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Palliative Care. Practice Improvement Series Meeting September 25, 2008 David F. Giansiracusa, M.D. Director, Center for Pain and Palliative Care Maine Medical Center. Definition: Palliative Care. Patient- and family-centered care that

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palliative care

Palliative Care

Practice Improvement Series Meeting

September 25, 2008

David F. Giansiracusa, M.D.

Director, Center for Pain and Palliative Care

Maine Medical Center

definition palliative care
Definition: Palliative Care
  • Patient- and family-centered care that
  • Optimizes the quality of life by anticipating, preventing, and treating suffering
  • Is provided throughout the continuum of illness
  • Involves:

-addressing physical, intellectual, emotional,

social, and spiritual needs

-facilitating patient autonomy

-providing access to information and choice.

National Quality Forum

goal of palliative care
Goal of Palliative Care

To prevent and relieve suffering and support the best possible quality of life for patients and their families facing life threatening illness regardless of the stage of disease or the need for other therapies.

Clinical Practice Guidelines for Quality Palliative Care,

National Consensus Project, 2004

palliative care programs
Palliative Care Programs
  • Provide assessment and treatment of pain and other symptoms
  • Help with patient-centered and family-centered communication and decision making
  • Coordinate care across settings and through serious illness
hospice care a service delivery system
Hospice Care:A Service Delivery System
  • Palliative care for patients with limited life expectancy and require comprehensive biomedical, psychosocial, and spiritual support as they enter the terminal stage of illness or condition.
  • Supports family members coping with the complex consequences of illness, disability, and aging as death nears.
  • Addresses the bereavement needs of family following the death of the patient.

National Quality Forum

palliative care for quality of life
Palliative Care for Quality of Life

Bereavement

Disease Modifying Therapy

Hospice

PalliativeCare

Acute

Chronic

Advanced

Death

Last

Hours

Diagnosis LTI

Life

Closure

palliative care is provided by interdisciplinary teams
Palliative Care Is Provided by Interdisciplinary Teams
  • Medicine
  • Nursing
  • Social Work
  • Chaplaincy
  • Counseling
  • Nursing assistants and other health care professionals.
causes of suffering in life threatening illness
Pain

Present

Future

Dyspnea

Delirium

Nausea/ vomiting

Anxiety

Depression

Uncertainty

Fear of disability

Fear of death

Hopelessness

Remorse

Loneliness

Loss of

Meaning

Control

Dignity

Relationships

Causes of Suffering in Life Threatening Illness
palliative care symptom management pain
Palliative Care Symptom Management: Pain
  • Carefully Assess:

-Patient’s self-report is gold-standard

-If patient cannot communication, must rely on family/caregiver report, observation, assumption (previous tx)

  • Provide Comfort
  • Improve Quality of Life
  • Maximize Function
pain management
Pain Management
  • Discern cause of pain: underlying disease, complication of therapy, other process such as bladder or bowel distension, neuropathy, rheumatic disorder, PUD
  • Determine type of pain: nociceptive (somatic, visceral), neuropathic
types of persistent pain
Neuropathic Pain

Herpes Zoster

Diabetes

Stroke

Nociceptive Pain

Early cancer pain

Arthritis

Myofascial pain

Infection

Ischemia

Trauma

Mixed Pain Syndromes

Most common

Late cancer pain

Lumbar radiculopathy

Osteoporosis

Types of Persistent Pain
approach to pain management
Approach to Pain Management
  • Address treatable causes
  • Utilize non-pharmacological modalities
  • Optimize analgesic medications and address side effects
  • Consider invasive procedures
pain assessment tools intensity

0

1

2

3

4

5

6

7

8

9

10

Pain Assessment Tools: Intensity

Simple Descriptive Pain Intensity Scale

0-10 Numeric Pain Intensity Scale

Very Severe

None

Mild

Moderate

Severe

Worst Possible

0-10 Numeric Pain Intensity Scale

None

Moderate

Worst Possible

Visual Analog Scale (VAS)

None

Pain as bad as itcould possibly be

Faces scale reprinted with permission from Patt RB. Cancer Pain. Philadelphia: JB Lippincott Co.; 1993.

