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End of Life Care
- 1. Care of PatientsFacing the End of Life and Their Families M. Elizabeth Paulk, M.D., F.A.C.P. July 13, 2015
- 2. M. Elizabeth Paulk,M.D. has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on or near, patients. Disclosure of Financial Relationships
- 3. Welcome! Don’t worry– it is all going to be ok. Do it right – you get the credit. Do it wrong – it’s the resident’s fault. Believe it or not – it will be fun
- 4. The English viewdeath as imminent, Canadians view death as inevitable, Americans view death as optional. - unknown
- 6. Anticancer Treatment Cancer pain reliefand palliative care Anticancer Treatment Traditional Allocation of Resources Proposed Model of Resource Allocation Cancer pain relief and palliative care
- 7. Palliative Care Makinglife as easy as possible for patients and families living with serious illness Our team: MD, Social Worker, Nurse, Chaplain, MA, and Clerk What we do: Consults, Clinics When to call us: life expectancy < 1 year How to call us: Janice 2-5805, or page through directory
- 8. Inpatient Consults Painand Symptom Management Social Work Disasters Discussion of Goals of Care: ◦ Artificial nutrition/hydration ◦ DNR status ◦ Breaking bad news Clinic follow-up PLEASE – have a question in mind when you call. Please – if patient has been seen, call the provider who wrote the note!
- 9. Clinic Visits Painand Symptom management Discussion of Goals of Care Provide a home, close follow-up for patients and their families
- 10. Reality of theEvidence in Palliative Medicine What does the evidence support? ◦ Very little evidence available Patients are ill Drugs are mostly generics What do clinicians actually do in practice? ◦ Almost entirely empiric ◦ Things that are cheap
- 11. End of Lifein the ICU 10-20% of all ICU patients die Often illnesses are unanticipated – little previous discussion of illness with family Prognostication variable Culture of aggressive treatment Patients not generally able to participate ◦ May seem dehumanized by circumstances
- 12. © 2004 LippincottWilliams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2 Symptom Burden in the Chronically Critically Ill The symptom burden of chronic critical illness *. Nelson, Judith; MD, JD; Meier, Diane; Litke, Ann; Natale, Dana; Siegel, Robert; Morrison, R Critical Care Medicine. 32(7):1527-1534, July 2004. Percent of patients reporting at least one symptom episode rated as moderate or severe (n = 36).
- 13. Simple Strategies forSymptom Management in ICU Good oral care helps mitigate thirst Hunger relieved by feeding Actively elicit symptoms and treat ◦ Dypsnea ◦ Pain ◦ Depression ◦ Anxiety To the extent it is safe and feasible, minimize sleep disruption and liberalize visitation Optimize communication
- 14. Five Most Common Symptoms Pain Nausea/vomiting Breathlessness Weight loss Weakness / fatigue Brunnhuber, K., Nash, S., Meier, D.E., et al (2008). Putting evidence into practice: Palliative care (BMJ Group). Retrieved from Clinical Evidence website: http://clinicalevidence.bmj.com/downloads/end-of-life.pdf
- 15. Pain is amore terrible lord of mankind than even death itself. Albert Schweitzer
- 16. Basics of PainManagement Use a pain scale WHO pain ladder Use standing doses, not prn Always have a breakthrough pain plan ◦ 10% of daily opioid dose q 1-2 h ◦ Reassess dosage needs daily
- 17. Assessment of Pain PQRST ◦ P = Provoking/Palliating factors ◦ Q = Quality in patient’s own words ◦ R = Radiates ◦ S = Severity ◦ T = Time • Interference with activities, degree to which patient is bothered • Goals for management • Recommended instruments: • McGill Pain Questionnaire (MPQ) and its short form (SF-MPQ) • Edmonton Symptom Assessment System (ESAS), and • Memorial Symptom Assessment Scale (MSAS) • For patients with dementia: • Many dementia patients can use established scales • Observational pain scale underestimates patients’ estimate of pain Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 18. Pain assessment scales. AbrahmJ L , Ann Intern Med 1999;131:37-46 ©1999 by American College of Physicians
- 19. WHO 3-step Ladder 1 mild(1-3) 2 moderate (4-6) 3 severe (7-10) Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants
- 20. Practical Issues inPain Management KISS WHO Step one : ◦ Use your favorite NSAID &/or APAP Be vigilant for contraindications Protect the stomach • WHO Step two: • Pick the combination agent of your choice • Watch APAP doses • WHO Step three: • Hydrocodone:morphine is 1:1 • Dose your pure opioid agents like insulin: • long acting basal agent (e.g., MSContin) • short acting rescue as needed (MSIR or morphine elixir) For patients who need a change in route of administration, remember that conversion of oral MSO4 to IV 3:1 PREVENT CONSTIPATION!
