April 15, 2008 Jenny Legassie, PGY5 Palliative Care Anne Boyle, MD CCFP

April 15, 2008

Jenny Legassie, PGY5 Palliative Care

Anne Boyle, MD CCFP

Objectives

Develop an understanding of what palliative care is.

Develop an approach to opiate use in hospitalized patients.

Explore role for palliative care in surgical patients

What is Palliative Care?


Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

WHO, 2002

What is Palliative Care? Palliative care:

provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible

until death; offers a support system to help the family cope during the patients

illness and in their own bereavement; uses a team approach to address the needs of patients and their

families, including bereavement counseling, if indicated; will enhance quality of life, and may also positively influence the

course of illness; is applicable early in the course of illness, in conjunction with other

therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

WHO, 2002


It's just good medicine.

What is Palliative Care? It’s Just Good Medicine.

Pain Control

Control of Vomiting

Giving a Prognosis

Outlining Disease Trajectory

Spiritual Care

Bowel Care

Nutrition

PhysiotherapyWound Care

Mouth Care

Planning for Discharge

Discussion of Recesutation Wishes

Treatment Of Dyspnea

Special Mattress

Discussing Feeding Tubes

Answering Questions Honestly

Antibiotics

DiagnosisFinancial Care/Planning

RehabOptimizing Function

Addressing Care Giver Burnout

Education

Caring for Families

ListeningSetting Goals

Reassessing GoalsIdentifying Patients Wishes

Saying you “don’t know”

Acknowledging that Patient Cannot Return Home

Acknowledging Death

Saying “Good-Bye”


Patients are NOT PalliativePatients may have a terminal or incurable illnessPatients may opt for a palliative goal of care

Palliative Care provided for one patient is not appropriate for all patients

Case 1 - Mr. Smith’s Delirium

Case 1 – Mr. Smith’s Delirium 78 year old male with prostate cancer. Mets to

Bone identified 6 months ago. Disease currently stable with hormonal therapy.

PHX: cholesystectomy 1976 Presents to Hospital with nausea and vomiting

times 2 days. Exam and imaging are consistent with SBO.

Current Meds are:○ Oxycontin 60mg po BID (for bone mets)○ Oxycocet 2-3 tabs po q4hprn (takes about one dose per day)○ Colace 200mg BID○ Senekot 3 tablets BID○ Hormonal therapy q3months

Case 1 – Mr. Smith’s Delirium

Mr. Smith still has pain from his bone mets. How are you going to manage Mr. Smith’s pain in hospital?

○ What Drug?○ What Dose?

Case 1 – Mr. Smith's Delirium

Mr. Smith is given morphine 5mg IV q4h prn

24 hours after admission, nursing staff call you to say Mr. Smith is confused, calling out, combative, tremulous, trying to climb out of bed.He has had a total of 5mg morphine every 6 hours since he came to hospital (30mg in 24 hours).

What is your approach to his change in behavior and level of confusion?


Physical Exam confirms that Mr. Smith is confused, tremulous, combative. Looks uncomfortable.

Infection workup is negative. No metabolic abnormalities.

So why is he confused and combative?


Opiate WithdrawalAt home using Oxycontin 60mg po bid

○ Conversion Oxycontin 10 approx.= Morphine 15○ Total daily Morphine dose 180mg po

○ Conversion Morphine 2mg po = Morphine 1mg SC/IV○ Total daily Morphine dose 90mg SC/IV

○ SC/IV Morphine dosed q4h○ Morphine 15 mg SC/IV q4h

Morphine 5-7 SC/IV q2h prn for breakthrough pain


What Do you Do Now?Change his morphine to 15mg IV q4h and 5-

7mg IV q4h as long as patient’s RR > 10 and no myoclonus

Mr. Smith settles quickly with pain management and re-orientation.

Case 2 – Mr. Brown’s Delirium


78 year old male with prostate cancer. Mets to Bone identified 6 months ago. Disease currently stable with hormonal therapy.

PHX: cholesystectomy 1976 Presents to Hospital with nausea and vomiting

times days. Exam and imaging are consistent with SBO.

Current Meds are:○ Tylenol 3 1-2 tabs q4h prn (patient does not take these

as feels pain is well controlled)○ Colace 200mg BID○ Senekot 3 tabs BID○ Hormonal therapy q3months


Mr. Brown has significant pain from his SBO. How are you going to manage this in hospital?What Drug?What Dose?


Mr. Brown is given morphine 5mg IV q4h prn

24 hours after admission, nursing staff call you to say Mr. Brown is confused, calling out, combative, tremulous, trying to climb out of bed.He has had a total of 5mg morphine every 6 hours since he came to hospital (30mg in 24 hours).

What is your approach to his change in behavior and level of confusion?


