on

45 Minutes of Suffering

Anesthesia Grand Rounds

Mike Aref, MD, PhD, FACP

Palliative Medicine Service, IU Health University Hospital

Assistant Professor of Clinical Medicine, Indiana University School of Medicine

Disclosure of Financial Relationships and

Conflicts of Interest

None

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

“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

Suffering

Goal-of-Care

Suffering

Goal-of-Care

Palliative Care

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

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.

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.

http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-hospice-palliative-medicine/

Evolving Model of Palliative Care

Cure/Life-prolonging

Intent

Palliative/

Comfort Intent

“Active

Treatment”

Palliative

Care

D

E

A

T

H

D

E

A

T

H

http://www.nationalconsensusproject.org

Evolving Model of Palliative Care

D

E

A

T

H

Comfort-

Focused Care

Psychological and Spiritual Support

Disease-

Focused Care

http://www.nationalconsensusproject.org

And not or

Of the 151 patients who underwentrandomization, 27 died by 12 weeks and107 (86% of the remaining patients)completed assessments. Patientsassigned to early palliative care had abetter quality of life than did patientsassigned to standard care (mean scoreon the FACT-L scale [in which scoresrange from 0 to 136, with higher scoresindicating better quality of life], 98.0 vs.91.5; P=0.03). In addition, fewer patientsin the palliative care group than in thestandard care group had depressivesymptoms (16% vs. 38%, P=0.01).Despite the fact that fewer patients inthe early palliative care group than inthe standard care group receivedaggressive end-of-life care (33% vs.54%, P=0.05), median survival waslonger among patients receiving earlypalliative care (11.6 months vs. 8.9months, P=0.02).

08/27/14 14

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 environmentBrief 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

DO IT!

Palliative care is like intubation, if you think it needs to be done,

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

Palliative Care and Hospice

Rosenberg, M et al, Clin Geriatr Med 2013; 29:1–29

Palliative CareSymptom Management of Life Limiting Illness

End of Life Care/HospiceSymptom Management and Comfort Care

Hospice and Palliative Care

• Hospice is for

patients who are

expected to die

within less than 6

months.

Palliative care is for

patients who you

would not be

surprised if they die

within less than 6-12

months.

Hospice

It's a service not a sentence (it's hospice not house arrest).

Hospice is a program, not a place.

Patient's with an estimated life-span of less than six months who are no longer candidates for curative therapy are eligible for services.

Patient's requiring active symptom management, who are too tenuous to move, or are actively dying may be eligible for in-patient hospice. In these patients death is expected within 5 days.

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

Pain/Symptom Assessment

– Are there distressing physical or psychological symptoms?

Social/Spiritual Assessment

– Are there significant social or spiritual concerns affecting daily life?

Understanding of illness/prognosis and treatment options

– Does the patient/family/surrogate understand the current illness,

prognostic trajectory, and treatment options?

Identification of patient-centered goals of care

– What are the goals for care, as identified by the

patient/family/surrogate?

– Are treatment options matched to informed patient-centered goals?

– Has the patient participated in an advance care planning process?

– Has the patient completed an advance care planning document?

Transition of care post-discharge

– What are the key considerations for a safe and sustainable transition

from one setting to another?

Weissman, DE, Archives in Internal Medicine 1997;157:733–737

Weissman, DE et al, Journal of Palliative Medicine 2011; 14(1):1-8

Primary Palliative Care Assessment

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

http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/ Central Baptist Hospital Palliative Care Screening Tool

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

Hope for the best, plan for the worst.

What are you hoping for?

What worries you the most?

What gives you strength?

Case

• 74 y/o WM with end-stage NASH cirrhosis, progressive hepatorenal syndrome, active on transplant list for liver and kidney transplant.

• Patient relocated to Indianapolis for transplant, family taking turns staying with patient, socially isolated.

• Abdominal pain related to umbilical hernia.

ACTIVE

TRANSPLANT

CANDIDATE

AND

PALLIATIVE

CARE?!?