- 21. The Pain Curve Time OpioidLevel PainThreshhold Pain Threshhold
- 22. Texas Triplicate Requirement All schedule 2 prescriptions have to be written on a special form called a Triplicate. It is not actually a triplicate form – just one piece of blue paper. YOUR ATTENDING MUST WRITE THIS so make sure it gets done during rounds. You can write for one month, no refills.
- 23. Practical Concerns about Opioids •Risk of addiction low when used properly* • Respiratory depression unlikely at recommended doses • New drugs no better than morphine • Regulatory issues • Thoroughly review and document pmhx, sochx, functional status, response to medications ◦ For check list of best practices: http://hrsa.dshs.wa.gov/Pharmacy/Best_Practi ces_Summary_Checklist.pdf Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 24. Biblical Tenet ofPalliative Care The hand that doth hold the pen that scribes the opioid, yea let that hand also prescribe the laxative.
- 25. Myths and Misconceptions: Hospice No inpatient hospices in Dallas DNR NOT required for home hospice Full-time caregiver in the home NOT REQUIRED Cannot be arranged on the day of discharge LONG waiting list for non-funded patients (01, 20) - 2 to 3 weeks Meds, DME not provided for non-funded patients
- 26. Neuropathic Pain TricyclicAntidepressants (1 in 3 pts respond) ◦ Desipramine, other TCA’s, venlafaxine ◦ Use limited by CV adverse effects Gabapentin/Pregabalin (1 in 4 patients respond) ◦ usual effective dose 900–1800 mg / d; max may be > 3600 mg / d ◦ minimal adverse effects ◦ drowsiness, tolerance develops within days • Systemic administration of local anesthetics • Lidocaine or mexiletine effective in 30 RCT’s Combination may be the most effective Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 27. Bone pain Metastasisto bone ◦ 70% of pt with prostate, breast CA ◦ 30% of pt with thyroid, lung, bladder CA Multidisciplinary approach, including: Analgesics: opioids, NSAIDs Disease modifying therapy (chemotherapy, hormone therapy) Corticosteroids Bisphosphonates Radiopharmaceuticals (strontium, samarium) External beam radiation Orthopedic intervention External bracing Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 28. Depression Loss of socialposition, job, prestige, income Loss of role in family Insomnia, chronic fatigue Sense of helplessness Disfigurement Anger Bureaucratic bungling Delays in diagnosis unavailable physicians uncommunicative physicians Failure of therapy Friends who do not visit Total Pain Anxiety Fear of hospital or nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest, uncertainty about future Physical pain Other symptoms Adverse effects of treatment O'Neill, B., Fallon, M. BMJ 1997, 315p. 801-804
- 29. Nausea/Vomiting • Patients withcancer • 13-17% of terminally ill cancer patients in the last 1-2 weeks of life • 6-68% of all patients with cancer Patients with other illnesses: ◦ AIDS: 43% to 49% of patients ◦ Heart disease: 17% to 48% of patients ◦ Renal disease: 30% to 43% of patients Assessment: simple visual analogue scales or numerical rating scales Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 30. Management of Nausea/VomitingCause ReceptorsInvolved Drug Classes Drug Examples V – Vestibular Cholinergic Histaminic Anticholinergic Antihistaminic Scopolamine Promethazine Diphen- hydramine O – Obstructive Cholinergic Histaminic 5HT3 Drugs stimulating the myenteric plexus Senna products M- Motile (dysmotility of upper gut) Cholinergic Histaminic 5HT3 Prokinetics (stimulating 5HT4 receptors) Prokinetics, metoclo- pramide I – infectious/inflam- matory Cholinergic Histaminic 5HT3 Neurokinin 1 Anticholinergic Antihistaminic 5HT3 antagonists Neurokinin 1 ant. Anti-inflammatory Scopolamine Promethazine Diphenhydramine Odansetron Apprepitant Corticosteroids Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)See handout for doses, cost Treat anxiety if present
- 31. Practical Issues inManagement of Nausea/Vomiting Many neurotransmitters involved ◦ Use “dirty” drugs ◦ Let side effects work for you Strategy analogous to HTN management ◦ Stack up drugs ◦ Once symptoms controlled can start to wean
- 32. Empiric Recommendations for ConstipationManagement Prophylaxis for all patients on opioids with senna/colace 2 PO BID If inadequate, use PEG OTC – 8 oz in AM, and then q 6h until BM Manually disimpact if necessary Consider subcutaneous methylnaltrexone if refractory
- 33. Dyspnea Prevalence ◦ 17-30%of patients living with cancer ◦ 90-95% of end-stage COPD patients ◦ 60-88% of end-stage heart disease patients Increasingly common as the end of life approaches Best assessment is patient report
- 34. Dyspnea Recent ACPguidelines show evidence supports treatment with: ◦ Oxygen for hypoxemia Strong evidence for COPD & exercise ◦ Opioids Theoretical effect of respiratory depression not supported by the literature ◦ Beta-agonists for dyspnea from COPD Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146