Jacox A, et al. Management of Cancer Pain: Clinical Guideline No. 9. March 1994. AHCPR Publication No. 94-0592.

pain management1
Pain Management
  • Often requires multimodality-approach of drug therapy and non-drug strategies
  • Requires frequent monitoring for response and side effects and for adjustment of therapy
pain management in the elderly non pharmacologic interventions
Pain Management in the Elderly: Non-pharmacologic Interventions
  • Cold/warmth
  • Massage
  • Exercise/PT
  • Positioning
  • TENS
  • Acupuncture
  • Cognitive-behavioral therapies: relaxation, guided imagery, music/art therapy, hypnosis, meditation, biofeedback
  • Socialization, time with pets
who analgesic ladder
WHO Analgesic Ladder

Pain Relief

Opioid for moderate to severe pain

+ non-opioid +/- Adjuvant

Pain Persists or increases

Opioid for mild to moderate pain

+ non opioid +/- Adjuvant

Pain Persists or increases

Non opioid (NSAID) +/- Adjuvant

Pain

slide17

Morphine is a naturally occurring analgesic“among the remedies that almighty god has given man to relieve his pain and suffering none as efficacious as opium” Sydenham 1690

commonly used opioid formulations
Short Acting:

Morphine

Oxycodone

Hydromorphone

Oxymorphone

Buccal Fentanyl

Sustained Release

Morphine: (MS Contin

Kadian, Avinza)

Oxycodone (Oxycodone

CR, Oxycontin)

Transderm Fentanyl

Long Acting:

Methadone

Commonly Used Opioid Formulations:
rules of ones
Rules of Ones

One background and one short acting opioid at a time.

equi analgesic doses of opioids
Equi-Analgesic Doses of Opioids

PO IV

Codeine 300 mg

Morphine 30 mg 10 mg

Hydromorphone 7.5 mg 1.5 mg

Fentanyl --------- 100 mcg

Oxycodone 20 mg ---------

Methadone Chart

Fentanyl 25 mcg/hr patch=50 mg oral MS/24hr

opioid dose titration
Opioid Dose Titration
  • Start with PRN short acting opioid
  • Add long-acting opioid in dose equal to 75-100% of 24 hour dose of PRN opioid consumed
  • Continue PRN opioid in dose of 10-15% (5% in frail elderly) of 24 hour dose of long-acting opioid every 1-2 hours
opioid side effect management
Opioid Side Effect Management:
  • Constipation
  • Nausea
  • Dry mouth
  • Sedation
  • Respiratory depression
  • Delirium
preventing and treating opioid side effects
Preventing and Treating Opioid Side Effects
  • Start bowel regimen-stool softener and laxative on all patients when starting opioids
  • Anticipate sedation/cognitive changes: fall precautions, assistance with mobility
  • Consider 5 day course of anti-emetic:

-dopamine antagonist: haloperidol, prochlorperazine, metoclopramide

-5 HT-3 antagonist: ondansetron

opioid side effects sedation
Opioid Side Effects: Sedation
  • Eliminate other etiologies
    • polypharmacy
    • CNS pathology
    • metabolic dysfunction
  • Consider psycho-stimulants if appropriate
    • Methylphenidate (Ritalin)
    • Dextroamphetamine (Dexedrine)
  • Increased drowsiness and weakness are common in the final days before death
rationale for changing opioids
Rationale for Changing Opioids:
  • Intolerance:

