Sam was a 56 y/o single male Palliative care was asked to see ... retroperitoneal
node that was biopsy positive for the same cancer. .... Morley JS et al. Low dose ...
Denise Waugh, MD FACEP FAAHPM Assistant Professor of Medicine, TAMHSC Associate Faculty, The Institute for Palliative Medicine at San Diego Hospice (254) 724-6859
Data from the Public Opinion Strategies National Survey supported by the American Cancer Society ◦ 800 adults age > 18 conducted June 5-8, 2011
Doctors might not provide all of the treatment options or choices available Doctors might not talk and share information with each other Doctors might not choose the best treatment option for a seriously ill patient’s medical condition
58%
Patients with serious illness and their families leave a doctor’s office or hospital feeling unsure about what they are supposed to do when they get home
51%
Patients with serious illness and their families do not have enough control over their treatment options
51%
Doctors do not spend enough time talking with and listening to patients and their families
50%
55% 54%
Physicians tend to either equate palliative care with “hospice” or “end of life” care, and they are very resistant to believing otherwise. We spoke with a total of eighty physicians across the IDIs and focus groups. Although these physicians say they have referred patients to palliative care services, they admit they only do so when it is end of life care. “Comfort care during one’s last few weeks or days of life to allow patients to pass in comfort and dignity.” “Make a patient’s remainder of life comfortable and pleasant, without side effects of treatment, no aggressive measures are taken.” “Comfort care. The goal is to keep a patient comfortable and out of intensive medical treatment. The goal is not to cure but to treat their symptoms.”
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
The Case of Sam
Sam was a 56 y/o single male Palliative care was asked to see for intractable pain. Sam had a history of metastatic pleomorphic giant cell carcinoma of the lung diagnosed 12 months earlier. He was status post right upper lobectomy with en bloc resection of the chest wall including ribs 3-7 on the ipsilateral side with mesh placement. He had undergone chemotherapy but despite this treatment he developed a retroperitoneal node that was biopsy positive for the same cancer. Unfortunately, he had 4 other surgical procedures due to a bronchopleural fistula and aspergillus fungal infection at the primary surgical site. His last surgical procedure was 2 months prior to our consult and he felt he never fully recovered from that procedure. He had symptoms of severe pain despite opioids, dyspnea, anxiety, depression, insomnia and constipation of 3 days duration.
Of interest is the fact that Sam had been attempting to wean himself from the fentanyl patch even though his pain was not fully relieved . He stated he felt it was his duty to take as little pain medication as possible
1.
2. 3. 4. 5. 6.
Desire to be a good patient Fear that the need for increased opioid indicates worsening cancer Perception that decreasing opioids improves the ECOG score Desire not to distract one’s oncologist from treating the cancer Inability to afford opioids, particularly long acting opioids Knowledge that opioids weaken the immune system
1. 2. 3.
4. 5. 6.
Choice Choice Choice Choice Choice Choice
One Two Three Four Five Six
17%
1
17%
2
17%
17%
3
4
17%
5
17%
6
Sam had been using a stable dose of a Fentanyl 50 mcg patch and Dilaudid 8 mg q 4 hours for pain until 2 days prior to admission when he had sudden increase in dull, boring tightness in his right chest and additionally he suffered lightening-like sharp, burning, stabbing discomfort in the right posterior chest 10/10. This pain made it difficult for him to breath and lasted approximately 30-60 seconds each time it occurred. Due to the severity of the pain, Sam had increased his Dilaudid to 16 mg every 2-3 hours and the 50 mcg patch of fentanyl and the pain persisted at a 8-9/10 scale. He was very groggy and described feeling drunk. He presented to the hospital to see if he might have a pneumonia causing the increased pain. He has not had a cough or fever.
1. 2.
3. 4.
2.5 mg/hr hydromorphone 25% basal only IV 1.25mg/hr hydromorphone and 2 mg Iv q 15 min. 5mg/hr hydromorphone and 2mg q 15 min. prn IV 2mg/hr hydromorphone and 2mg q 15 min. prn IV
25%
25%
25%
120 1
2
3
4
Countdown
50 mcg fentanyl patch = 100 mg po Morphine 100mg po Morphine = X mg IV Hydromorphone 15 1 X = 6mg of HM divided by 24 = .25mg/hr IV HM 128 mg po HM = XX mg/hr IV HM 3 1 XX = 42 divided by 24 = 1.75 mg/hr IV HM X + XX = 2mg/hr IV HM and can give 2 mg q 15 min. because you know he has tolerated 8mg po for a long time
1. 2. 3.
4.
Somatic and visceral Purely nociceptive Nociceptive and neuropathic Purely neuropathic
25%
25%
25%
25%
10 0 of 90
1
2
3
4
Countdown
20%
20%
20%
20%
20%
Aspirin 2. Naproxen 3. Methadone 4. Ketamine Give your recommended dose? 1.
30 1
2
3
4
5
Countdown
Sam was begun on 1mg/hr HM and 1mg q 20 minutes prn/ PCA In 24 hours his pain was still not managed and he winced with severe pain periodically on his initial PCC. It was recommended that he be increased to 2mg/h and 2mg Q 15 min. prn and to begin 5mg Methadone Q HS the next evening if pain was not fully resolved. After addition of the methadone, Sam’s lancinating pain significantly improved to average of 3/10 scale and he was using only 2-3 doses of breakthrough in 24 hours. He did occasionally have the spikes of 8/10 lancinating pain and requested that he be increased to Methadone 5 mg q 12 hours Sam was discharged on Fentanyl 100 mcg patch, 8mg hydromorphone po q 3 hours prn and 5 mg Methadone q 12 hours with good pain control.