- 35. Practical Aspects inthe Management of Dyspnea Mild dyspnea ◦ Select a weak opioid and offer q2h prn dyspnea Watch your APAP doses Start lower in elderly Severe dyspnea ◦ Opioid naïve – morphine IR (5-15mg) or hydromorphone (0.5 – 2mg) q 2-4h prn ◦ On scheduled opioids already – 10% of total daily dose given q1h prn
- 36. Practical Aspects ofManaging Dyspnea EPEC Project, American Medical Association, 1999 Pursed lip breathing , smoke
- 37. Practical Aspects ofManaging Dyspnea Anxiolytics to decrease the anxiety associated with dyspnea: *there is not strong evidence to support this practice, but this is commonly done in hospice patients and is empirically effective. EPEC Project, American Medical Association, 1999
- 38. Fatigue • Approximately 40%of cancer patients experience fatigue at the time of diagnosis • Worse during or after chemotherapy • Higher than 75% in patients with advanced cancer • Common with COPD, heart failure • Multifactorial • Best evaluated by self-assessment measures • No gold standard measurement Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 39. Management of Fatigue Evidence supports use of: ◦ Psychological, psychoeducational interventions (small) ◦ Methylphenidate – small, significant improvement • Exercise - small improvement Energy conservation, activity management - small but significant effect No effect: progestational steroids, paroxetine, or multivitamins. Insufficient data to recommend any specific complementary therapies Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 40. Practical aspects inthe management of fatigue / weakness . . . Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines
- 41. Practical aspects inthe management of fatigue / weakness Dexamethasone ◦ 4mg PO once daily ◦ feeling of well-being, increased energy ◦ effect may wane after 4-6 weeks ◦ continue until death Methylphenidate ◦ 5mg PO q 8AM and q noon ◦ May increase up to 20mg daily Do not give after 2pm to avoid interfering with sleep
- 42. Anorexia/Cachexia • Prevalence: 70%of patients with advanced cancer • Best assessment is patient report • Treatments: • Megesteral acetate, medroxyprogesterone • Corticosteroids • Orally consumed supplements • Parenteral nutrition Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 43. Empiric Observations about Anorexia/Cachexia Family education is key Tailor diet to patient preferences ◦ Fresh fruit Melon, peaches, grapes ◦ Things that are cold and sweet Ice cream, popsicles, jello ◦ Lemon drops, zinc lozenges for bad taste in mouth ◦ Most patients do not want dairy, fried foods Manage grief, disappointment about change in diet Encourage socializing at meal times even if patient does not want to eat
- 44. Depression Recent ACPGuidelines: ◦ Physicians should screen for and treat depression in patients facing end-of-life ◦ Evidence supports use of TCA’s and SSRI’s ◦ Psychosocial interventions also effective Some providers will use methylphenidate in patients with very short life expectancy Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146
- 45. Mental Health About50% of advanced cancer patients meet criteria for a psychiatric disorder ◦ adjustment disorders (11% to 35%) ◦ major depression (5% to 26%) ◦ less evidence for patients with cardiac, pulmonary, renal, or neurologic disease. Sources of anxiety: ◦ symptom management ◦ isolation ◦ family needs Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 46. Assessment of Depression No recommended instrument ◦ Cannot use vegetative sx as a marker ◦ Low mood, low interest best markers, with sensitivity of 91% and specificity of 86% Must be actively solicit sx, because pts may: ◦ view psychological distress as being appropriate ◦ consider that distress reflects a lack of coping skills, or ◦ believe that it is not appropriate to report such issues to their clinician. Depression may be perceived somatically as fatigue or chronic pain Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 47. Delirium • Prevalence: • 20%to 30% of people with cancer, COPD and end-stage liver disease in SUPPORT • 26% to 44% in terminal cancer • 83% in people during their final days. • Assessment: • Confusion Assessment Method (CAM) • Memorial Delirium Assessment Scale (MDAS) • Treatment in the terminally ill is difficult • Prevention is key Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 48. Delirium: Treatment • Drugsare the most common cause of delirium • reduction and possibly withdrawal of anticholinergic and psychoactive drugs • opioid dose reduction and/or rotation (usually at an equianalgesic dose with a reduction of 20% to 30%) • Newer antipsychotics no better than haloperidol Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 49. What Do Patientswith Serious Illnesses Want? • Pain and symptom control • Avoid inappropriate prolongation of the dying process • Achieve a sense of control • Relieve burdens on family • Strengthen relationships with loved ones Singer et al. JAMA 1999;281(2):163-168.