-sedation

-persistent nausea/vomiting

-pruritus

-urinary retention

  • Difficulty with compliance/adherence
  • Renal function impairment: morphine metabolites
incomplete cross tolerance
Incomplete Cross Tolerance
  • A patient tolerant to the effect and side effects of one opioid may not be equally tolerant to the effects and side effects of another opioid
  • When switching opioids, after calculating the equivalent conversion, reduce the new opioid by 25-50%
neuropathic pain
Neuropathic Pain
  • Due to injury to peripheral nerves, spinal cord, central nervous system
  • Common illnesses: cancer, AIDS, diabetes mellitus, alcoholism, herpes zoster, amputation, stroke, chemotherapy, radiation tx, surgery
  • Characterized by burning, lancinating,

tingling, shooting, electrical or pins-and-needles associated with numbness

adjuvant medications
Adjuvant Medications
  • Helpful for neuropathic pain syndromes: diabetic neuropathy, postherpetic neuralgia, trigeminal neuralgia
    • Lidoderm (5% Lidocaine patch, up to three for 12-24 hours a day); lidocaine infusions
    • Gabapentin or other anti-convulsants
    • Opioid analgesics
    • Tramadol
    • Tricyclic antidepressants (desipramine or nortriptyline) or noradrenergic/specific seritonergic uptake inhibitors

(Dworkin RH, Backonja M, Rowbotham MC et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003; 60:1524-1534.)

antidepressant analgesics for neuropathic pain
Antidepressant Analgesics for Neuropathic Pain:
  • For burning, tingling pain:
  • Tricylic antidepressants:

-Analgesic in days to weeks, anticholinergic-delirium and urinary retention, cardiac toxicity

-desipramine or nortriptyline 10-25 mg qhs,- minimal anticholinergic or sedating effects

  • Serotonin-noradrenaline uptake inhibitors: duloxetine (Cymbalta), venlafaxine (Effexor)

(Onghena P el al. Pain, 1992;49:205-219; Bradley RH et al. (Venlafaxine) Am J Ther.2003;10:318-323; Raskin J et al.(Duloxetine) J Palliat Med 2006:9:29-40.)

anticonvulsant adjuvants for neuropathic pain
Anticonvulsant Adjuvants for Neuropathic Pain

Gabapentin (Neurontin)

-100 mg po qd to TID

-increase dose every 1-3 days

-usual effective dose 900-1800 mg/d,

maximum may be >3600mg/d

-tolerance to drowsiness develops in days

-adjust for renal failure (CrCl 30-59: 400-1400mg/d; CrCl 15-29: 100-300 mg/d; CrCl <15: proportionate decrease

Pregabalin (Lyrica)

-50 mg po BID to 300 mg BID

topical analgesics
Topical Analgesics
  • Lidocaine 5% patches (12-24 hour/day safety (PHN, PDN, low back pain)
  • Capsaicin (0.025% and 0.0.75%)
  • Antipressants (Zonalon-doxipen HCl)-PHN, PDN, mucositis, pain of intermittent urinary bladder catheterization.
  • Topical opioids-pressure ulcers (10 mg morphine, mucositis-2% morphine)
  • (Argoff C. Topical Local Anesthetics; McCleane G. Topical Opioids; McCleane G. Nitrates, Capsaicin, and Tricyclic Antidepressants; in Clinical Management of the Elderly Patient in Pain. Haworth Press, NY, 2006)
treatment of bone pain
Treatment of Bone Pain
  • Non-steroidal anti-inflammatory drugs
  • Steroids
  • Opioids
  • Bisphosphonates
  • Radiation
  • Neuropathic treatment
palliative care symptom management dyspnea
Palliative Care Symptom Management: Dyspnea
  • Etiologies:

-Pulmonary: tracheal, bronchial obstruction; edema; pneumonia; lymphangitic spread; pleural effusion; pulmonary embolus;

interstitial disease; pneumothorax; neuromuscular disease

- Cardiac: ischemia; heart failure; superior vena cava syndrome; pericardial disease

-Anemia:

