Bernie Wiebe, MD
Roger Lemmen, MD
Carol Butler, MD

Bernie Wiebe, MD
Board Certified in Family Medicine and in Hospice and Palliative Medicine

Q: Is a feeding tube a good option for a patient who has dementia and who can no longer eat?

A: Tube feeding does not reduce suffering, nor does it prolong the lives of people with severe dementia.  Gentle spoon feeding is better.

Q: If I take narcotics to control my pain, will I become an addict?

A: People do not become addicted when they use narcotics for the right reasons, and as directed.

Q: Are there circumstances when radiation would be beneficial for the hospice patient?

A: Radiation can be used in hospice patients to relieve pain from certain kinds of tumors.

Q: If my loved one does not want to eat and I abide by his wishes, am I starving him?

A: The natural course of disease towards death often involves loss of desire and ability to eat.  This does not constitute starvation as such, as the underlying disease will cause the death.

Q: Are there times you would use an antibiotic in hospice care?

A: If use of antibiotics will relieve symptoms like pain or difficulty breathing, their use would be appropriate.

Roger Lemmen, MD
Board Certified in Neurology, in Pain Management, and in Hospice and Palliative Medicine

Q: What are some examples of how methadone has been used successfully?

A: Methadone, in essence, is our most effective opioid.  This is because it is not only an opioid, but also a potent NMDA blocker, and it has antidepressant activities in addition.  Methadone really needs to be used at low dose to begin with especially.  It is usually most effective at low dose.  In a general chronic pain population that had been on opioids for their pain, rotating to methadone on average, one could state that 90% of the patients have 50% improvement in their pain.  This is an estimated average of what patients have said over the last more than ten years of using methadone as the preferred long-acting opioid.  It should be used by physicians that are experienced with its' use and are fully versed in the uniqueness that methadone has.  In that context, it can be used with expected safety.  Usually, when compared to the other opioids, methadone has better pain control with less side effects and is much less expensive.

Q: My loved one, who has dementia, is having aggressive outbursts.  Could there be an underlying cause to their outbursts besides their dementia disease?

A: In dementia, individuals that have outbursts or apparent distress, restlessness, aggressive behavior, etc., it is expected that the majority may have some underlying “discomfort.”  Some studies suggest 80-90% of patients with dementia and abnormal behavior may show some improvement if they are treated for pain.  Commonly, trials of various interventions including a focus on pain management are advised to attempt identifying measures that clearly help the individual with dementia.  A patient with dementia is almost never helped by things that sedate them.  Sometimes sedation cannot be completely avoided, though it is felt it is always preferred to attempt looking for, and addressing, potentially reversible causes of “outbursts” as the best possibility before simply attempting to “suppress” behaviors.  In other words, a trial-and-observe process looking for interventions that clearly help the patient is certainly preferred before one would simply expect that behaviors would be a natural part of a dementia process.

Q: Does Palliative Care only focus on pain?

A: Palliative Care is a general focus on pain and symptom management.  The goal, in essence, is to help individuals be more comfortable and focus on enhancing quality of life as best possible.   Other issues that Palliative Care can focus on include essentially any distressing factor, but also behavioral issues, nausea, vomiting, anxiety, depression, breathlessness, fatigue, weakness, etc.

Q: Do I have to be at the end of life to receive Palliative care services?

A: Palliative Care intervention does not require one to be at end of life.  Commonly, Palliative Care patients may have more serious or difficult medical situations with pain and symptom issues involved.  There are no specific age restrictions, and there is no restriction on life expectancy.  Palliative Care is separate from hospice.  Hospice does have specific requirements for eligibility of life expectancy of less than six months, though, as stated, with Palliative Care it does not have that requirement.

Q: If I do not have a family physician, how can I receive Palliative Care services?

A: It is certainly preferred that patients have a “family physician.”  This would promote general well-being and care and would be a nearly necessary and appropriate component to the “team” that may care for patients in a time of need.

Carol Butler, MD
American Board of Pediatrics

Q: Can narcotics be used in children?

A: Absolutely. Narcotics work much the same in children as in adults and though we have to dose the medicine based on the child's weight, narcotics can be very useful and helpful in managing pain in children on hospice.

Q: What are some common symptoms that hospice addresses with children?

A: Anxiety, often because they are worried about their family members, not themselves. Pain is also a common symptom that we address. The most common "symptom" we address is just allowing the kids to be kids as much as we can.

Q: How does hospice support the child's parents and siblings?

A: I believe that the whole hospice team supports the parents and siblings, much as they do with adults. We have Social Workers that can develop memory books and pictures with siblings and help the parents negotiate end of life issues like funeral arrangements. Social Workers sometimes will work with the family and the Make a Wish Foundation to help make a dream come true for a child. The physician is there to help with management of symptoms and support parental decisions regarding health care. Volunteers are valuable supports for the family and siblings, possibly staying in the home while the parent goes grocery shopping or has a few minutes away. They may also provide their time and support by staying with siblings while parents are attending to the child and funeral arrangements after death. Hospice Aids come to the home to provide a variety of services from helping bathe the child to helping feed the child to helping with some household chores, thus allowing a parent to spend more time with their child.

Q: If it is too difficult to bring my baby to you, as a hospice physician would you make a home visit?

A: Yes, most of my visits to hospice children are in the home.

Q: Why would I choose hospice for my child?

A: Unfortunately, sometimes children are born with life limiting illnesses or develop illnesses that will limit their life. Though many childhood cancers are curable today, there are some that are not. In this instance, when there is no further curative treatment available, parents may choose to focus on the quality of life their child has instead of trying to prolong their child's life with aggressive, yet not curative, treatments. These parents are generally interested in controlling symptoms as much as possible, having the child at home whenever possible, and letting the child do what children love to do, live life in the moment and have as much fun as possible. Sometimes children are born with genetic or developmental abnormalities for which there is no cure or treatment. This is another instance where parents may choose to focus on the quality of life their child has and not pursue aggressive and futile treatments that may prolong life but not improve quality and may actually decrease quality due to side effects or need to be in the hospital instead of at home where kids are happiest.