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Time
Palliative
Care
Routine Medical Care:
antibiotics, dialysis, chemotherapy, surgery
“Dying”?
“Nothing more to do”?
“Pt...
RAND, 2005.
AT ANY STAGE IN A
SERIOUS ILLNESS
Time
General / Specialty
Palliative
Care
Routine Medical Care
The Course of Illness
Gastroenterology
Generalist
Palliative Care
Specialist
Palliative Care
•MOA
•TACE
•Antibiotics
•ondansetron
•opioids
•Comp...
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PAIN, SYMPTOMS, AND STRESS
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1, Pain 1 – 3
2, Pain 4 – 6
3, Pain 7 – 10
Morphine
Hydromorphone
Fentanyl
Oxycodone
Methadone
± Adjuvants
Tramadol
A / Hy...
General Principles
(Maximize non-pharm / non-opioid adjuvants)
Initiate at low doses
Dose by pharmacologic principles
Long...
Gabapentin:
Visceral pain, sleep, anxiolysis
Minimal hepatic metabolism
Minimal protein binding
Renal excretion
Dwyler et ...
Morphine Oxycodone Tramadol
Inc half-life &
bioavailability; dec
clearance
Elimination is
severely impaired
CYP2D6
metabol...
Consider:
Fentanyl
Short-acting morphine
Pain
Disease
Mgmt
Physical
Psych
SocialSpiritual
Practical
EOL
Worry
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• BUYING OPIOIDS ON STREET
• DOCTOR SHOPPING
• PRESCRIPTION FORGERY
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Passik et al. JClinPain. 2006.
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Alcohol or Substance Abuse
Hx “chemical coping”
Perceiving judgment / blame
Alexithymia (not “in tune”)
• Symptom assessme...
Limit-setting
Use adjuvant medications whenever possible
Use non-drug adjuvants (relaxation, distraction,
biofeedback)
Cli...
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Chou et al. JClinPain. 2009.
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EXPERT COMMUNICATION
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Goals
of
Care
Hopes
Fears
Values
Code
Status
Patient/Family Us
P
E
R
S
O
N
Restorative
or Cure
Return to
Baseline
Improve
Survival
Improve
Function
Relieve
Symptoms
Allow
Natural
Death
Adapted from...
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PARTNERING WITH YOU
TOLERATE CURATIVE
TREATMENT
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“ADDICTION”?
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• “DEPRESSED”?
• COMPLEX PAIN
• NO ABERRANT
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• GRIEVING
• UNCERTAINTY
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PAIN, SYMPTOMS, AND STRESS
• AT ANY STAGE IN A SERIOUS ILLNESS
• EXPERT COMMUNICATION
• PARTNERING WITH YOU
TOLERATE CUR...
KPEDMONDS@UCSD.EDU
Specialist Palliative Care in ESLD: An Introduction
Specialist Palliative Care in ESLD: An Introduction
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Specialist Palliative Care in ESLD: An Introduction

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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.

Published in: Health & Medicine
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Specialist Palliative Care in ESLD: An Introduction

  1. 1. • • • • •
  2. 2. Time Palliative Care Routine Medical Care: antibiotics, dialysis, chemotherapy, surgery “Dying”? “Nothing more to do”? “Pt / family request”? “Really sick”? “Really, really sick”?
  3. 3. RAND, 2005.
  4. 4. AT ANY STAGE IN A SERIOUS ILLNESS
  5. 5. Time General / Specialty Palliative Care Routine Medical Care The Course of Illness
  6. 6. Gastroenterology Generalist Palliative Care Specialist Palliative Care •MOA •TACE •Antibiotics •ondansetron •opioids •Complex pain •High dose opioids •Limit setting •Hope & Prognostication
  7. 7. • • • • • • • • •
  8. 8. • • • • • • • •
  9. 9. • • • • • • • • • •
  10. 10. PAIN, SYMPTOMS, AND STRESS
  11. 11. • • • • • • •
  12. 12. 1, Pain 1 – 3 2, Pain 4 – 6 3, Pain 7 – 10 Morphine Hydromorphone Fentanyl Oxycodone Methadone ± Adjuvants Tramadol A / Hydrocodone A / Oxycodone ± AdjuvantsAcetaminophen NSAID’s ± Adjuvants WHO. Geneva, 1996.
  13. 13. General Principles (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.
  14. 14. Gabapentin: Visceral pain, sleep, anxiolysis Minimal hepatic metabolism Minimal protein binding Renal excretion Dwyler et al., 2014.
  15. 15. Morphine Oxycodone Tramadol Inc half-life & bioavailability; dec clearance Elimination is severely impaired CYP2D6 metabolism to active M1 form?? 22 Grond & Seblotzki 2004.
  16. 16. Consider: Fentanyl Short-acting morphine
  17. 17. Pain Disease Mgmt Physical Psych SocialSpiritual Practical EOL Worry 19
  18. 18. • • • • BUYING OPIOIDS ON STREET • DOCTOR SHOPPING • PRESCRIPTION FORGERY 20 Passik et al. JClinPain. 2006.
  19. 19. • • • •
  20. 20. Alcohol or Substance Abuse Hx “chemical coping” Perceiving judgment / blame Alexithymia (not “in tune”) • Symptom assessment challenging • Need alternative ways to assess 5
  21. 21. Limit-setting Use adjuvant medications whenever possible Use non-drug adjuvants (relaxation, distraction, biofeedback) Clinic risk stratification / procedures Multidisciplinary assessments Involve addiction specialists 34 Passik et al. 2006.
  22. 22. • • • • • • • Chou et al. JClinPain. 2009.
  23. 23. • • •
  24. 24. EXPERT COMMUNICATION
  25. 25. • • • •
  26. 26. Goals of Care Hopes Fears Values Code Status Patient/Family Us
  27. 27. P E R S O N
  28. 28. Restorative or Cure Return to Baseline Improve Survival Improve Function Relieve Symptoms Allow Natural Death Adapted from Mulkerin, 2011.
  29. 29. • • • •
  30. 30. PARTNERING WITH YOU TOLERATE CURATIVE TREATMENT
  31. 31. • • • • “ADDICTION”? • • “DEPRESSED”?
  32. 32. • COMPLEX PAIN • NO ABERRANT • • GRIEVING • UNCERTAINTY • • • • •
  33. 33. • • • •
  34. 34. • • • •
  35. 35. • PAIN, SYMPTOMS, AND STRESS • AT ANY STAGE IN A SERIOUS ILLNESS • EXPERT COMMUNICATION • PARTNERING WITH YOU TOLERATE CURATIVE TREATMENT
  36. 36. KPEDMONDS@UCSD.EDU

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