- 50. Advance Care Planning Recent ACP Guidelines: ◦ Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness (strong recommendation, low quality of evidence) Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146
- 51. My Philosophy onACP (the other ACP) Goal is understanding/documenting patient goals of care Care Planning is: ◦ A team effort ◦ An ongoing conversation ◦ Best initiated as an outpatient ◦ Requires time, communication, documentation Patient/family must understand Diagnosis, prognosis Risks and Benefits of Available interventions Possible Outcomes
- 53. Conveying Prognosis • Mostwant accurate and detailed prognostic information BUT – SUPPORT study around 1 in 5 would rather not discuss end-of-life options. • Most prefer physician to raise the subject • Many preferred physician to ask first – if they wished to know their prognosis – in what detail • In some other cultures (e.g., Asian, Navajo, African, Central and South American and Eastern European cultures), nondisclosure of bad news or use of nonverbal means is expected. – Assumptions based on ethnic background can be misleading – better to ask. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 54. The Collusion ofHope Providers fear relaying honest prognosis for fear of destroying hope 98% wanted doctor to be realistic. Hope giving behaviors: ◦ offering the most up to date treatment (90%) ◦ appearing to know all there is to know about the patients cancer (87%) ◦ saying that the pain will be controlled (87%). Hope depleting behaviors: ◦ being nervous/uncomfortable (91%) ◦ giving prognosis to the family first (87%) ◦ using euphemisms (82%) Hagerty et al. JCO 2006; 23(6): 1278-1288
- 55. Expectations regarding Treatment: CPR TVShows = #1 Source of Info for older adults regarding CPR Older adults overestimate CPR success by 200% CPR Success on Television (NEJM): ◦ ER, Chicago Hope, Rescue 911 75% survived Immediate Arrest 67% appeared to survive to D/C 83% = Young Adults Outcomes = ALWAYS either Full Recovery or Death
- 56. Survival After InpatientCardiac Arrest Bedell, et al. prospectively studied 294 patients resuscitated at Beth Israel Hospital 1981-1982 ◦ 160 men, 134 women, age 18-101, mean 70 ◦ 128 (44%) survived the arrest, and 41 (32% of survivors) lived until discharge renal failure (3% of 75 patients survived, none on hemodialysis) cancer (7% of 59 survived, none with metastases) pneumonia (0% of 58 survived) none of the 42 patients with sepsis and none of the 16 patients with CVA survived to discharge homebound before hospitalization (4% of 137 homebound survived) ◦ Age was not a significant predictors Slide couresty of Déon Cox Hayley, DO and Don Scott, MD, MHS University of Chicago Part of the CHAMP curriculum, supported by the Donald W. Reynolds Foundation
- 57. Mental Health, TreatmentPreferences, and Advance Care Planning EOL discussions not associated with patients feeling “depressed, sad, terrified, worried” or meeting DSM criteria for mental disorder Patients participating in EOL discussions more likely (p<=0.001) to: ◦ Accept that illness is terminal (52.9% vs. 28.7%) ◦ Prefer medical treatment focused on relieving pain/discomfort over life-extending therapies (85.4% vs. 70%) ◦ Have completed a DNR order (63% vs. 28.5%) Wright, A. A. et al. JAMA 2008;300:1665-1673. Slide courtesy of Holly Prigerson, Ph.D.
- 58. Medical Care atthe End of Life Even after controlling for desire for prognostic information, TIA, and treatment preferences, patients who reported having EOL conversations with their physicians at baseline received significantly fewer aggressive medical interventions near death Wright, A. A. et al. JAMA 2008;300:1665-1673 Slide courtesy of Holly Prigerson, Ph.D.
- 59. Copyright restrictions mayapply. Wright, A. A. et al. JAMA 2008;300:1665-1673. Medical Care Received in the Last Week of Life by End-of-Life Discussion
- 60. Patients’ Quality ofLife at End- of-Life Quality of life decreased with number of aggressive interventions ◦ No aggressive care: mean QOL score 6.4 ◦ 3+ aggressive measures: mean QOL score 4.6 Quality of life improved with length of time on hospice ◦ No hospice: mean QOL score 5.6 ◦ One week of hospice: mean QOL score 5.6 ◦ 2 months or more of hospice: mean QOL score 6.9 (P=.01) Wright, A. A. et al. JAMA 2008;300:1665-1673 Slide courtesy of Holly Prigerson, Ph.D.
- 61. Cost Savings withACP: Insights from Coping with Cancer 188/603 pt (31.2%) reported EOL discussions Cost of care in last week of life (+) EOL discussion: $1876 (-) EOL discussion: $2917 a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Arch Intern Med. 2009 Mar 9;169(5):480-8.
- 63. How to Increaseuse of Advance Directives • There is moderate-quality evidence that: –Multifaceted interventions increase completion of advance directives and the likelihood of adherence to patient preferences –Providing a trained facilitator increases decisional competence –Forms designed for those with low literacy increase completion rates –Peer mentoring increases advance Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 64. Bereavement Outcomes Caregiversof patients who received any aggressive care were at higher risk for: • developing MDD (adj OR=3.37, 95% CI, 1.12-10.13) • Experiencing regret • Feeling unprepared for patient’s death • Worse overall QOL, self-reported health, and role limitations • High patient QOL assoc with better caregiver outcomes: • Overall QOL • Self-reported health • Physical functioning • Mental health • Also felt better prepared for the patient’s death, less regret Wright, A. A. et al. JAMA 2008;300:1665-1673 Slide courtesy of Holly Prigerson, Ph.D.