Physical Exam confirms that Mr. Brown is confused, combative, focal muscle twitching, pin point pupils. Looks uncomfortable.

Infection workup is negative. No metabolic abnormalities.

So why is he confused and combative?


Opiate Toxicity○ Opiate Naive○ Now on 30mg Morphine per day○ Has myoclonus, pin point pupils and

confusion

What would you do now?


You change Mr. Brown’s prescription to morphine 0.5-1mg IV q4 hours plus 0.5mg IV q1h prn.

You reassess him two hours after last dose – he has not needed any breakthrough Reports pain is manageable. Confusion clearing.

Take Home Points - Case 1 & 2

We use a lot of opiates in hospital

Too much and too little opiate has the ability to cause side effects

A patients opiate requirements should be based on their previous opiate doses and experiences.

Opiate doses must be reassessed frequently.

Case 3 – Reevaluating Mrs. Taylor’s Goals


90 year old woman from retirement home Admitted with nausea and vomiting for 2

days, abdominal pain for one day. O/Ex: BP 80/65, HR 137, RR 24,

Confused, RUQ pain, guarding and rigidity PMHx: Angina, HTN, DM type II, OA





Patient felt not to be a candidate for surgery. Team discusses goals with patient and family.

Opt for comfort care only.

What does comfort care mean?


Comfort Care is not a standard type of care. Need to clarify with each patient.

○ Fluids○ Feeds○ Interventions such as NGs, decompressing PEGs,

heparin for PE○ Non-invasive ventilation


Mrs. Taylor and her family opt for focus on symptom control.

○ No IV○ Oral intake as Mrs. Taylor tolerated. (Mainly

ice chips and rice pudding.)○ Opiates, antiemetics, antibiotics○ Gave consent for NG if intractable vomiting.○ No CPR, defib, intubation


5 Days later, Mrs. Taylor doing well clinically. Pain minimal (uses Tylenol only). No nausea or vomiting. Up to chair with assistance.

Mrs. Taylor asks if she can return to her retirement home.

So what now?


Case 3 – Reevaluating Mrs. Taylor’s Goals Urgent Laparotomy

Lysis of adhesive bandViable small bowel

Patient recovered well, tolerated regular diet, alert, responsive


Palliative Care and Comfort Care are not only applicable to actively dying patients.

Patients don’t always die when we expect them to.

Part of providing good care is reassessing our goals daily.

Case 4 – Palliation for Katie


38 year old woman with metastatic breast cancer.○ Treatment to date includes modified radical

mastectomy, adjuvant chemo, local rads, tamoxifen. Palliative chemo through two clinical trials after mets found in liver, lungs and bone.

Married, mother of three (ages 13, 9, 6 years). Independent of ADLs at home prior to admission.

Admitted for surgical repair of pathologic femur fracture


Day 2 post op Katie develops central chest pain and shortness of breath.

○ No cough○ Low grade fever○ RR 26○ O2 sat 90% RA○ JVP Elevated○ Pulsus of 30mmHg

What do you do now?


Chest X-ray negative for infiltrate but shows large heart

V/Q scan low risk for PE Cardiac Echo shows moderate to large

pericardial effusion with tamponade.

What Now?


Katie wants to get home to her kids. Opts for pericardiocentesis.

Three days later, fluid re accumulates.

After lengthy discussion, Katie opts for a pericardial window.


3 days after insertion of pericardial window, Katie complains of SOB and pain in her left leg.

○ Left leg is grossly swollen, tender to palpation behind knee and decreased pulses

U/S is positive for large proximal clot

Katie is anticoagulated despite the increased risk of bleeding. Still wants to get home to her kids. Begins to Ambulate.

Palliation for Katie How could a palliative care consult benefit

Katie?o Symptoms – Pain

- Dyspnea- Ambulation

o Discharge - Is discharge home feasible?- How much help does she need at home?-Are they prepared for increasing symptoms at home?-Are they prepared for death at home?

o Psychosocial - What do her kids know?- Who will look after her kids after her death?- Who else provides emotional support?- Has she talked about death to anyone?

Take Home Points - Katie

Patients do not have to be actively dying to benefit from Palliative Care

Patients can seek active treatment and still benefit from a palliative care consult.

Take Home Points

Good Care requires assessment of each patient as an individual.

Reevaluation of your approach and the patient's goals needs to occur frequently.

Palliative Care is much more than care at the time of death.

Palliative Care and active treatment can occur at the same time.

Palliative Care can be provided by the primary care team.

Palliative Care involves some difficult discussions. If you’re not comfortable with these, don’t avoid them, consult.

Questions/Comments?

Documents

April 15, 2008 Jenny Legassie, PGY5 Palliative Care Anne Boyle, MD CCFP