An overview of concurrent palliative care in serious liver disease including the concepts of generalist vs. specialist palliative care, pain management, psychosocial concerns and advanced communication techniques.
This model portrays how people who give these answers see palliative care. “Philosophy of care”Very distinct line where aggressive curative treatment ends and palliative care begins once it has been decided that “everything else has been done”
This model is what we hope for. Dotted line represents that PC and curative treatment can be given simultaneously, working together. Why wouldn’t we help relieve suffering while also trying for curative treatment? The patient and family don’t notice the lines of where one ends and one begins they just want to be taken care of and feel good.General palliative care in the clinic: social work to establish DPOA and discuss early goals of care, assess coping & intervene
When you do everything you know and its just not working and you see your patient sufferingOne of the tings we do as a team is sort through the different types of suffering. Is it emotional, spiritual or physical?We don’t want to be treating other kinds of suffering with opioids
Does this sound familiar to anybody?
Patient was dyingWe tried to address his suffering by rapidly titrating opioids for relief of his pain and dyspneaDPOA was called, she told us they had multiple conversations about end of life and he wanted to die at home with hospiceIt does not need to be this way. We have an opportunity to change how care is done and together do much better than this.
We, as a group, like to put things in boxes – to classify them. [CLICK] Let’s begin by looking at the different physiologic types of painWhen we think about pain from a physiologic standpoint, we think about it being nociceptive, neuropathic or mixedNociceptive painfollows the 4 basic steps we have just learned aboutThis is a healthy, intact nervous system doing what it is designed to doWe continue to develop an understanding of this type of pain and how the body reacts to painful stimuliNeuropathic pain does not follow the steps we have just learned aboutReflects a damaged or traumatized nervous systemWe do not know as much about neuropathic pain as we know about nociceptive painWe have to understand whether our patients have either nociceptive or neuropathic pain, or a combination of the two…referred to as “mixed” pain
A 3-step model to guide analgesic choice depending on the severity of the patient’s painThis ladder can be used for nociceptive and neuropathic painDepending on the severity of the pain, start management at the corresponding stepFor mild pain (1–3/10 on a numerical analogue scale), start at step 1For moderate pain (4–6/10), start at step 2 For severe pain (7–10/10), start at step 3 It is not necessary to traverse each step sequentially; a patient with severe pain may need to have step 3 opioids right awayThe addition of adjuvant analgesics is often critical to achieving an excellent outcomeAs you move between steps and between medications, approaches have been developed to switch opioids while maintaining analgesiaAlthough not displayed on this ladder, nonpharmacologic approaches may significantly increase the relief achievedAsk the group which step contains the most dangerous medications[CLICK] Step 1ASAInhibits thromboxane-induced platelet aggregation, producing an irreversible effect on platelets and a reported increase in bleeding time for up to 7 days after the last doseHigh risk for GI toxicity AcetaminophenHepatic effectNSAIDSRenal effectPlatelet effectCardiovascular effectGI effect
Due to the changes in absorption and metabolism of medications, caution is advised. “Start low and go slow.”
Tramadol requires metabolism by liver to active form (Grond and Sablotzki 2004)Mu-receptor action primarily via M1 metaboliteCYP2D6 is the primary source of M1
Why is this applicable?
Pharmacologic tolerance is the reduced effectiveness of a given dose of medication over time Clinical importance is rareTolerance to unwanted effects is observed commonly and is favorableTolerance to analgesia is rarely significant clinically when opioids are used routinely Doses may remain stable for long periods if the pain stimulus remains unchangedWhen increasing doses are required, suspect worsening disease rather than pharmacologic toleranceDependenceProcess of neuro-adaptationAbrupt cessation withdrawalTitrate down if stoppingAvoid antagonistsDiversionRegulationRecord keepingAccountabilityPseudo-addictionMost common cause of apparentdrug ‘ failure ’ is under-dosingBehavior LOOKS like drug seekingAddictionPsychological dependenceCompulsive useLoss of control over drugsLoss of interest in pleasurable activities
A multidisciplinary team including behavioral health professions is necessary to assist in the assessment and management of those patients with a history of substance abuse and palliative care needs.Controlled substances are often required to control symptoms, but need to be provided in a setting of strict limits with integration of non-pharmacologic approaches.
Low, moderate or high risk.In our own clinic, 25% of the patients with cancer or sickle cell screen high (Ma, Horton, Hwang, Atayee & Roeland, 2014)
In patients who have historically coped with stress by using substances, there is real risk of that behavior returning.
Another thing we specialize in is communicationWe spend lots of time sorting through with patients what their worst fears are, what their hopes are, what they understand about their diseaseI have yet to meet a patient with ESLD who has not thought about his/her own deathWe discuss where in a perfect world they would be when they take their last breath
About values, hopes, wishes; what makes this patient a person? what is their story?
Reevaluation, then, is an assessment and sharing the plan rather than another question-and-answer session. Save the family from the hard decision.
Specialist Palliative Care in ESLD: An Introduction
Routine Medical Care:
antibiotics, dialysis, chemotherapy, surgery
“Nothing more to do”?
“Pt / family request”?
“Really, really sick”?
(Maximize non-pharm / non-opioid adjuvants)
Initiate at low doses
Dose by pharmacologic principles
Long-acting formulations avoided as much as possible
Monitor decompensated patient for side effects
Kirsch & Passik, 2006.
Visceral pain, sleep, anxiolysis
Minimal hepatic metabolism
Minimal protein binding
Dwyler et al., 2014.
Morphine Oxycodone Tramadol
Inc half-life &
active M1 form??
Grond & Seblotzki 2004.