- 65. What Do FamilyCaregivers Want Study of 475 family members 1-2 years after bereavement • Loved one’s wishes honored • Inclusion in decision processes • Support/assistance at home • Practical help (transportation, medicines, equipment) • Personal care needs (bathing, feeding, toileting) • Honest information • 24/7 access • To be listened to • Privacy • To be remembered and contacted after the death Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
- 66. Sharing Prognostic Information Mostfamilies want to know prognostic information* Most families also doubt prognostic information ◦ 57.4% of public believe divine intervention can save a person when physicians believe treatment is futile** 56% of family members wanted a physician recommendation about WLST but 42% did not*** *Apatira et al. Ann Intern Med 2008; 149:861-868 **Jacobs et al. Jacobs LM et al. Arch Surg 2008; 143:730-735 ***White et al. Am J Respir Crit Care Med 2009; 180:320-325
- 67. Family Caregivers andthe SUPPORT study Patient needed large amount of family caregiving: 34% Lost most family savings: 31% Lost major source of income: 29% Major life change in family: 20% Other family illness from stress: 12% At least one of the above: 55% JAMA 1995;272:1839
- 68. Key Points Askabout pain, assess, and treat using the WHO pain ladder – it works! Patients with life limiting illness have many symptoms – assess aggressively A simple conversation about EOL wishes is an excellent start to helping achieve your patient’s goals
- 69. Breaking Bad News The manner in which this is done have long term implications for patient and family ◦ Caring attitude of the news giver ◦ Clarity of message ◦ Opportunity to ask questions Find a good setting Find the time Make sure the key players are there ◦ Parents ◦ Significant others
- 70. Breaking Bad News Tell the truth – gently, but honestly. Make yourself say the words you try to avoid: cancer, dying Tolerate the response in silence Convey hope – ◦ Continued care and support ◦ Symptom management ◦ “We are in this together.” Plan for follow-up
- 71. Pronouncement of Death “A person is dead when, according to ordinary standards of medical practice, there is irreversible cessation of the person’s spontaneous respiratory and circulatory functions.” Texas health and safety code, title 8, chapter 671, subchapter A, section 671.001a.
- 72. Pronouncement Procedure Family Absent Find out from chart, nursing staff who key family members are Identify yourself, ask to speak to person closest to patient What does speaker know about patient’s condition? “I’m afraid I have some bad news” Convey clearly, “I’m sorry to have to tell you that ____ has just died.”
- 73. Step 2: Meetingthe Family Enter Quiet, respectful attitude Ask nurse to accompany for introductions Introduce “I am the doctor on call” Determine relationships of persons present Inform family of purpose, invite to remain Offer to answer questions or to contact others
- 74. Condolences Empathize Simply “Iam sorry for your loss…” “This is a difficult time” Avoid “I know how you feel”
- 75. Family Response Familiesappreciate and respond to a respectful and kind approach to this final medical act Strong emotions are often expressed – do not be driven away by this Active listening, patience Let the chaplain help you
- 76. Step 3: ClinicalExamination ID bracelet and pulse Pupils for position and response to light Response to tactile stimuli - Examine respectfully - NO STERNAL RUBS OR NIPPLE PINCHES Spontaneous respiration Heart sound and pulses Record the time of death
- 77. Step 4:Death Notein Chart Date and time Name of provider pronouncing death Note absence of pulse, respiration, pupil response Note if family present or informed Note family response if indicated Note notification of attending, pastoral care, social work, or others as appropriate
- 78. Step 5: Notificationof M.E. Review list of circumstances on back of form ◦ Less than 24 hours in hospital ◦ Suspicion of foul play If patient meets any of the criteria, call M.E. Often, they will give you a “no case” number If autopsy is required by law, all devices must be left in place (ET tubes, central lines, etc)
- 79. Summary Sick peopledie sometimes The Palliative Care team is here to help you with the care of terminally ill patients: ◦ Pain and Symptom management ◦ Discussion of Goals of Care ◦ Out-patient follow-up and Caregiver Support Death is as much a part of life as birth If you avoid and fear it, you cannot take good care of your patients. It is normal to be freaked out by this stuff – talk with your colleagues about it!