-Acidosis:

management of dyspnea
Management of Dyspnea
  • Treating reversible causes: diuretics, bronchodilators, thoracentesis, radiation therapy, blood transfusion
  • Comfort measures: blowing air over face, oxygen for hypoxemia, opioids in low doses (ie. Morphine elixir 2.5-5 mg po q4 hrs titrated to relief discomfort of shortness of breath, tx of anxiety with benzodiazepine (lorazepam 0.5 mg po q4-6hr)
nausea and vomiting mechanisms pathways
Nausea and Vomiting: Mechanisms/Pathways
  • Chemoreceptor Trigger Zone: drugs- opioids, digoxin, antibiotics, NSAIDS; Chemotherapy; metabolic-hypercalcemia, uremia, hyponatremia
  • Higher Cortical Structures -elevated ICP-tumor, bleed, infection; conditioned, anxiety
  • Vestibular Apparatus -movement
  • Vagal Afferent Nerve -mucosal irritation, constipation, gastroparesis, gastric outlet or SBO, distension or infiltration of a viscus
treatment of nausea and vomiting vomit 1 eperc
Treatment of Nausea and Vomiting: VOMIT (1) eperc
  • V-vestibular:

-receptors: cholinergic, histaminic

-meds: Scopolamine patch, promethazine

  • O-obstruction by constipation:

-receptors: chol, histaminic, ?5HT3

-meds: senna; octreotide-cramps, secretions

treatment of nausea and vomiting vomit 2
Treatment of Nausea and Vomiting: VOMIT (2)
  • dysMotility of upper gut: gastroparesis

-meds: metoclopramide

  • Infection, Inflammation:

-receptors: cholinergic, histaminic, ?5HT3

-meds: promethazine (Phenergan), cyto-protective (PPI, H2 blockers)

  • Toxins stimulating the chemoreceptor trigger zone:

-receptors: dopamine 2, 5HT3

-meds: prochlorperazine, haloperidol, olanzapine, ondansetron

palliative care communications
Palliative Care: Communications
  • Understand who the person is (ABCDE)-attitudes, beliefs, context, decision making, environment
  • Assessment of physical and psychosocial symptoms
  • Determine what patient and family know about patient’s condition
  • Determine how much patient wishes to be told
  • Convey information
  • Advanced care planning (advanced directives, surrogate, goals and sites of care)
  • Closure at the end of life
  • Bereavement
psychological and spiritual assessment
Psychological and Spiritual Assessment
  • Evaluate what strengths and vulnerabilities patients bring to their illness experiences
  • Assess the meaning patients ascribe to their illness

Block SD JAMA 2001:85(22):2898

psychosocial assessment 1
Psychosocial Assessment (1)
  • Meaning of illness: “How have you made sense of why this is happening to you?” “What do you think is ahead?”
  • Coping style: “How have you coped with hard times in the past?” “What have been the major challenges you have confronted in your life?”

(Block SD. JAMA 2001)

psychosocial assessment 2
Psychosocial Assessment (2)
  • Social support network: “Who are the important people in your life now?” “How are the important people in your life coping with your illness?”
  • Stressors: “What are the biggest stressors you are dealing with now?” “Do you have concerns about pain or other kinds of physical suffering?” “About your and your family’s emotional coping?” (Block JAMA)
psychosocial assessment 3
Psychosocial Assessment (3)
  • Spiritual resources: “What role does faith or spirituality play in your life?”
  • Psychiatric vulnerabilities: “Have you experienced periods of significant depression, anxiety, drug or alcohol use, or other difficulties in coping?” “What kinds of treatment have you had and which have you found helpful?”

(Block JAMA 2001)

psychosocial assessment 4
Psychosocial Assessment (4)
  • Economic circumstances: “How much concern are financial issues for you?”
  • Patient-physician relationship:

“How do you want me, as your physician, to help you in this situation?” “How can we best work together?”

