Palliative Care: What every medical student needs to know


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Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video:
Link to PDF of the slide show:

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  • My story:This is April. I met her in my clinic in Billings. She first came to me for symptom management of her metastatic breast cancer. She also wanted to know what to eat, how to keep her function high. She was curious about our “Hope for Tomorrow” program for cancer patients. She and her husband joined – and participated in yoga, cooking class, groups support with mindfulness. This picture was taken 6 weeks before she died. 1- my patients found me. They wanted someone to listen, to manage their symptoms while someone else battled their illness, someone to help make plan “b” and to address their whole person.2- I realized I was not as good at managing symptoms for patients as I thought I was. I thought Zofran was the be-all-and-end-all for nausea. I was wrong. I thought opioids were taught in residency. I was wrong. I thought at end of life, all meds, except morphine and ativan were given, generally speaking. I thought I knew how to tell who was dying.3- I liked tending to the seriously ill. I was intrigued and curious about their ability to live so very fully. To find joy. To talk about difficult things and to find meaning. I often found them to be more alive than many. They showed me what hope really meant.
  • Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
  • I used to think that this was the model. We “treat” and then we help people die peacefully. I was wrong.
  • It is more like this… but I still don’t fully agree with this picture. After all – it is usually symptoms (except when there are screens) that bring our patients to us: dyspnea, nausea, pain… But anyway, curative and palliative therapies tend to work hand in hand. You do this every day, and better than most.
  • The paradigm of palliative care is to approach the person from a multi-dimensional model. Biopsychosocialspiritual was the way I learned it in medical school. Mind-body-spirit might be the way integrative medicine physicians call it. Good care, is another name. Most of us tend to 1-6 with our patients all the time. Even in palliative care, 7 and 8 are often not in the mix.
  • Nurse with metastatic breastca – loves to golf and to work 12 hour shifts.Hip pain was limiting her activity, however. How to respond?Intrathecal pump – coordinated between neurosurgery, anesthesia, and palliative care
  • LL is a 57 yo woman with metastatic pancreatic cancer, diagnosed 5 years ago.She now presents to hospital with:Pain (rectal)Breathlessness (pleural effusion and pericardial effusion)Anorexia, weight lossFatigueHer goals have always been to live as long as possible, to see her children grow, and in the words of USC, to “fight on!”Pain: Opioids, steroids, plus: nerve block – impar or sub-gastric ganglion.Dyspnea: Opioids, chlorpromazine, plus: thoracentesis, pericardial window
  • We want to offer hope… so how can we?Story: 21 year old, dying of adenocarcinoma – Crohn’s – bowel obstructionAfter he was told that the cancer was found everywhere, there there was no more curative treatment available…He asked:Will I have to stay in the hospital or can I get home to see my dog? – He had a 4 month old golden retriever. He didn’t want to see her in hospital – just at home.He is at home now. His brother brought him his golden retriever home. She now visits daily – when he is up for it.He asked his hospice nurse: Will I see my best friend before I die? Where is she? In Germany. Well, we shall see then.They found an agency to help. She flew home 3 days later to spend time with him.I asked him if he had any questions… He asked:When will the bad pain start again? – I answered, If I do my job well, if the hospice nurses do theirs well, it will never start again.
  • Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
  • You can help them secure their hopes… for how they wish to be cared for at the end of life…
  • And avoid what most of us will end up facing
  • Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
  • Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
  • Help our way… Engage with grace – the one slide project – promoted over ThanksgivingNational healthcare decisions day – In April – this year, this weekend. Perhaps we could coordinate something for next year?
  • Everybody dies.Cancer continues to be one of the leading causes of death.Good symptom management, coordination of care and help patients live better and longer.The obligation of the physician is to alleviate suffering.
  • Palliative Care: What every medical student needs to know

    1. 1. Palliative Care:What every 1st year medicalstudent needs to knowSuzana Makowski, MD MMM FACP FAAHPMAssistant Professor of MedicineSlide presentation for 1st year medical students in the Cancer Concepts Course atUMass Medical School
    2. 2. • What is Palliative Care?• What is Hospice?• How do we care for the dying?Overview
    3. 3. “an approach that improvesthe quality of life ofpatients and their familiesfacing the problemsassociated with life-threatening illness, throughthe prevention and relief ofsuffering by means of earlyidentification andimpeccable assessment andtreatment of pain and otherproblems, physical, psychosocial and spiritual.” WHO definitionPalliative Care
    4. 4. • ―It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.‖- Diane Meier, NYTimesWhy discuss palliative care?