- 81. The Nature ofSuffering and the Goals of Medicine The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Cassell, Eric NEJM 1982;306:639-
- 82. Opioids for Step3 (Severe) Pain. Abrahm J L , Ann Intern Med 1999;131:37-46 ©1999 by American College of Physicians
- 83. Management guidelines forsevere cancer pain.4. Abrahm J L , Ann Intern Med 1999;131:37-46 ©1999 by American College of Physicians
- 84. Opioid Failure • Occursin 10% to 30% of patients • No predictive factors • May improve with opioid rotation is variable and unpredictable • Opioid rotation is always an indication for consultation Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 85. Coanalgesics • Acetaminophen • Contraindicatedin patients with liver disease • 4 g/day is the dose limit (2-3g/d in elderly) • NSAIDs • increase the risk of renal failure and GI bleeding • risky in the elderly • Opioid sparing effect when used in combination • cyclooxygenase-2 (COX-2) inhibitors • Analgesics may be combined with: • tricyclic antidepressants • anticonvulsants • bisphosphonates for specific pain syndromes • Corticosteroids (low quality evidence) Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 86. Opioid Pearls • Hydromorphone(extended or immediate release): • 5 to 10 times more potent than oral morphine • Oxycodone: • 1.5 to 2 times more potent than oral morphine • Fentanyl (a lipid-soluble synthetic opioid): • 50 to 100 times more potent than oral morphine • transdermal delivery for up to 72 hours • similarly effective in equivalent dosing • lower risk of constipation and daytime drowsiness • Stable serum levels achieved only after 12 to 24 hours • inflexible dosing with patch • not recommended in opioid-naïve patients or those whose dose requirement has not stabilized • Methadone: • complex pharmacokinetics and long half-life • Requires regular monitoring • administered in consultation with experienced physicians only Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 87. Opioid Rotation Asystematic review found that opioid rotation resulted in clinical improvement in over 50% of patients with chronic pain and poor response to one Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 88. Non-Drug Treatments forPain • Proven effective: Cognitive Behavioral Therapy • Insufficient evidence to support any of the CAM treatments • Use of CAM modalities very common • 90/102 (88%) of CA patients enrolling in a phase I trial used at least one CAM modality • 93% used pharmacologic • Vitamins E and C, mineral preparations (71%) • Green tea (30%) • Echinacea (13%) • Essiac (10%) • 53% used non-pharmacologic • Prayer and spiritual practices (52%) • 47% used both • Used more frequently by women (54% vs. 40% in men), younger patients, worse stated prognosis, poorer quality of life • No effect on survival. • The majority of patients are reluctant to disclose their use of CAM to their physician Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 89. Treatment of Dyspnea: Oxygen •Improved symptoms during exercise in COPD • BUT weak evidence for symptom relief in: • COPD at rest • heart failure • cancer • Even in hypoxic cancer patients: • oxygen and air can improve dyspnea • Fan may be just as effective Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 90. Treatment of Dyspnea: Opioids High-quality evidence of a benefit from opioid use in COPD • Poor-quality evidence of benefit in cancer • Subsequent RCTs in COPD and advanced cancer: • benefit from oral morphine for • improved subjective dyspnea • Improved sleep, • No compromise of respiratory function. • Side effects: constipation, nausea and vomiting. • Theoretical effect of respiratory depression not supported by the literature. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 91. Treatment of Dyspnea: Anxiolytics •Data lacking, urgently needed • Low-dose phenothiazines, benzodiazepines widely used • A small RCT of terminally ill cancer pts: • SQ midazolam might be a safe and effective adjunct to morphine • Combine with nonpharmaceutical interventions. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 92. Treatment of Dyspnea: Non-DrugStrategies There is a paucity of evidence for most interventions ◦ high-quality evidence from a meta- analysis of 20 RCTs showing a benefit from pulmonary rehabilitation in advanced COPD • Poor quality evidence/mixed results for acupuncture Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 93. End of Lifein the ICU 10-20% of all ICU patients die Often illnesses are unanticipated – little previous discussion of illness with family Prognostication variable ◦ May not be useful anyway (SUPPORT) Culture of aggressive treatment Patients not generally able to participate ◦ May seem dehumanized by
- 94. Psychological Symptoms Psychologicaldistress ◦ anxiety, depression, worry, fear, sadness, hopelessness, etc ◦ 40% worry about “being a burden” ◦ fear of the unknown – learn about death from television and movies loved ones no longer die at home in hospital deaths not always optimally managed Portnoy RK et al. Qual Life Res. 1994 Jun;3(3):183-9.
- 95. Sleep Disturbances • 30%to 50% of cancer patients (2x general population) • Not much data available, but improvement with massage, aromatherapy, and CBT. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 96. Antiemetics: Practical Guideto Prescribing Abrahm J L , Ann Intern Med 1999;131:37-46 ©1999 by American College of Physicians
- 97. Pain Data fromSUPPORT % of 5176 patients reporting moderate to severe pain between days 8-12 of hospitalization: colon cancer 60% liver failure 60% lung cancer 57% MOSF + cancer 53% MOSF + sepsis 52% COPD 44% CHF 43% Desbiens & Wu. JAGS 2000;48:S183-186.
