-hourly dose
• Q: Bernard is now on Morphine 10mg po q4hr and taking 4-5
PRN doses of 5mg/day: What would you prescribe now?
• Morphine 15mg po q4hrs straight
• Don’t forget to increase ‘rescue’ dose too
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• 2 weeks later, Bernard’s pain is under good control (2/10). He
is now on Morphine (IR) 20mg po q4hrs straight, and taking
only 1 -2 ‘rescue’ doses a day. He finds the q4hr regimen
inconvenient.
• Q: What dose of slow release morphine would you start?
• Slow release Morphine 60mg po q12hrs
• And continue IR Morphine for breakthrough pain
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• Bernard’s disease progresses. He is managing at home with his
wife, family, and community team (Family physician and home
care nursing). He now develops vomiting from a bowel
obstruction.
• Q: How will you control his pain now that the oral route is no
longer working?
• Change to subcutaneous route.
• Generally, the po to subcut conversion dose for Morphine and
Hydromorphone is 2:1
• Morphine SR 60mg po q12hrs = 120mg po/24 hours
• = 60mg subcut/24hrs = 10mg subcut q4hr straight
• Add subcut option for breakthrough pain (5mg subcut q1hr prn)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Illness Trajectories
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Murray SA , et al. BMJ 2008,336,958-9
3 Triggers for Palliative/ Supportive Care
• (1) The ‘Surprise’ Question:
– Would you be surprised if this patient were to die in the
next 6 - 12 months?
• (2) Choice/Need
• (3) Clinical indicators: Specific indicators of advanced disease
for each of the 3 main EOL patient groups
• Prognostic Indicator Guidance from the Gold Standards
Framework ™
• Available @
• www.goldstandardsframework.org.uk
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Prognosis: “Doctor: How long do I have to live?”
• How frequently is the
patient observed to
decline?
The Thinker, Auguste Rodin, 1902
– Every Month: estimated
prognosis of months
– Every Week: estimated
prognosis of weeks
– Every Day: estimated
prognosis of days
– Every Hour: estimated
prognosis of hours
BUT with caveat: in setting of advanced cancer, patient’s condition
can change very quickly (Another disclaimer: life expectancy can be longer)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
See Chapter 4 in Pallium Palliative Pocketbook
Goals of Care
• Establish patient’s Goals of Care
• Assess the patient and/or family’s knowledge of the illness
and prognosis
• Assess priorities
– Comfort – Allow a Natural Death
– Life-prolongation
– Special events
• Communication: Is everyone on the same page?
– Role for Family Meeting
• Detailed documentation, including ‘level of care’, code status
[Back to Basics– Palliative Care – Dr. Shirley Bush]
See Chapter 3 in Pallium Palliative Pocketbook
The Normal Dying Process - The Last Days
•
•
•
•
•
•
•
Weaker: need assistance with all care
Bed-bound
Reduced oral intake - food/ fluids
Difficulty swallowing oral medications
Drowsy or reduced cognition and difficulty concentrating
More time asleep
Some symptoms may increase e.g. delirium, dyspnea
• “Withdraw” - say their goodbyes
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Signs that Death is Imminent: “days to hours”
• Explain these signs to the family and other caregivers:
• CNS: Refractory delirium (in up to 85% of patients @ EOL),
(N.B. exclude reversible causes e.g. urine retention, opioid toxicity),
Reduced consciousness
• RESP: Rate, pattern
– Altered breathing
• Cheyne-Stokes respiration
• Periods of apnea
• Agonal breathing
– Profuse upper airway secretions – “terminal respiratory
congestion” or “death rattle”
• CVS: Weak and rapid pulse, decreased capillary refill
• SKIN: Cold extremities, mottling of periphery (hands, feet, legs)
• GU/GI: Reduced output
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Terminal Respiratory Congestion: “Death Rattle”
•
•
•
•
Inability to clear secretions from oropharynx and trachea
Relaxation of pharynx
Noisy “rattling” respiration
Patients usually unconscious/ semi-conscious and too weak to
expectorate – likely not distressing to patient
– Explain to and reassure family
• Nursing care
–
–
–
–
Nurse semi-prone
Nurse side to side
Maintain scrupulous oral hygiene
Suction rarely required
• Light oral suctioning may be needed – avoid deep suctioning
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Terminal Respiratory Congestion Management contd.
• Discontinue parenteral fluids
• Anticholinergic drugs may be required….