(Block SD. JAMA 2001)

common psychiatric disorders in dying patients
Common Psychiatric Disorders in Dying Patients
  • Depression
  • Anxiety
  • Delirium

(Block SD. Psychological considerations, growth, and transcendence at the end of life. JAMA 2001;285(22):2898-2905)

depression in terminal illness
Depression in Terminal Illness
  • Not normal, Under-diagnosed, Under-treated
  • Major depression in about 25%, increases with advanced disease
  • Impairs quality of life: impairs capacity for pleasure, meaning, connection; amplifies pain and other symptoms; causes family anguish; is a risk factor for suicide

(Block JAMA 2001)

indicators of depression
Indicators of Depression
  • Emotional symptoms (most reliable)*

-Hopelessness

-Helplessness

-Worthlessness

-Guilt

-Suicidal ideations

*Neuro-vegetative symptoms common in dying patients

(Block JAMA 2001)

treatment of depression
Treatment of Depression
  • Combination of supportive psychotherapy, patient and family education, and stimulants and/or antidepressants
  • Medication:

-Methylphenidate (Ritalin) 2.5 mg q8am and noon, increase q2-3 days-max. of 30 mg/d

-SSRI’s (may take 4-6 weeks for effect)

ie. Sertraline (Zoloft) 25-200 mg/d

(Block JAMA 2001)

anxiety and fear
Anxiety and Fear
  • Significant anxiety in about 25% patients with life-threatening illness
  • Contributors to anxiety: substance abuse and withdrawal, pain, corticosteroid therapy, delirium
  • Assessed: “What are you afraid of?” “What do you imagine dying will be like?” “Where do these worries come from?”

“What is hardest for you?”

treatment of anxiety and fear
Treatment of Anxiety and Fear
  • Ongoing exploration and support
  • For persistent, high levels:

-low dose benzodiazepines (clonazepam 0.5 mg BID)

-behavioral modalities-relaxation training, meditation

-SSRI’s

-Neuroleptics

delirium in terminal illness
Delirium in Terminal Illness
  • Very frequent-as many as 85% experience delirium as a terminal event
  • Intensely distressing to patient, family, and clinical staff
delirium in terminal illness cardinal symptoms
Delirium in Terminal Illness-Cardinal Symptoms:
  • Disorientation
  • Waxing and waning levels of consciousness and attention
  • Disorders of memory, emotion, and behavior
  • Disturbances of sleep-wake cycle

(Block SD JAMA 285:2892, 2001)

delirium in terminal illness common etiologies
Delirium in Terminal Illness-Common Etiologies:
  • Medications: opioids, benzodiazepines, steroids
  • Organ failure
  • Infection
  • Metabolic derangements-sodium, calcium
  • CNS effects of the disease
delirium in terminal illness treatment
Delirium in Terminal Illness-Treatment:
  • Environment: family members present, well-

lit room, familiar objects/surroundings

  • Neuroleptic agents:

Haloperidol, Olanzapine, Risperidone, Chlorpromazine (sedating, less EPS,

causes postural hypotension)

-Benzodiazepines: alone-generally ineffective, may worsen cognitive fx; with neuroleptics, may speed resolution of agitated delirium, reduce extrapyramidal adverse effects

of importance at end of life
Of Importance At End of Life
  • Optimizing physical comfort
  • Maintaining a sense of continuity with one’s self
  • Maintaining and enhancing relationships
  • Making meaning of one’s life and death
  • Achieving a sense of control
  • Confronting and preparing for death

(Block JAMA 2001)

making meaning at the end of life
Making Meaning at the end of life:
  • Sharing of memories, values, wisdom
  • Finding a sense of meaning or transcendence:

“How do you understand what is happening to you?”

“What would allow you to feel that going through this has a purpose?”

“Do you have traditions or beliefs that can help you deal with your illness?”

