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

Disclosure of Financial Relationships and

Conflicts of Interest

None

TRANSPLANT

SURGERY

AND

PALLIATIVE

CARE?!?

“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.”

“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

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/

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 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

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

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

DO IT!

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

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).

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

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

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

Physical

Cause?

Assoc. Sx

Debility and Fatigue

Social

Role

Relationship

Occupation

Financial Cost

SpiritualExistential

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

Maslow’s Hierarchy of Needs

Self-Actualization

Esteem

Love / Belonging

Safety

PhysiologicalPhysical

Psych

Social

Spiritu

al

FICA• Faith and Belief

Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs thathelp you cope with stress?" If the patient responds "No," the health care provider mightask, "What gives your life meaning?" Sometimes patients respond with answers such asfamily, career, or nature.

• Importance

"What importance does your faith or belief have in our life? Have your beliefsinfluenced how you take care of yourself in this illness? What role do your beliefs play inregaining 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?" Communitiessuch as churches, temples, and mosques, or a group of like-minded friends can serve asstrong 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

http://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool

Social Factors

• Tail-light Test

• Transitions of Care

– Communicating with patient, family, and provider

22

Social

Physiologic versus Pathologic

Emotions

• Happiness

• Sadness

• Anger

• Fear

Disorders

• Bipolar with mania

• Depression / Bipolar

• Anxiety

• Personality disorders

Psychologica

l

Hospital Anxiety and Depression Scale

Psychologica

l

2-for-1 Specials

• Itching + anxiety = hydroxyzine

• Neuropathic pain + muscle spasm = gabapentin

• Neuropathic pain + anxiety = pregabalin

• Depression + neuropathic pain = duloxetine

Physical

Nausea

Cause Receptors Drug Classes Examples

Vestibular Cholinergic, Histaminic

Anticholinergic,

AntihistaminicScopolamine patch,

Promethazine

ObstipationCholinergic, Histaminic,

likely 5HT3

Stimulate myenteric

plexusSenna products

MotilityCholinergic, 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, 5HT3Antidopaminergic,

5HT3 Antagonists

Prochlorperazine,

Haloperidol,

Ondansetron

Physical

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

Pain Classifications

Somatic

(Nocioceptive)

Visceral

(Nocioceptive)

Neuropathic

(Central)

Neuropatic

(Peripheral)Psychogenic

EtiologySkin and Deep

Tissue DamageOrgan Damage Nerve Damage Nerve Damage

Primary

psychological origin

or worsening due to

mood disorder

Temporal

Dependence

Acute or

ChronicAcute

Chronic >

Acute

Chronic >

Acute

Acute or

Chronic

CharacteristicsLocalized 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

Neuropathic Pain Criteria

Am J Med. 2009 Oct;122(10 Suppl):S3-12

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

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

COMPLICATIONS OF OPIATES

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?