– Reduce production of pharyngeal secretions
– ? Less effective on chest secretions compared with oral
secretions
– E.g. Glycopyrrolate 0.2 – 0.4 mg subcut. q2-4 hr PRN
– E.g. Hyoscine hydrobromide (Scopolamine™) 0.2 – 0.4 mg
subcut. q2-4 Hr PRN
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Still
Active Management of Symptoms
• Prepare patient and family (Difficulty with prognostication)
• Full nursing cares - for patient comfort and dignity
–
–
–
–
–
–
Eyes: Artificial tears, lacrilube
Nose: Reassess nasal prongs, salinex
Oral hygiene: Regular mouth care, moisture spray, gels
GI: Suppository PRN
GU: Pads, Foley catheter PRN
Skin: Pressure area care (Including mattress)
• Ongoing review and relief of physical symptoms
–  delirium,  dyspnea @ EOL
• Psychosocial (settle affairs)/ spiritual and/or religious needs
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Preparing for Death
• Communication with family: explanation and support
• Clinical management
– Vitals – discontinue
– Investigations – discontinue
– Life-prolonging treatments
• Evaluate benefit, role in ongoing symptom management
• Stop non-essential medications/ ? Discontinue oxygen
– Comfort treatments – continue/ institute
• Appropriate dosing & schedule
– Parenteral route for medications (subcut. route generally) when
patient no longer able to swallow/ in anticipation of this
• Review role for Medically Assisted Hydration & Nutrition
• Deactivate Implantable Cardioverter Defibrillator (ICD)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Review Venue of Care
• Knowledge of options available
• ? Hospital vs. Palliative Care unit vs. hospice vs. nursing home
vs. home
• Single room if possible
• If needed, liaise with Palliative Care Hospital Consult service
– Liaise with Family Physician – As Early as possible
– Community palliative care team (24 hr cover) - RPCT
– Referral to community nursing service (CCAC)
• Supply of drugs with medication orders, hospital bed and
other equipment, ?Foley catheter, ? Dressings, ??Oxygen
• Insert indwelling Subcut. butterfly needle
• Urgent ambulance home
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Planning for Crises
• Community: Supply of emergency drugs at home
– E.g. Subcut. opioid, neuroleptic, antiemetic, benzodiazepine,
anticholinergic (EOL)
• Risk of Hemorrhage
• E.g. Carotid hemorrhage in Head and Neck (H&N) cancer
• E.g. Massive GI bleed, massive hemoptysis
– Discuss with family and staff
– Green towels
– Catastrophic order/ Crisis pack
• Midazolam 5- 10mg subcut. (or I.M.), +/- Usual opioid rescue dose
and repeat q5 minutes PRN if needed
– Stay with patient (At home, family not to call 911)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Essential Medications at EOL ……
• Cessation or subcut. conversion of oral medications
– Consider continuous Subcut. infusion
• ? Opioid (e.g. for pain, dyspnea)
• +/- Neuroleptic for delirium
– E.g. Haloperidol, methotrimeprazine (Nozinan™)
• +/- Sedative agent for refractory delirium, refractory dyspnea
at the end of life
– E.g. Midazolam, lorazepam, methotrimeprazine (Nozinan™),
phenobarbital
• +/- Antiemetic
• +/- Anticholinergic for respiratory secretions
– E.g. Glycopyrrolate, hyoscine
• Review parenteral fluids/ oxygen
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Caring for Patients - and Families - at the End of Life
•
•
•
•
•
Address fears and concerns
Reassurance where appropriate
? Hearing and Touch last senses to go
Suggest notifying family/ friends, especially if overseas
Consider allied health support (social work, spiritual care,
psychology) if not already involved
• Ensure family members looking after selves (eating, drinking,
sleep)
• “Keeping vigil”: Give permission for family to leave room and
take breaks, or create a roster for family shifts
• Enquire if any cultural or religious/spiritual needs for end of
life care, and after death
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Orienting Ourselves for End of Life (EOL) Care
• Reflective Discussion Video – Orienting Ourselves for Hospice,
Palliative & EOL Care (5 minutes)
• From pallium.ca
• http://www.youtube.com/watch?v=sP4Fkjn3OwU
[Back to Basics– Palliative Care – Dr. Shirley Bush]
• Any Questions…..
• Please feel free to contact me:
• [email protected]
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Guerir quelquefois
Soulager souvent
Consoler toujours
To cure occasionally
To relieve often
To comfort always
Death in the sickroom, Edvard Munch, 1895
[Back to Basics– Palliative Care – Dr. Shirley Bush]

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