- 98. Opioid Side Effects: Commonand/or Transient • Nausea and vomiting • Anti-emetics effective for treatment, usually < 7 days • Drowsiness – usually transient, may be related to sleep debt • Cognitive impairment • Minimal in most patients on stable dose • driving not significantly impaired in alert patients on stable dose • Pruritus – histamine mediated • Constipation • Very common (in up to 90% of patients) and persistent effect • therapy with softening and stimulating laxatives • Bulk laxatives risky if insufficient liquid intake • Dry mouth • Common. • Good mouth hygiene, regular sips of water and sugar-free chewing gum Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 99. Opioid Side Effects: Uncommon •Delirium • May respond to opioid rotation • Urinary retention: • Uncommon; may occur with spinal opioids • Respiratory depression • dose, drug and route dependent • rapid IV infusion or rapid dose escalation of methadone • other risk factors include renal failure, limited pulmonary reserve, and concomitant use of sedating drugs such as benzodiazepines • The Principle of Secondary Effect
- 100. Alternate Routes of Administration •Subcutaneous (requires dose conversion) • Rectal/vaginal (does not require dose conversion) • Transmucosal fentanyl citrate: • More effective than placebo or morphine IR for reducing breakthrough pain intensity. • Transdermal fentanyl: • noninvasive alternative for opioid-tolerant patients who require stable doses • Variable absorption • Lipophilic • Adhesive issues • Can also be given centrally • intracerebroventricular (ICV) • epidural (EPI) • or subarachnoid (SA) routes • Intramuscular opioid injections are not recommended Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 101. Prevention of Delirium Cognition: orientation board (carry pen!), (day) open drapes, clock, calendar, family photos Sleep: min deprivation (d/c 2am labs & o/n BD/vitals; meds when awake); warm drink; limited pm awake Mobility: Early OOBchair ; PT/OT; no foley/restraints Vision: glasses HOH: get aids; adapt environment (stethoscope!) Dehydration: po fluids; observe at mealtime Feeding: assist with meals Activity: Involve family (rotate members) or get sitter; move pt to room close to RN station, current events Inouye, SK. JAGS 2006; 54: 1492-1499 This slide courtesy of Shellie Williams, MD Prepared as part of the CHAMP curriculum Funded by Reynolds Foundation http://champ.bsd.uchicago.edu/
- 102. Delirium: Indications forMedical Management Patients pose a danger to themselves or others Uncontrollable agitation despite nonpharmacologic interventions Anxiety in the presence of agitation or hallucinations Need to control agitation during a diagnostic or clinical intervention Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 103. Delirium: Medical Management • Newerantipsychotics no better than haloperidol • In pt with dementia, olanzapine, risperidone increase risk • sudden death • nonfatal cerebrovascular events • When using antipsychotics, monitor QT interval if consistent with patient’s goals of care Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 104. Constipation • Opioids actson peripheral opioid receptors in the GI tract, causing constipation • The prevalence ranges from 15% to 90% • 23% in pt following WHO guidelines for cancer pain management • 40-63% of hospice patients • Prophylaxis (e.g., with senna plus docusate) is recommended in all people starting opioid treatment Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 105. Medical Management of Constipation •Oral laxatives • Senna as effective as lactulose, Misrakasneham • No good evidence to support docusate • Lactulose more effective than placebo, may be as effective as golytely, though obstruction/Ogilvie syndrome more common with lactulose • Inadequate data to recommend bisacodyl, sodium picosulfate, isapaghula husk, (psyllium), methylcellulose or magnesium salts • Rectally applied medications • Insufficient data to recommend phosphate enemas, liquid paraffin, glycerol suppositories, sodium citrate, micro- enemas, and arachis oil enemas Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 106. Medical Management of Constipation,cont’d • Opioid antagonists • block GI opioid receptors • drawback of their use is the difficulty of retaining the central beneficial effects while preventing constipation • SQ methylnaltrexone (MNTX) vs placebo in hospice/palliative care pt • increased the rate of bowel movements within 4 hours • No interference with central analgesia. • Subcutaneous methylnaltrexone bromide has just gained FDA approval • Also proven efficacy of alvimopan, but not approved in the U.S. for opioid induced constipation. • Insufficient evidence to recommend oral naloxone Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 107. Dehydration Multifactorial • Treatreversible causes (delirium, opioid toxicity) • Further treatment based on discussion about goals of care • May not cause suffering in the terminal phases as long as oral hygiene maintained • Perception of thirst associated with hyperosmolality (300 mosmol/kg or more), poor general condition, stomatitis, oral breathing, and use of opioids. Medically assisted hydration an area of controversy. Routes of medically assisted hydration: ◦ IV ◦ SubQ (hypodermoclysis) ◦ Via gastrostomy ◦ intravenously, subcutanously (hypodermoclysis) or via gastrostomy, remains a much debated issue among palliative care physicians. Insufficient evidence to clarity effects of short-term hydration in terminal cancer ◦ weak evidence that it might improve sedation and myoclonus ◦ no beneficial affect on other outcomes ◦ increased fluid retention (e.g., pleural effusion, peripheral edema and ascites) Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 108. Cancer Pain Management •Best practice : • Right analgesic, right dose, right time • Most appropriate route (preferably oral) • Maximize dose of one agent before moving to another • Considering coanalgesics • Managing adverse effects • One clinician steering the ship Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 109. Pain Management RecentACP clinical guidelines found sufficient evidence to recommend: ◦ NSAIDs ◦ Opioids ◦ Bisphosphonates ◦ XRT ◦ Radiopharmaceuticals Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146
- 110. Discomfort Ratings For16 Common Hospital Procedures For 165 Subjects Severe Nasogastric tube Mechanical ventilation Mechanical restraints Central line placement Moderate Arterial blood gas Urethral catheter Mild IV insertion Phlebotomy IV catheter IM/SC injection Waiting for procedures Movement from bed to chair Chest X-ray None Transfer to a procedure Vitals signs PO medications Morrison et al, JPSM 1998 Slide courtesy of Sean Morrison, M.D.