– Patient

“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.”

Course• Initial consultation to provide support, discuss resources, and connected

patient with transplant social worker.

• Adjusted tramadol for liver failure, recommended low-dose alternative opiates.

• Recommended surgical evaluation for hernia, which was repaired due to incarceration.

• Followed patient intermittently as he was admitted for complications with liver and kidney failure. Explored history, spiritual coping, meaning of disease, and dealing with suffering of chronic, progressive organ failure.

• Ultimately started to decline, prepared for referral to hospice when organs became available, currently s/p transplantation of liver and kidneys and undergoing rehabilitation.

Case

• 21 y/o WF with cystic fibrosis, chronic respiratory failure, cystic fibrosis induced pancreatic exocrine and endocrine failure.

• Consulted for symptom management of cystic fibrosis pain, depression, and anxiety.

• Minimal psychosocial support, history of “non-compliance”.

• Multiple goals-of-care conversations over the past 17 month period.

THAT’S TOO YOUNG FOR

PALLIATIVE CARE!?!

DEATH HAS NO RESPECT FOR AGE

Admission and increased mortality

Cohort Number %

Died in ED 205 / 76,060 0.27

Died within 30 days of discharge from ED

111 / 59,366 0.19

Died within 30 days of being admitted from ED

876 / 16,489 4.6

Emerg Med J. Aug 2006; 23(8): 601–603

Death does not respect age

http://www.medicine.ox.ac.uk/bandolier/booth/Risk/dyingage.html

Median Death Age in Cystic Fibrosis

BMJ 2011;343:d4662

For select candidates, lung transplantation

improves survival and quality of life.

The five-year survival post-transplant is about

50%

www.eperc.mcw.edu/EPERC/FastFactsIndex/265-Palliative-Care-for-Patien

SUFFERING DOESN’T RESPECT AGE EITHER*

Symptoms

• Cough

• Dyspnea

• Fatigue

• Pain

www.eperc.mcw.edu/EPERC/FastFactsIndex/265-Palliative-Care-for-Patien

worsen as lung disease progresses

}

Pain

Pediatrics 1996; 98(4):741 -747

DECREASE SUPPORT INCREASE MORTALITY

Socioeconomics and Mortality

BMJ 2011;343:d4662

– Patient

“I get scared when there are more than two or

three people in the room, so I just say ‘yes’ to

their questions so they leave.”

Course• Pulmonary service sought to limit opiate usage due to concerns of

abuse and transplant eligibility, pain control was improved by starting and titrating pregabalin and venlafaxine.

• Worked on strategies for coping with managing her disease, such as teaching her to use a day planner, having health department inspect home for mold, healthcare representative declaration, and POST form.

• Often we conveyed concerns to the pulmonary team because her anxiety was exacerbated by the number of team members on pulmonary service and changing faces of the team.

• She has since died of complications of cystic fibrosis.

DO NOT REPRESENT

Do-Not-Resuscitate not Do-Not-Treat!

• “DNR orders only preclude resuscitative efforts in the event of cardiopulmonary arrest and should not influence other therapeutic interventions that may be appropriate for the patient.”

JAMA. 1991;265(14):1868-1871.

“Out-of-hospital” DNRIC 16-36-5-1"Cardiopulmonary resuscitation" or "CPR"

Sec. 1. As used in this chapter, "cardiopulmonary resuscitation" or "CPR" means cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation, including:

(1) cardiac compression;(2) endotracheal intubation and other advanced airway management;(3) artificial ventilation;(4) defibrillation;(5) administration of cardiac resuscitation medications; and(6) related procedures.

The term does not include the Heimlich maneuver or a similar procedure used to expel an obstruction from the throat.As added by P.L.148-1999, SEC.12.

My attending physician has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or pulmonary failure resulting in death.I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain.

www.in.gov/legislative/ic/2010/title16/ar36/ch5.html

Hospital DNR

www.indianapost.org

What’s a DNR?

