Pallimed: Case Conferences

Transdermal Granisetron for Refractory Nausea and Vomiting

noreply@blogger.com (Christian Sinclair) — Wed, 27 Apr 2011 23:03:00 +0000

By Gordon J Wood, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Original PDF

Vol 11, No. 1 - January 2011

Case:

Ms JB is a 32 year old woman with type 1 diabetes who underwent a living related donor renal transplant and a subsequent pancreas transplant. Unfortunately, both transplants were complicated by rejection and graft failure requiring re-initiation of hemodialysis in 2007. Since that time she has suffered with constant, intractable nausea with multiple episodes of vomiting throughout each day. Her symptoms were initially thought related to diabetic gastroparesis but they did not respond to metoclopramide, erythromycin or pylorus muscle botulinum toxin injections. An electrical gastric stimulator was to be placed but was aborted when a gastric emptying study was normal. Extensive workup, including laboratory studies, endoscopy, CNS imaging and abdominal imaging, was unrevealing. She received little or no benefit from adequate trials of domperidone, prochlorperazine, ondansetron, oral granisetron, promethazine, trimethobenzamide, scopolamine, mirtazapine, dronabinol, pancreatic enzymes and a proton pump inhibitor.

She underwent voluntary admission to a psychiatric hospital for treatment of any possible contributing eating disorder without any improvement. Since 2007, she has had more than 40 admissions to the hospital for nausea and vomiting. A feeding J-tube was placed to maintain adequate nutrition in 2008. She presented to the Palliative Care clinic in 2010 for further management of her nausea and vomiting. After a complete history and physical, the etiology of her symptoms remained somewhat elusive. She had nausea before her transplant and it had resolved when the kidney was working then recurred when it failed so the final conclusion was that her symptoms may be due to a poorly defined metabolic process related to her renal failure. Olanzapine was initiated on the first visit for refractory nausea and vomiting and the patient was referred to psychology and psychiatry to help with coping and to address underlying depression and anxiety. At the subsequent visit she noted some benefit so the olanzapine dose was increased and a granisetron transdermal patch was added. At the next visit her symptoms had improved dramatically with a clear temporal relation to starting the granisetron patch. She was only vomiting once or twice in the morning and was relatively asymptomatic through the day. In her first clinic visit she had vomited multiple times through the visit and appeared miserable.

At this visit she was asymptomatic, neatly dressed, wearing makeup and was thrilled at this new level of symptom control which was allowing her to re-engage her life.

Discussion: There were many factors that likely contributed to the dramatic improvement in Ms JB’s refractory nausea and vomiting. Better psychiatric care through the palliative care psychologist and psychiatrist almost certainly played a role in her overall clinical turn-around. The close attention, serial visits and supportive counseling she received in the Palliative Care clinic could also have been therapeutic. Up-titration of her olanzapine also likely was helpful. Olanzapine is an atypical antipsychotic that works on multiple receptors including dopaminergic, serotonergic, adrenergic, histaminergic and muscarinic receptors. Of particular interest is its antagonism of 5HT2 receptors which are located in the vomiting center and are not well targeted by other traditional antiemetics. Multiple small trials have demonstrated efficacy of olanzapine for chemotherapy-induced nausea and vomiting.¹ Many palliative care practitioners are now also starting to use olanzapine for refractory nausea and vomiting in patients with advanced cancer and other life-limiting conditions.^2-4

Even with all of these possible contributors to her improvement, there still seemed to be a clear benefit that came with initiation of the granisetron patch. While intravenous and oral granisetron have been available for some time, transdermal granisetron (Sancuso©) is a relatively new addition to the practitioner’s toolbox for difficult to control nausea and vomiting. Transdermal granisetron was approved by the FDA for chemotherapy-induced nausea and vomiting (CINV) in September of 2008 based largely on a trial of 582 patients receiving multi-day moderately or highly emetogenic chemotherapy. Patients received either oral or transdermal granisetron and achieved equally good control of their symptoms with either method (approximately 60% in each group achieving complete symptom control). The most common side effect in both groups was constipation.⁵ The patch is an 8x6cm clear, plastic-backed patch and is worn for 7 days. Pharmacokinectic studies suggest that the patch delivers a dose equivalent to 2 mg of oral granisetron each day it is worn.⁶

It is thought to exert its antiemetic effect through antagonism of 5HT3 receptors in the gut and chemoreceptor trigger zone.⁷ Experience with the patch outside of CINV, however, is limited. This case suggests that transdermal granisetron may have a role in other cases of refractory nausea and vomiting. It is unclear why the transdermal form of the drug worked so much better than the oral version for Ms JB. It could reflect absorption issues, especially if she was unable to keep the pills down. It could also reflect compliance issues and may bring into question the adequacy of her prior trial of oral granisetron. Whatever the mechanism, however, the result was dramatic. Further study of this agent in settings other than CINV is clearly needed. Hopefully these results can be replicated and other patients with difficult-to-control nausea and vomiting can achieve life-changing results similar to those achieved by Ms. JB.