    5. 5. Study (2010): Early Palliative Care improves longevity andquality of life for patients with advanced non-small cell lung cancer
    6. 6. What is palliative care?
    7. 7. Not just end-of-life care…
    8. 8. Adapted from Frank Ferris – EPEC-O
    9. 9. Myth: Palliative care = just end-of-life careWe often help patients whose life expectancy is good
    10. 10. Cancer pain management
    11. 11. • 50 to 90 percent of oncology inpatients report breakthrough pain• 35 percent of community based oncology practices patients report breakthrough pain• 1 in 3 patients with active cancer report pain• 3 out of 4 of patients with advanced cancer report painCancer pain prevalence
    12. 12. • Bone metastases• Visceral metastases• Immobility• Neuropathic pain• Soft tissue• Constipation• Esophagitis• Lymphedema• Muscle cramps• Chronic postoperative scar• Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with advanced cancer. J Pain Symptom Manage 1996;12:273-282.Causes of cancer pain
    13. 13. Physical Emotional Existential• Increased catabolic demands: Depression Suffering – poor wound healing, weakness, muscle Anxiety ―why me?‖ breakdown Decreased• Decreased limb movement: intimacy Suicidality increased risk of DVT/PE• Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis• Sodium and water retention Decreased gastrointestinal mobility• Tachycardia and elevated blood pressure• Decreased functional status• Increased chronic pain Effects of under treated pain
    14. 14. • Intensity • Location • Quality • Timeline • Alleviating factors • Meds triedPain Assessment
    15. 15. Category Cause Symptom ExamplesPhysiologic Brief exposure to a Rapid yet brief pain Touching a pin or hot noxious stimulus perception object Somatic or visceral tissue Moderate to severe pain, Surgical pain,Nociceptive/infla injury with mediators described as crushing or traumatic pain, sicklemmatory having an impact on stabbing cell crisis intact nervous tissue Damage or dysfunction Severe lancinating, Neuropathy, CRPS.Neuropathic of peripheral nerves or burning or electrical Postherpetic Neuralgia CNS shock like pain Combinations of Low back pain, back Combined somatic andMixed symptoms; soft tissue plus surgery pain nervous tissue injury radicular pain Pain Quality
    16. 16. WHO pain relief ladderNon-opioid = acetaminophen, NSAID, neuroleptic • Adjuvant = steroid, etc.
    17. 17. • Mrs. Dolores de Barriga is a 67 year old Peruvian immigrant with metastatic colon cancer, who has increasing abdominal pain. She has a colostomy and has regular bowel movements.• Her current pain regimen is: • Morphine ER 15mg twice daily • Percocet (oxycodone 5mg + acetaminophen 500mg) – 1-2 tablets every 4 hours as needed. She has been taking 2 tablets every 4 hours for the last week.Why is this dangerous?
    18. 18. Opioid Pharmacology
    19. 19. Short-acting Long-acting• Hydrocodone/APAP • Transdermal fentanyl• Oxycodone +/- APAP • methadone• Morphine • morphine ER• Hydromorphone • oxycodone ER• Oral transmucosal fentanyl• Cmax ~ 45 min Cmax and T1/2 vary based on• T1/2 ~ 2-4 hours formulation and drug• Except fentanyl Opioid Pharmacology
    20. 20. What is the half life (range) for opioids?• 2-4 hoursHow many half lives to get to steady state?• 4-5What do you base your scheduled dosing on: Cmax or C?• t1/2What do you base your breakthrough dosing on: Cmax or t1/2?• CmaxA quick quiz
    21. 21. • Follow first order kinetics• Conjugated by liver• 90-95% excreted in urine• Dehydration, renal failure, severe hepatic failure • Decrease interval/dosing size Why is morphine contraindicated in • If oliguria/anuria renal failure? • STOP routine dosing (basal rate) of morphine• Use ONLY PRNOpioid pharmacology(except methadone)
    22. 22. • Morphine 3-glucoronide • Not an opioid agonist • Stimulates the GABA/glycinergic system • Can cause neuro-excitation – agitation, hyperalgesia, myoclonus, se izures. • Morphine 6-glucoronide • Active metabolite that acts as an opioid agonist – especially against the mu-opioid receptorMorphine metabolitesbuild-up disproportionately in renal failure
    23. 23. Optimal symptom • Same ―rules‖ apply management • CMO ≠ Continuous Morphine Only Personalized • Goals of care based healthcare • Not problem based Whole-person • Bio-psycho-social-spiritual approach care • Interdisciplinary Palliative Care