DNR

• A: DNR

• B: Limited or Full

• “If you find 'em dead, leave 'em dead.”

DNR with comfort measures

• A: DNR

• B: Comfort Measures

• “When they're dying, dignity, peace, and comfort we’re trying”

ARTIFICIAL NUTRITION AND HYDRATION

Benefits of Artificial Nutrition and Hydration

• Physiological support for temporary inability to swallow or to use their gastrointestinal tract due to otherwise reversible conditions.

• Artifical nutrition and hydration (ANH) mayprolong life and allow a more accurate assessment of the patient's chance of recovery.

• For patients with chronic disabilities who are unable to take in adequate nutrition by mouth and who enjoy the life they lead, ANH is physiologically and qualitatively useful.

Nutr Clin Pract. 2006 ;21:118-125

Supportive not curative

• ANH alone, while sometimes supportive, does not cure or reverse any terminal or irreversible disease or injury.

• Multiple studies have consistently failed to show meaningful clinical benefit from ANH in terminally ill patients.

• A review of 70 published, prospective, randomized trials of nutrition support among cancer patients failed to demonstrate the clinical efficacy of nutrition support for such patients. Nutr Clin Pract. 2006 ;21:118-125

Nutr Clin Pract.1994;9:91– 100

Stop or don’t start ANH

• ANH support by either the enteral or parenteral route to terminally ill patients suggests increased suffering without improved outcome.

• ANH, whether provided by “feeding tube” or vein, is often associated with significant complications, including bleeding, infection, physical restraints such as tying the patient down, and in some cases a more rapid death.

• TPN does not alleviate hungerJAMA.1999 ;282:1365– 1370

J Gerontol.1998 ;53:M207– M213

Lancet.1997 ;349:496– 498

Appetite. 1989;13(2):129-41

Agenda

• Introduction

• Palliative Care

• Hospice

• Primary Palliative Care

• Goals of Care

• Symptom Management

Curative and Palliative

J Palliat Med. 2012; 15(1):106-14

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).

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

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

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?

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

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

Dose Equivalents

WHO Analgesic Ladder

Canadian Family Physician 2010; 56(6):514-517

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 minutes75 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

http://www.medscape.com/viewarticle/720539

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 dayuntil 1-2 tablets Q4H of “low” dosemedication then wean dosinginterval:

✓ Q6H-Q8H-Q12H-QHS

✓ 16 “doses”

http://paincommunity.org/blog/wp-content/uploads/Safely_Tapering_Opioids.pdf

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 8oxycodone (mg)

20

7 Q4H 15 4 10

25% 50%

Example Opiate Wean

National Cancer Institute: Last Days of

Life (PDQ®)

• “Many patients fear uncontrolled pain during the final hours of life, while others (including family members and some health care professionals) express concern that opioid use may hasten death. Experience suggests that most patients can obtain pain relief during the final hours of life and that very high doses of opioids are rarely indicated. Several studies refute the fear of hastened death associated with opioid use. In several surveys of high-dose opioid use in hospice and palliative care settings, no relationship between opioid dose and survival was found.”

• The goal is to provide symptom management, specifically of pain and dyspnea, not to cause death.

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/page2

Continuous Opioid Infusions

• Fentanyl start at 50 mcg/hr and titrate by 25 mcg/hr every 15 minutes

• Hydromorphone start at 1 mg/hr and titrate by 0.5 mg/hr every 15 minutes

• Morphine start at 5 mg/hr and titrate by 2.5 mg/hr every 15 minutes

COMPLICATIONS OF OPIATES

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)

http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf

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.

How is she not dead?!?

CDC Grand Rounds, January 13, 2012 / 61(01);10-13

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.

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.

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.

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.

www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_142.htm

Course

• Patient was switched to fentanyl, but at 75% equianalgesic dose.

• Pain controlled, delirium improved, myoclonic jerks resolved.

• Patient died on in-patient hospice.

THANK YOU

Questions? Concerns? Comments?