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What Can Palliative Care Do For You?


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The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.

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What Can Palliative Care Do For You?

  1. 1. What Can Palliative Do For You? Mike Aref, MD, PhD, FACP Palliative Medicine Service, IU Health University Hospital Assistant Professor of Clinical Medicine, Indiana University School of Medicine
  2. 2. Disclosure of Financial Relationships and Conflicts of Interest None
  4. 4. “Every day with liver failure is agony. I’ve disrupted my family’s life. It will only be worth it if I get a transplant.”
  5. 5. “Are They Going Palliative?” • Is a philosophy of care for seriously ill patients, it is – NOT a place – NOT a status – NOT limited by curative intent
  6. 6. Suffering Goal-of-Care
  7. 7. Suffering Goal-of-Care Palliative Care
  8. 8. Palliative Care • The area of medicine that deals with alleviating the physical, mental, spiritual and familial suffering of patients with chronic, progressive illness. • Symptom management and setting goals of care in “life-limiting” illness. • Palliative care is concerned with three things: the quality of life, the value of life, and the meaning of life. • “Sufferology”. Doyle D, Oxford Textbook of Palliative Medicine, 3 ed.
  9. 9. Choosing Wisely • Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease- directed treatment.
  10. 10. 08/27/14 10 Type Goal Investigations Treatments Setting Active (Blue) To improve quality of life with possible prolongation of life by modification of underlying disease(s). Ex: Pt. who has potentially resectable pancreatic carcinoma. May require immediate symptom control or need guidance in setting future goals. Active (eg, biopsy, invasive imaging, screenings) Surgery, chemotherapy, radiation therapy, aggressive antibiotic use, Active treatment of complications (intubation, surgery) In-patient facilities, including critical care units; Active office follow-up Comfort (Green) Symptom relief without modification of disease, usually indicated in terminally ill patients. Ex. Pt. who has unresectable pancreatic carcinoma, no longer a candidate for or no longer desires chemo or radiation therapy. Minimal (eg, chest radiograph to rule out symptomatic effusion, serum calcium level to determine response to bisphosphonate therapy) Opioids, major tranquilizers, anxiolytics, steroids, short- term cognitive and behavioral therapies, spiritual support, grief counseling, noninvasive treatment for complications Home or homelike environment Brief in-patient or respite care admissions for symptom relief and respite for family Urgent (Yellow) Rapid relief of overwhelming symptoms, mandatory if death is imminent. Shortened life may occur, but is not the intention of treatment (this must be clearly understood by patient or proxy). Ex. Patient who has advanced pancreatic carcinoma reporting uncontrolled pain (8 on a scale of 10), despite opioid therapy. Only if absolutely necessary to guide immediate symptom control Pharmacotherapy for pain, delirium, anxiety. Usually given intravenously or subcutaneously and in doses much higher than most physicians are accustomed to using. Deliberate sedation may need to be used and may need to be continued until time of death. In-patient or home with continuous professional support and supervision Victoria Classification of Palliative Care
  11. 11. Palliative Care and Hospice Rosenberg, M et al, Clin Geriatr Med 2013; 29:1–29 Palliative Care Symptom Management of Life Limiting Illness End of Life Care/Hospice Symptom Management and Comfort Care
  12. 12. Palliative Perception  The patient: – is not a candidate for curative therapy – has a life-limiting illness and chosen not to have life prolonging therapy – has uncontrolled symptoms – has uncontrolled psychosocial or spiritual issues – has been readmitted for the same diagnosis in last 30 days – has prolonged length of stay without evidence of progress – has Catch-22 criteria: the indicated treatment of one potentially fatal problem is contraindicated by another Central Baptist Hospital Palliative Care Screening Tool
  13. 13. DO IT! Palliative care is like intubation, if you think it needs to be done,
  14. 14. And not or  Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
  15. 15. Quality has quantitative benefit  Poor pain control is associated with delayed wound healing.  After bypass surgery, depressive symptoms are associated with infections, impaired wound healing, poor emotional and physical recovery.  Interventions to reduce the patient's psychological stress level may improve wound repair and recovery following surgery. McGuire L, Ann Behav Med, 2006;31(2): 165-72 Doering LV, Am J Crit Care, 2005;14(4): 316-24 Broadbent E, Psychosom Med, 2003; 65(5): 865-9
  16. 16. Curative and Palliative Sympto m YesNo Disease modifiable ? Review Alleviate symptom through disease- specific intervention Alleviate symptom through global/systemic intervention J Palliat Med. 2012; 15(1):106-14
  17. 17. Curative or Palliative? • Morphine – No mortality benefit. • Oxygen – No mortality benefit (unless hypoxic). • Nitrates – No mortality benefit. • Aspirin – OK, now we start decreasing mortality (anti-platelet effects onset of action is 2 hours, analgesic effect is 10-15 minutes).
