Specialist Palliative Care in ESLD: An Introduction

SPECIALIST PALLIATIVE CARE IN

ESLD:AN INTRODUCTION

KYLE P. EDMONDS, MD

ASSISTANT CLINICAL PROFESSOR

HOWELL PALLIATIVE CARE SERVICE

UCSD HEALTH SCIENCES

OBJECTIVES

• UNDERSTAND THE ROLE OF PALLIATIVE CARE IN SERIOUS ILLNESS

• AWARENESS OF THE CONCEPTS OF GENERALIST VS. SPECIALIST PALLIATIVE CARE

• NAME THE PREFERRED ADJUVANT PAIN MEDICATION IN ESLD

• DESCRIBE THE DIFFERENTIAL OF ABERRANT DRUG-TAKING BEHAVIOR & A STRATEGY TO SAFELY PRESCRIBE CONTROLLED SUBSTANCES

• EXPLAIN HOW THE CONCEPT OF TIME-LIMITED TRIALS RELATES TO GOALS OF CARE

YOUR CHALLENGES IN INVOLVING PALLIATIVE CARE?

THE COMMON ANSWER

Time

Palliative

Care

Routine Medical Care:antibiotics, dialysis, chemotherapy, surgery

“Dying”?

“Nothing more to do”?

“Pt / family request”?

“Really sick”?

“Really, really sick”?

PROGNOSIS: MOVING TARGET

RAND, 2005.

PALLIATIVE CARE AS EXPERT PARTNER

AVAILABLE AT ANY AGE AND AT ANY STAGE IN A SERIOUS ILLNESS AND

CAN BE PROVIDED ALONG WITH CURATIVE TREATMENT.

Time

General / Specialty Palliative

Care

Routine Medical Care

The Course of Illness

Gastroenterology

Generalist Palliative

CareSpecialist Palliative

Care

•MOA•TACE•Antibiotics

•ondansetron•opioids

•Complex pain•High dose opioids•Limit setting•Hope & Prognostication

A.R. CASE

• 67 YEAR OLD MALE

• ETOH & HEP C CIRRHOSIS

• JANUARY DX’ED WITH HCC

• SYMPTOMS: FATIGUE AND CHRONIC BACK PAIN ON HIGH DOSE OPIOIDS

• APRIL: TACE

• SYMPTOMS: “SEVERE” PAIN, NAUSEA AND CONSTIPATION

• MAY

• ADMITTED “SEVERE” ABDOMINAL PAIN

• REQUESTING SPECIFIC MEDS AND DOSES

A.R. CASE

• OVERNIGHT: DECOMPENSATED

• “SEVERE” ABDOMINAL PAIN, “HARD TIME BREATHING”

• TRANSFERRED TO ICU

• PALLIATIVE CARE CALLED

• PATIENT DNAR/FULL CARE

• SEVERE PAIN AND DYSPNEA

• PATIENT DIED NEXT MORNING IN THE ICU

• DPOA: “HE TOLD ME HE WANTED TO DIE AT HOME.”

HOW COULD WE HAVE HELPED EARLIER?

• EXPERT PAIN MANAGEMENT

• ACUTE ON CHRONIC PAIN

• EVALUATING ABERRANT DRUG-TAKING BEHAVIOR

• PAIN CONTROL W/ HX OF SUBSTANCE ABUSE

• “TOTAL PAIN” ASSESSMENT

• COPING ASSESSMENT / INTERVENTION

• SEVERE DISEASE

• HISTORICAL ALCOHOLISM

• EARLY GOALS OF CARE

• RAPPORT BUILDING

PALLIATIVE CARE AS EXPERT PARTNER

A TEAM THAT CAN HELP YOUR PATIENTS AND FAMILIES MANAGE THE PAIN, SYMPTOMS,

AND STRESS OF SERIOUS ILLNESS.

CLASSIFICATION OF PAIN

• PHYSIOLOGIC

• NOCICEPTIVE

• NEUROPATHIC

• MIXED

• TEMPORAL

• ACUTE

• CHRONIC

WHO LADDER ELEVATOR

1, Pain 1 – 3

2, Pain 4 – 6

3, Pain 7 – 10

Morphine

Hydromorphone

Fentanyl

OxycodoneMethadone

± Adjuvants

Tramadol

A / Hydrocodone

A / Oxycodone

± AdjuvantsAcetaminophen

NSAID’s

± Adjuvants

WHO. Geneva, 1996.

EXPERT PAIN MGMT

General Principles

(Maximize non-pharm / non-opioid adjuvants)

Initiate at low doses

Dose by pharmacologic principles

Long-acting formulations avoided as much as possible

Monitor decompensated patient for side effects

Kirsch & Passik, 2006.

FAVORED ADJUVANT

Gabapentin:

Visceral pain, sleep, anxiolysis

Minimal hepatic metabolism

Minimal protein binding

Renal excretion

Dwyler et al., 2014.

OPIOIDS

Morphine Oxycodone Tramadol

Inc half-life & bioavailability; dec clearance

Elimination is severely impaired

CYP2D6 metabolism to

active M1 form??

22

Grond & Seblotzki 2004.

OPIOIDS

Consider:

Fentanyl

Short-acting morphine

19

“TOTAL PAIN”

Pain

Disease Mgmt

Physical

Psych

SocialSpiritual

Practical

EOL Worry

20

DX: ABERRANT DRUG-TAKING BEHAVIOR

• DESPERATION OVER SXS

• AGGRESSIVELY COMPLAINING

• REQUESTING SPECIFIC DRUG

• BUYING OPIOIDS ON STREET

• DOCTOR SHOPPING

• PRESCRIPTION FORGERY

Passik et al. JClinPain. 2006.