Constipation – Sam had used Miralax 17 gm daily prior to admission but was admitted on nothing for constipation. He stated even with the Miralax he had no BM for 72 hours.
1. 2.
3. 4.
Enema every other day as needed Miralax 17 gms qd Senna S 1 tab twice/day Senna S and Miralax
25%
25%
25%
25%
30 1
2
3
4
Countdown
Anxiety – described as moderate to severe. Lorazepam causes him to be unable to function and be very forgetful (lives alone) Depression – moderate with very little relief from long term Wellbutrin 300 mg/day
25%
1. 2. 3.
4.
25%
25%
2
3
25%
Wellbutrin Lorazepam Combivent inhaler Trazadone
1
4
Sam was weaned off Bupropion and placed on escitalopram (Lexapro) which causes much less likelihood of anxiety and is known to have less drug-drug interactions than most of the SSRIs. It is also less likely to worsen anorexia Sam was taken off lorazepam without weaning and placed on Haloperidol 1mg q 12 hours scheduled and 1 mg q 2 hours prn anxiety not to exceed 10 mg/day
Dyspnea – Sam was unaware that opioids can be used to control his shortness of breath Anorexia – He feels this is adequately treated with 2.5 mg/day
Sam had a 23 year relationship with another male and no history of female relationships yet he felt he was heterosexual. Sam preferred not to discuss any negative news feeling that this might lead to a worsened outcome Sam knew he wanted his sister to move in with him when he was ready for hospice but not until he was ready because she might sit on his furniture and mess up his things.
1. 2.
3.
4.
Tell Sam he is dying 25% Ask permission to discuss what will happen if he worsens Speak with Sam alone because he is private Enlist all the supportive assistance Sam will allow
1
25%
25%
2
3
25%
4
Sam invited his brother, sister-in-law and sister to be present to discuss his discharge issues Sam did not want his lover of many years present due to resentments about recent events The PC team allowed Sam to preside over the family meeting stopping any discussion he did not want His siblings reassured him of their love and desire to assist in any way they might.
His sister offered to move in at time of discharge and if he recovered she would move out Sam requested information about his prognosis Sam agreed to accept the assistance of hospice to avoid further hospitalization but reserved the prerogative to discharge hospice if he got better or felt they were intrusive Sam strongly desired not to die on a ventilator He felt his perfect death would be “just to fall asleep”
71 days prior to death he told the psychologist “I don’t feel I was treated fairly…Wish I had been told sooner about my prognosis” He noted that when he did not know the prognosis, he was more anxious about the future. He said that now he actually feels calmer because now ” I know what to do”
30 days prior to his death, the psychologist visited Sam at his home where he said, “Even if I do die like they say I will, I’m going to go out kicking and screaming” He then told the psychologist that he didn’t want to be rude but he was hoping she would not come again that it made him sad and he didn’t feel a need to discuss anything sad The psychologist felt he was still using avoidance and denial to cope with his impending death and that he was not willing to acknowledge emotional pain, sadness or anger.
76
days after discharge from the hospital, Sam died peacefully and without pain on Providence Hospice. He never required any major changes to his medication and died in his sleep.
Serious Side Effects from All Opioids
The Desire to be Alert but Comfortable
The Desire Not to Speak of Hospice
1. 2. 3. 4.
Visceral Somatic Neuropathic Nociceptive
25%
25%
25%
25%
10 0 of 90
1
2
3
4
Countdown
1) 2) 3) 4) 5) 6)
7) 8) 9)
Gabapentin/pregabalin Carbamazepine (tegretol) Topirimate (topamax) Nortriptyline/desipramine Escitalopram (lexapro) Duloxetine (cymbalta) Ketamine Methadone Lidocaine
11%
11%
11%
11%
11%
11%
11%
11%
11%
15 0 of 90
1)
2)
3)
4)
5)
6)
7)
8)
9)
Countdown
Palliative Care
◦ CAPC.org Patient Barriers to Opioid Therapy Vallerand A. Chronic opioid therapy for nonmalignant pain: the patient’s perspective. Part II Barriers to opioid therapy. Pain Manag Nurs 2010Jun; 11(2):126-131.
Equianalgesic Dosing
Scott and White Resident Handbook
Methadone
Morley JS et al. Low dose methadone has an analgesic effect in neuropathic pain: A double blind randomized controlled crossover trial. Palliat Med 2003 Oct;17(7). Bennet GJ. Update on the neurophysiology of pain transmission and modulation: focus on the NMDA receptor. J Pain Symptom Manage 2000 Jan;19(1Suppl):S2-6.
Lidocaine ◦ 1)Sharma S. Rajagopal M, Palat G A phase II pilot study to evaluate use of intravenous lidocaine for opioid-refractory pain in cancer patients. J Pain Symptom Manage 2009;37(1):85-93. ◦ 2)Challapalli V, Tremont-Lukats IW Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev. 2005 October 19;(4):CD003345
