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.
• The area of medicine that deals with
alleviating the physical, mental, spiritual and
familial suffering of patients with chronic,
• 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.
Doyle D, Oxford Textbook of Palliative Medicine, 3 ed.
• Don’t delay palliative care for a patient
with serious illness who has physical,
psychological, social or spiritual distress
because they are pursuing disease-
Type Goal Investigations Treatments Setting
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,
radiation therapy, aggressive
Active treatment of
care units; Active
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
Minimal (eg, chest
radiograph to rule out
serum calcium level to
determine response to
Opioids, major tranquilizers,
anxiolytics, steroids, short-
term cognitive and behavioral
therapies, spiritual support,
grief counseling, noninvasive
treatment for complications
Home or homelike
Brief in-patient or
symptom relief and
respite for family
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
Pharmacotherapy for pain,
delirium, anxiety. Usually given
subcutaneously and in doses
much higher than most
physicians are accustomed to
Deliberate sedation may need
to be used and may need to be
continued until time of death.
In-patient or home
Victoria Classification of Palliative Care
Palliative Care and Hospice
Rosenberg, M et al, Clin Geriatr Med 2013; 29:1–29
Symptom Management of Life Limiting Illness
End of Life Care/Hospice
Symptom Management and Comfort Care
– is not a candidate for curative therapy
– has a life-limiting illness and chosen not to have life prolonging
– 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
http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/ Central Baptist Hospital Palliative Care Screening Tool
Palliative care is like intubation, if you think it
needs to be done,
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
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
Curative and Palliative
J Palliat Med. 2012; 15(1):106-14
Curative or Palliative?
– No mortality benefit.
– No mortality benefit (unless hypoxic).
– No mortality benefit.
– OK, now we start decreasing mortality (anti-platelet effects onset
of action is 2 hours, analgesic effect is 10-15 minutes).
• Physical problems (multiple)
• Anxiety, anger and depression—
elements of psychological distress
• Interpersonal problems — social
issues, financial stress, family
• Nonacceptance or spiritual
• Physical symptoms
• Psychological concerns
• Social impact
• Existential suffering
Curr Opin Support Palliat Care. 2008; 2(2):110-3
Debility and Fatigue
disorder ± anxiety
Adjustment to new
Art & Music Therapy
Acute Pain Service
Chronic Pain Service
Maslow’s Hierarchy of Needs
Love / Belonging
• 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.
"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?"
"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
• Tail-light Test
• Transitions of Care
– Communicating with patient, family, and
Physiologic versus Pathologic
• Bipolar with mania
• Depression / Bipolar
• Personality disorders
Hospital Anxiety and Depression Scale
• Menthol salve for olfactory-induced nausea
• Wean IV anti-emetics for at least 24 hours prior to
• Oral anti-emetics for nausea prophylaxis
• Sublingual and rectal for acute nausea
Skin and Deep
Organ Damage Nerve Damage Nerve Damage
or worsening due to
Diffuse, referred to
squeezing, and dull
Burning, coldness, "pins n’
needles", numbness and itching
Chronic back pain
Irritable Bowel Syndrome
stroke, MS, tumor
Opioids First line First line Third line Second line No
Neuropathic Pain Criteria
Am J Med. 2009 Oct;122(10 Suppl):S3-12
• What type of pain are we managing?
• What was their level of function and regimen prior to
• Why not PO? (IV keeps you in the hospital)
• What is your patient’s goal?
• What is the plan and is everyone in agreement?
• Do not cure anything (at best they are neuro-
• Are poor choice for neuropathic pain
• Have abuse / “self-medicating” potential
• Have social stigma
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
WHO Analgesic Ladder
Canadian Family Physician 2010; 56(6):514-517
Ascending the Ladder
– Initial loading dose of 0.1 mg/kg
– Subsequent dosages of 0.025 to 0.05 mg/kg every 5 minutes
– Initial loading dose of 0.015 mg/kg hydromorphone
– Subsequent dosages of 0.0075-0.015 mg/kg every 5-15
– 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
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
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
✓ 16 “doses”
Opiate-Induced Bowel Dysfunction
– Oral hydration
– Physical activity
– Privacy/scheduled visit to commode
– 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)
• 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.
CDC Grand Rounds, January 13, 2012 / 61(01);10-13
• 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.
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
• There is a progression of the frequency, duration and intensity of
• 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.
• 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.
• 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.
• Patient was switched to fentanyl, but at 75%
• Pain controlled, delirium improved, myoclonic jerks
• Patient died on in-patient hospice.