  18. 18. Total Symptoms Pain • Physical problems (multiple) • Anxiety, anger and depression— elements of psychological distress • Interpersonal problems — social issues, financial stress, family tensions • Nonacceptance or spiritual distress Dyspnea • Physical symptoms • Psychological concerns • Social impact • Existential suffering Curr Opin Support Palliat Care. 2008; 2(2):110-3
  19. 19. Physical Cause? Assoc. Sx Debility and Fatigue Social Role Relationship Occupation Financial Cost Spiritual Existential coping Religious beliefs Meaning of life/illness Personal value Psychological Emotional Response Comorbid mood disorder ± anxiety Adjustment to new baseline Symptom Chaplaincy Art & Music Therapy Social Work Financial Navigator Occupational Therapy Social Work Psychology Psychiatry Acute Pain Service Chronic Pain Service Palliative Care Other Specialties Pharmacy Physical Therapy
  20. 20. Maslow’s Hierarchy of Needs Self-Actualization Esteem Love / Belonging Safety Physiological Physical Psych Social Spiritu al
  21. 21. FICA • Faith and Belief Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs that help you cope with stress?" If the patient responds "No," the health care provider might ask, "What gives your life meaning?" Sometimes patients respond with answers such as family, career, or nature. • Importance "What importance does your faith or belief have in our life? Have your beliefs influenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?" • Community "Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?" Communities such as churches, temples, and mosques, or a group of like-minded friends can serve as strong support systems for some patients. • Address in Care "How would you like me, your healthcare provider, to address these issues in your healthcare?" Spiritu al
  22. 22. Social Factors • Tail-light Test • Transitions of Care – Communicating with patient, family, and provider 22 Social
  23. 23. Physiologic versus Pathologic Emotions • Happiness • Sadness • Anger • Fear Disorders • Bipolar with mania • Depression / Bipolar • Anxiety • Personality disorders Psychologica l
  24. 24. Hospital Anxiety and Depression Scale Psychologica l
  25. 25. 2-for-1 Specials • Itching + anxiety = hydroxyzine • Neuropathic pain + muscle spasm = gabapentin • Neuropathic pain + anxiety = pregabalin • Depression + neuropathic pain = duloxetine Physical
  26. 26. Nausea Cause Receptors Drug Classes Examples Vestibular Cholinergic, Histaminic Anticholinergic, Antihistaminic Scopolamine patch, Promethazine Obstipation Cholinergic, Histaminic, likely 5HT3 Stimulate myenteric plexus Senna products Motility Cholinergic, Histaminic, 5HT3, 5HT4 Prokinetics which stimulate 5HT4 receptors Metoclopromide Infection/Inflammation Cholinergic, Histaminic, 5HT3, Neurokinin 1 Anticholinergic, Antihistaminic, 5HT3 antagonists, Neurokinin 1 antagonists Promethazine (e.g. for labyrinthitis), Prochlorperazine Toxins Dopamine 2, 5HT3 Antidopaminergic, 5HT3 Antagonists Prochlorperazine, Haloperidol, Ondansetron Physical
  27. 27. Nausea • Menthol salve for olfactory-induced nausea • Wean IV anti-emetics for at least 24 hours prior to discharge • Oral anti-emetics for nausea prophylaxis • Sublingual and rectal for acute nausea Physical
  28. 28. Pain Classifications Somatic (Nocioceptive) Visceral (Nocioceptive) Neuropathic (Central) Neuropatic (Peripheral) Psychogenic Etiology Skin and Deep Tissue Damage Organ Damage Nerve Damage Nerve Damage Primary psychological origin or worsening due to mood disorder Temporal Dependence Acute or Chronic Acute Chronic > Acute Chronic > Acute Acute or Chronic Characteristics Localized dull or aching Diffuse, referred to superficial structure, sickening, deep, squeezing, and dull Burning, coldness, "pins n’ needles", numbness and itching Mixed, non- physiologic Examples Fibromyalgia Tension headache Chronic back pain Arhtritis Irritable Bowel Syndrome Cystitis Prostate Pain Endometriosis Central pain syndrome 2° stroke, MS, tumor Diabetic neuropathy Shingles Complex regional pain syndrome Depression Anxiety Adjustment disorders Opioids First line First line Third line Second line No Physical
  29. 29. Neuropathic Pain Criteria Am J Med. 2009 Oct;122(10 Suppl):S3-12
  30. 30. Start Smart • What type of pain are we managing? • What was their level of function and regimen prior to this hospitalization? • Why not PO? (IV keeps you in the hospital) • What is your patient’s goal? • What is the plan and is everyone in agreement?