DDX: ABERRANT DRUG TAKING BEHAVIOR

• TOLERANCE• PSEUDO-

ADDICTION• DRUG DIVERSION• ADDICTION

PSYCHOSOCIAL CONSIDERATIONS

Alcohol or Substance Abuse

Hx “chemical coping”

Perceiving judgment / blame

Alexithymia (not “in tune”)• Symptom assessment challenging• Need alternative ways to assess

5

PALLIATION IN HISTORICAL SUBSTANCE ABUSE

Limit-setting

Use adjuvant medications whenever possible

Use non-drug adjuvants (relaxation, distraction, biofeedback)

Clinic risk stratification / procedures

Multidisciplinary assessments

Involve addiction specialists

34

Passik et al. 2006.

OPIOID RISK TOOL FOR SCREENING

• STRATIFY PATIENT OPIOID ABUSE RISK BASED UPON

• FAMILY HX OF SUBSTANCE ABUSE

• PERSONAL HX OF SUBSTANCE ABUSE

• AGE

• SEX

• HX OF PREADOLESCENT SEXUAL ABUSE

• PSYCH D/O

Chou et al. JClinPain. 2009.

HISTORICAL SUBSTANCE ABUSE

• MEANS OF COPING W/ STRESS

• MORE LIKELY TO RETURN W/ STRESS

• IMPACTS ADHERENCE TO RX REGIMENS

PALLIATIVE CARE AS PARTNER

EXPERT COMMUNICATION FOR CHALLENGING SITUATIONS.

GOALS OF CARE COMMUNICATION

• NORMALIZE DISCUSSION

• “HOPE FOR THE BEST & PLAN FOR THE WORST”

• PROGNOSTICATION NOT ASSOCIATED W/ LOSS OF HOPE

• COMMON PITFALL: ASSUMING HOPE ONLY = CURE

“GOALS OF CARE” ≠ CODE STATUS

Goals of

Care

Hopes

Fears

Values

Code Statu

s

Patient/Family Us

GOALS OF CARE

PERCEPTION OF CURRENT HEALTH

EXPLORE LIFE BEFORE PRESENT ILLNESS

RELATE PAST AND PRESENT

SOURCES OF WORRY OR CONCERN

OUTLINE THE PLAN

NOTIFY IMPORTANT PEOPLE

POTENTIAL GOALS OF CARE

Restorative or Cure

Return to Baseline

Improve Survival

Improve Function

Relieve Symptoms

Allow Natural Death

Adapted from Mulkerin, 2011.

TIME-LIMITED TRIALS

• AGREE EARLY WITH INTERESTED PARTIES ON:• EXACT LENGTH OF

TIME

• SPECIFIC GOALS

• WHAT WILL HAPPEN IF GOALS NOT MET

PALLIATIVE CARE AS PARTNER

PARTNERING WITH YOU FOR BETTER OUTCOMES BY HELPING YOUR PATIENTS TOLERATE CURATIVE TREATMENT.

A.L. CASE & QUESTIONS

• 65YOM W/ ETOH / HCV ESLD LISTED FOR TX

• HX OF IVDA AND METHADONE MAINTENANCE

• A/W AMS D/T HYPONA AND HEPATIC ENCEPHALOPATHY

• PAIN OUT OF CONTROL, THREATENING TO LEAVE AMA D/T OPIOID LIMITATIONS = “ADDICTION”?

• 6MG OF IV DILAUDID IN 24 HOURS (120MG OME)

• TEARFUL, ANGRY = “DEPRESSED”?

A.L. PALLIATIVE ASSESSMENT• COMPLEX PAIN

• NO ABERRANT DRUG-TAKING BEHAVIOR

• NOT DEPRESSED

• GRIEVING: “ACUTE GRIEF OVER LOSS OF FUNCTION”

• UNCERTAINTY: “WONDERING HOW HIS LIFE WILL UNFOLD”

• COPES THROUGH SPIRITUALITY & INTERACTION W/ PEOPLE

• GOALS

• PAIN CONTROLLED

• TRANSPLANT

• HOME

A.L. PALLIATIVE RECOMMENDATIONS

• CHANGE HYDROMORPHONE TO PO

• GABAPENTIN 300MG AT HS (SLEEP, PAIN, ANXIETY)

• EXPLORED GUIDED IMAGERY & JOURNALING

• ENCOURAGED NURSING TO MAKE FREQUENT VISITS

A.L. OUTCOME

• DECREASED OPIOID NEED

• DECREASED ANGER & INCREASED PARTICIPATION IN CARE

• TRANSPLANT

• HOME ON ORAL MEDS W/ PLAN TO WEAN

PALLIATIVE CARE

• A TEAM THAT CAN HELP YOUR PATIENTS AND FAMILIES MANAGE THE PAIN, SYMPTOMS, AND STRESS OF SERIOUS ILLNESS.

• AVAILABLE AT ANY AGE AND AT ANY STAGE IN A SERIOUS ILLNESS AND CAN BE PROVIDED ALONG WITH CURATIVE TREATMENT.

• EXPERT COMMUNICATION FOR CHALLENGING SITUATIONS.

• PARTNERING WITH YOU FOR BETTER OUTCOMES BY HELPING YOUR PATIENTS TOLERATE CURATIVE TREATMENT.

SPECIALIST PALLIATIVE CARE IN ESLD

KYLE P. EDMONDS, MD

KPEDMONDS@UCSD.EDU

858-534-7079