(Chaplains, psychiatrists, psychologists, social workers have special expertise in exploring these)

Block SD JAMA 85:2898, 2001

achieving a sense of control at the end of life
Achieving a Sense of Control at the End of Life
  • Conversations guided by patient’s preferences for information and participation in decision-making
  • Elicit patient’s ideas about the care they desire
  • Share information about the illness and reasonable treatment options
  • Inquire of rituals after death

(Block JAMA 2001)

preparing for death block
Preparing for Death: (Block)
  • Patients often wish to understand what is likely to happen as death approaches
  • Wish to speak frankly with physician about prognosis
  • Wish to have physician reassure commitment of care throughout the dying process

(Block JAMA 2001)

comfort focused care
Comfort-Focused Care
  • Opioids to relieve pain and dyspnea (morphine 5 mg po/sl; 2-4 mg iv/sc q 1 hour prn)
  • Secretions: Atropine 1% 2 drops SL q 2 hrs
  • Benzodiazepines for anxiety (Lorazepam 1 mg po/sl/sc/iv q 4 hours prn)
  • Neuroleptic for delirium (haloperidol 1 mg po/sl/sc/iv q 2 hours prn; olanzapine 5 mg qhs and q 6 hours prn po)
  • Mouth care
  • Psychosocial/spiritual support
palliative care care coordination
Palliative Care: Care Coordination
  • Facilitating patient communication wishes for type of care
  • Advanced care planning: Advanced directives (code status), identification and informing a surrogate, site of care
  • Assistance and coordination with Home Health Care, “Bridge Care”, Hospice
  • Bereavement: “A physician’s responsibility for the care of a patient does not end with the patient dies. There is one final responsibility—to help the bereaved family members.” (Bedell S et al. NEJM 2001;344:1162-64.)
bereavement for patient s family
Bereavement for Patient’s Family:

Make a phone call to family after patient’s death:

-Acknowledges the loss

-Expresses sympathy and concern

-Offers an opportunity to clarify questions about the patient’s terminal care

-Softens the psychological blow and reduces the family’s sense of abandonment by the health care system

-May help identify family members in need of professional help

(Bedell SE et al. NEJM 2001;344(15):1162-64)

condolence letter speak to
Condolence Letter: Speak to
  • Sorrow about the death: “I am writing to send my sympathies and condolences on the death of your husband.”
  • Personal memory of the patient and something aobut the patient’s family or work
  • An achievement, patient’s character, devotion to family, courage during illness, love and concern shared
  • Comfort the patient received from the family’s love
  • Privilege to have participated in patient’s care
  • Conclude letting family know our thoughts are with them (Bedell et al. NEJM 2001)
references
References:
  • Bascom PB, Tolle SW. Care of the family when the patient is dying. West J Med1995;163:292-296.
  • Bedell SE, Cadenhead K, Graboys TB. The doctor’s letter of condolence. N Eng J Med. 2001;344(15):1162-1164.
  • Block SD. Psychological considerations, growth, and transcendence at the End of Life. JAMA;2001:285(22):2898-2905.
  • Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med.1999;130:744-749.
references 2
References (2):
  • Lynn J. Serving patients who may die soon and their families: The role of hospice and other services. JAMA. 2001; 285(7):925-932.
  • Pantilat SZ. End-of-Life Care, 2nd edition, course syllabus, steven@medicine.ucsf.edu, Hospitalist Section, General Medicine, UCSF
  • Prigerson HG, Jacobs SC. Caring for bereaved patients. JAMA. 2001; 286(11): 1369-1376.
references 3
References (3)
  • Quill TE. Initiating end-of-life discussions with seriously ill patients: Addressing the elephant in the room. JAMA. 2000; 284(19):2502-2507.
  • Morrison RS, Meier DE. Palliative Care

N Engl J Med. 2004;350(25):2582-2590.

  • EPERC-End of Life/Palliative Education Resource Center: http://www.eperc.mcw.edu