    24. 24. Myth: Palliative care = “no more treatment”We assess the values & goals of a patient, designing care around them
    25. 25. On an average day in Massachusetts: 1 A few infant childre n 144 people die Some Most middle over 75 agedMassachusetts facts
    26. 26. MA: 67% want to die at home
    27. 27. MA: only 24% die at home
    28. 28. • In the United States, hospice is a form of care provided to patients whose life expectancy is 6 months or less.• It is generally provided in the patient’s home, but can be received in nursing homes, hospices houses, etc.• It is a Medicare benefit (that many other insurances cover)• Its approach is to help people live as well as possible, for the time they have left: alleviating symptoms, reaching goals, supporting family, addressing spiritual needs.• As long as a person’s prognosis remains 6 months, the benefit does not run out.• A patient may be ―full code‖, ―DNR/DNI‖ – according to their goals and preferences on hospice.Hospice care:1 way to help stay home
    29. 29. Hospice Home Palliative (VN)Requires Prognosis <6months Home-bound only (Not required: code status, Must show improvement primary caregiver)Services Nurse, social worker, Nurse, PT/OT chaplain, volunteer, home health aideDME* All covered Not coveredMeds Covered if associated with Not covered dxHours 24/7 Regular business hoursOther Bereavement for family up None to 13 months after death *DME = durable medical equipment (bed, oxygen, commode, etc.)
    30. 30. from Second City
    31. 31. Much of our practice is for patients nearing end-of-life
    32. 32. Caring for the dying
    33. 33. • Until recently, only 10% of medical students had any courses on how to care for dying patients.• Practicing non-abandonment is tough when we don’t know what to do.• Know the signs and symptoms of dying and means to treat them.• Address fears, anticipate problems “• Sir William Osler: “ To cure sometimes, to alleviate often, to comfort always.What we know
    34. 34. • Cancer Cachexia/Anorexia • Metabolic demands of cancer outpace that of the body • Malnutrition: protein and fat depletion • Loss of intravascular oncotic (osmotic) pressure due to low albumin and other proteins • ―third spacing‖ of fluid to abdomen, lungs, subcutaneous tissue How does this differ from starvation?Physiology of dying with cancer
    35. 35. • Decreased perfusion of brain • Increased fatigue, somnolence Signs/Symptoms • Poor control of bowel and bladder • Change in respiratory pattern (late) • Decreased energy • Decreased reflexes, including gag and • Increased sleep swallow – leads to pooling of saliva in back • Respiratory of throat pattern changes• Decreased cardiac output • ―Terminal • Poor peripheral perfusion: skin breakdown secretions‖ • Skin breakdown• Decreased perfusion of the kidneys (low • Peripheral intravascular volume/pressure, low cardiac ―mottling‖ output) leads to pre-renal azotemiaPhysiology of dying
    36. 36. Pain • Breathlessness • BleedingRetching • Hallucinations • Seizures
    37. 37. Pan = all Cyto = cell (usually referring to blood cells)• Dolores returns Penia = poverty • she is now pancytopenic due to bone marrow involvement • plts now 5,000/mcl, • Hct 12%, • WBC 2,000/mclWhat signs/symptoms might she experience?
    38. 38. • Brain • Seizures, brain stem herniation What to do once you can no longer transfuse blood? – Be• Mucosa prepared • Nose bleeds, vaginal bleeds • For bleeds you can see:• Lungs dark blue towels, surgicel • Dyspnea, hemoptysis or topical thrombin for nose/mucosa• GI tract • Benzodiazepam for seizures • Hematemesis, aspiration of • Opioid and benzo of blood, bloody stool phenobarbitol for• Retroperitoneal hemoptysis, pain, etc. • Back painWhere could she bleed?
    39. 39. Somehelp:
    40. 40. • Sir William Osler: “ ““ • Eric Cassell: “
    41. 41. • Most physicians practice Palliative Care every day• Palliative care includes any care that enhances quality of life (QOL) – regardless of its effect on longevity (it may prolong life!)• Prognostication is hard, but important. It helps patients plan, achieve goals that they can reach.• Palliative care can help patients at any stage of a serious illness, while hospice is available for patients whose prognosis is on average 6 months.Summary
    42. 42. • EPEC (Education on Palliative & End-of-Life Care)• Lois Green Learning Community• Get Palliative:• Pallimed ConnectHow to learn more