- 111. Practical Aspects ofManaging Dyspnea EPEC Project, American Medical Association, 1999
- 112. Nutrition Issues Nutritionalsupport is overused in general ◦ Use can be reduced via education ◦ guideline implementation ◦ shared decision making Gastrostomy tube feedings ◦ no evidence of improved outcomes in advanced dementia ◦ Use still as high as 90% in some states among patients ◦ Perceived by many patients as undesirable, but decision often made after incapacity 15% of patients had feeding tubes placed despite a recorded preference against them. ◦ Physician education + palliative care consultation halved feeding tube placement rates Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 113. Physician Communication • Goodcommunication requires: – preparing for the encounter – creating a supportive environment – active listening – appropriate awareness of nonverbal behavior – expressing empathy • Clinician’s should be open to exploring emotion and meaning • Evaluate the patient and family’s: – knowledge of the current situation – desire to learn new information about prognosis and what the future holds – communicate in a manner appropriate to their culture and education. • Bad news may be followed by acceptance or denial – appropriate strategies for both situations should be prepared • There is moderate-quality evidence that: – Intensive education improves clinician communication skills – Provision of prompt cards to patients improves communication. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 114. Advance Care Planning: Opportunities Goal is ongoing, collaborative discussion of patient goals with systems in place that ensure the wishes of the patient are actually honored Should be a part of routine care Patients should feel their values are important for decision making. Completion of advance directives is a process and there is a higher likelihood with repeated contact. The well-equipped office should include ◦ state-approved advance directive forms ◦ checklist in the patient chart to ensure that it is filled out A team approach involving other qualified health professionals is recommended The goal should be genuine understanding, not just completing a document Once completed, they need to be revisited regularly as patients’ preferences have been shown to change over time. ◦ Plans should be revisited at diagnosis ◦ following frequent hospitalizations ◦ on declining functional status. All stakeholders need to be aware of and involved in the plan. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 115. Advance Care Planning: Success Physician Orders for Life-Sustaining Treatment (POLST) form and program Physician Orders for Scope of Treatment (POST) Medical Orders for Life-Sustaining Treatment (MOLST). Information about the program and sites across the U.S. are available at http://www.ohsu.edu/polst/professionals.shtml. Key elements include: ◦ a protocol outlining policies and procedures for transferring information about preferences across health care settings ◦ distinctive and prominently displayed form that details specific wishes on medical interventions ◦ education of all those involved (patients, families, and health care professionals) ◦ revision of the template forms based on feedback and a system to monitor distribution of forms, education and quality improvement. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 116. DNR Orders Theself-reported prevalence of DNR policies in U.S. nursing homes has risen substantially DNR orders are frequently misunderstood, rarely discussed, and poorly implemented Patients may overestimate the prognosis following in-hospital resuscitation ◦ most surveys reporting that less than 15% of people survive to discharge. Many residents misinterpreted the terms “DNR” and “futility”. The SUPPORT study included patients with life expectancy less than 6 months and reported that: ◦ only 47% of physicians knew their patients’ CPR preferences ◦ 46% of DNR orders were written within the last 2 days before death ◦ 38% of these patients had spent more than 10 days in an ICU, on a ventilator, or in coma before dying. Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 117. Patient/Family Wishes forICU Timely, clear, and compassionate communication by clinicians Clinical decision-making focused on patients' preferences, goals, and values Patient care maintaining comfort, dignity, and personhood Family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Crit Care Med. 2010 Mar;38(3):808-18
- 118. Pain Ratings For16 Common Hospital Procedures For 165 Subjects Severe Arterial blood gas Moderate Central line placement Nasogastric tube Peripheral IV insertion Phlebotomy Mild IM/SC injection Urethral catheter Mechanical restraints Movement from bed to chair None IV catheter Chest x-ray Vitals signs Transfer to a procedure Waiting for a test or procedure PO medications Morrison et al, JPSM 1998 Slide courtesy of Sean Morrison, M.D.