  31. 31. Opiates… • Do not cure anything (at best they are neuro- hormonal-psychiatric scaffolding) • Are poor choice for neuropathic pain • Have abuse / “self-medicating” potential • Have social stigma
  32. 32. Dose Units Medication Route Real World 15 mg morphine PO 15 mg hydrocodone PO 10 mg oxycodone PO 4 mg hydromorphone PO 5 mg morphine IV 0.75 mg hydromorphone IV 50 mcg fentanyl IV Dose Equivalents
  33. 33. Dose Equivalents
  34. 34. WHO Analgesic Ladder Canadian Family Physician 2010; 56(6):514-517
  35. 35. Ascending the Ladder • Morphine – Initial loading dose of 0.1 mg/kg – Subsequent dosages of 0.025 to 0.05 mg/kg every 5 minutes • Hydromorphone – Initial loading dose of 0.015 mg/kg hydromorphone – Subsequent dosages of 0.0075-0.015 mg/kg every 5-15 minutes • Fentanyl – Initial loading dose of 1-1.5 µg/kg – Subsequent dosages of 0.25-0.5 µg/kg every 15 minutes 75 kg 90 kg Loading Dose PRN Loading Dose PRN morphine 7.5 mg 2-4 mg 9 mg 2.5-5 mg hydromorphone 1 mg 0.5-1 mg 1.5 mg 0.75-1.5 mg fentanyl 75-100 µg 20-50 µg 100-150 µg 25-75 µg
  36. 36. Patient Controlled Analgesia • If analgesia is reached with 3 bolus doses, the patient controlled analgesia (PCA) equivalent is approximately: Q12min dose 4° lockout morphine 0.8-1 mg 16-20 mg hydromorphone 0.15-0.25 mg 3-5 mg fentanyl 20-30 µg 400-600 µg
  37. 37. Descending the Ladder • PCA can probably be weaned if one vial is enough for > 24 hours. • Wean IV doses by 10-33% per day. • Wean PO dose by 25-50% per day until 1-2 tablets Q4H of “low” dose medication then wean dosing interval: ✓ Q6H-Q8H-Q12H-QHS ✓ 16 “doses”
  38. 38. Day Frequency morphine (mg) hydromorphone (mg) fentanyl (mcg) 1 Q2H 30 4 300 2 Q2H 20 3 200 3 Q2H 15 2 150 4 Q2H 10 1.5 100 5 Q2H 7.5 1 75 6 Q4H 30 8 oxycodone (mg) 20 7 Q4H 15 4 10 25% 50% Example Opiate Wean
  39. 39. Opiate-Induced Bowel Dysfunction Prophylaxis • Non-pharmacological – Oral hydration – Physical activity – Privacy/scheduled visit to commode • Pharmacological – Scheduled senna (stimulant laxative), hold for diarrhea – Scheduled bisacodyl (stimulant laxative), hold if bowel movement in the past 24° – Scheduled MOM (or lactulose if kidney disease) or polyethylene glycol (osmotic stool softener), hold if bowel movement in the past 48° – Do NOT use bulk producers (i.e. fiber) – Consider adding mineral oil (lubricating stool softener)
  41. 41. Case • 23 y/o WF with chronic abdominal pain, nausea, and food aversion secondary to multiple surgeries for hereditary pancreatitis and complications thereof. • Non-malignant abdominal pain managed with progressive increases in opiates, now on high-dose opiates, 200 mcg/hr fentanyl patch with 4-8 mg of hydromorphone as needed every 2-3 hours • Mother strong advocate for patient. • Consulted for pain management.
  42. 42. How is she not dead?!?
  43. 43. CDC Grand Rounds, January 13, 2012 / 61(01);10-13
  44. 44. Course • Basal opiates increased and discharged home • Patient seen on subsequent hospitalizations for other complications, e.g. line infection, portal vein thrombosis. Abdominal pain continues to worsen. • Having built a relationship with patient, discussed concerns that opiates were worsening her pain. Agreeable to weaning off opiates.
  45. 45. Narcotic Bowel Syndrome Chronic or frequently recurring abdominal pain that is treated with acute high dose or chronic narcotics and all of the following: • The pain worsens or incompletely resolves with continued or escalating dosages of narcotics. • There is marked worsening of pain when the narcotic dose wanes and improvement when narcotics are reinstituted (“Soar and Crash”). • There is a progression of the frequency, duration and intensity of pain episodes. • The nature and intensity of the pain is not explained by a current or previous gastrointestinal diagnosis* *A patient may have a structural diagnosis (e.g., inflammatory bowel disease, “chronic pancreatitis”) but the character or activity of the disease process is not sufficient to explain the pain. Clin Gastroenterol Hepatol. Oct 2007; 5(10): 1126–1122.
  46. 46. Case • 72 y/o WM with metastatic pancreatic cancer, admitted for pain control. • Patient has been on rapidly escalating doses of morphine. Delirious, in his lucid moments he weeps, morphine has been aggressively increased. In the past 24 hours he developed intermittent jerking of his limbs. • Consulted for pain management.
  47. 47. Opiate-Induced Hyperalgesia • Increasing sensitivity to pain stimuli (hyperalgesia). Pain elicited from ordinarily non-painful stimuli, such as stroking skin with cotton (allodynia). • Worsening pain despite increasing doses of opioids. • Pain that becomes more diffuse, extending beyond the distribution of pre-existing pain. • Presence of other opioid hyperexcitability effects: myoclonus, delirium or seizures. • Can occur at any dose of opioid, but more commonly with high parenteral doses of morphine or hydromorphone and/or in the setting of renal failure.
  48. 48. Course • Patient was switched to fentanyl, but at 75% equianalgesic dose. • Pain controlled, delirium improved, myoclonic jerks resolved. • Patient died on in-patient hospice.
  49. 49. THANK YOU Questions? Concerns? Comments?