References:
1. Navari RM, Einhorn LH, Loehrer PJ Sr, Passik SD, Vinson J, McClean J, Chowhan N, Hanna NH; Johnson CS (2007). A phase II trial of olanzapine, dexamethasone, and palonosetron for the prevention of chemotherapy-induced nausea and vomiting: a Hoosier oncology group study. Supportive Care in Cancer, 15 (11), 1285-91 PMID: 17375339

2. Srivastava M, Brito-Dellan N, Davis MP, Leach M, Lagman R (2003). Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer. Journal of Pain and Symptom Management, 25 (6), 578-82 PMID: 12782438

3. Jackson WC, Tavernier L (2003). Olanzapine for intractable nausea in palliative care patients. Journal of Palliative Medicine, 6 (2), 251-5 PMID: 12854942

4. Passik SD, Lundberg J, Kirsh KL, Theobald D, Donaghy K, Holtsclaw E, Cooper M, & Dugan W (2002). A pilot exploration of the antiemetic activity of olanzapine for the relief of nausea in patients with advanced cancer and pain. Journal of Pain and Symptom Management, 23 (6), 526-32 PMID: 12067777

5. Boccia RV, Gordan LN, Clark G, Howell JD, Grunberg SM, on behalf of the Sancuso Study Group (2010). Efficacy and tolerability of transdermal granisetron for the control of chemotherapy-induced nausea and vomiting associated with moderately and highly emetogenic multi-day chemotherapy: a randomized, double-blind, phase III study. Supportive Care in Cancer PMID: 20835873

6. Howell J, Smeets J, Drenth HJ, & Gill D (2009). Pharmacokinetics of a granisetron transdermal system for the treatment of chemotherapy-induced nausea and vomiting. Journal of Oncology Pharmacy Practice, 15 (4), 223-31 PMID: 19304880

7. Wood, G., Shega, J., Lynch, B., & Von Roenn, J. (2007). Management of Intractable Nausea and Vomiting in Patients at the End of Life: "I Was Feeling Nauseous All of the Time . . . Nothing Was Working" JAMA: The Journal of the American Medical Association, 298 (10), 1196-1207 DOI: 10.1001/jama.298.10.1196

What to do after the patient is made comfort measures only (CMO)

noreply@blogger.com (Christian Sinclair) — Sun, 13 Mar 2011 15:48:00 +0000

By Robert Arnold, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 11, No. 2 - February 2011

Case: The patient is a 75-year-old man who presented with a severe headache and syncopal episode. His past medical history is remarkable for diabetes, hypertension, hyperlipidemia and an MI in 2009. His family brought him to his local emergency room where it was noted that he had a blown right pupil, and CT scan revealed a large subarachnoid bleed. He was intubated and life flighted to the hospital. There he was seen by neurology and neurosurgery, and it was determined that he was not a surgical candidate. Over the next three days he had little neurological improvement, and after meeting with the family it was decided that he should be made comfort measures only. He was extubated and 24 hours had stable vital signs, although he was still comatose. The neurology and neurosurgery team are unclear about what should happen next or about the topics that need to be discussed with the family.

Discussion: Deciding to focus only on comfort is a major transition point for patients, families and health care providers. After making this decision, most families are not sure what comes next. They look to health care providers to reassure them that they are doing the right thing and to ensure that their loved one does not suffer and that they are prepared for the next few days. The following questions should guide one’s action after a patient is made CMO:

1. Are the patient’s symptoms adequately treated/prevented?

UPMC Health System has developed a comfort measures only order sheet in order to optimize symptom management in CMO patients. (see order on demand). It reminds clinicians that:

a. All medications and laboratory tests that do not promote comfort should be discontinued.

b. Most patients near the end of life are not awake enough to tell us when they have symptoms. Instead, clinicians should treat nonverbal signs such as rapid respiratory rate (>24/minute), grimacing, moaning, and restlessness presumptively as signs of discomfort or shortness of breath.

c. The appropriate medications to treat pain or shortness of breath are opiates.

To promote rapid control of symptoms, prn opiates can be titrated rapidly (every 15-30 minutes for iv dosage and 60 minutes for oral opiates.) An infusion may be started if the patient has active symptoms requiring several boluses.

d. Terminal delirium is treated using benzodiazepines.

e. The only evidence-based treatment for secretions, or “the death rattle,” is glycopyrrolate.

2. Does the family want information about what they are likely to see as their loved one dies?

Most families do not have a great deal of experience with death and dying. It is appropriate to ask them if they would like to hear what they are likely to see over the next hours/days. This information may decrease their fear of the unknown and reassure them that their loved one is “on the right trajectory” and not suffering. For example, one can tell families that as patients die it is normal that: 1

a. They are less responsive and sleep most of the time. Hearing may persist, however, and thus families should feel free to talk to their loved one.

b. They eat and drink less. This is not uncomfortable and good mouth care relieves any thirst the patient may have.

c. Their urine output will decrease, and their hands and feet may become cool.

d. Their breathing may become irregular with periods of apnea.

e. They may begin to “gurgle.” This is not uncomfortable to the patient but can be distressing to families who are worried that their loved one is “drowning.” Drawing an analogy to snoring may be helpful.

Finally, families often want to know how long their loved ones will live. This is an extraordinarily difficult question because of our limited ability to prognosticate the exact time of death.

(Our ability to predict the time of death is no better than our ability to predict the time of birth–we can set boundaries but not determine exact times). Acknowledge your uncertainty, and then give your best judgment–whether hours to days or days to a week or two. Asking the family if they have any specific concerns is often helpful.

3. Does the patient or family have religious traditions that the health care team should be aware of?

Ask the family whether there are any spiritual or religious traditions that are important to them or their loved one. In Western Pennsylvania, the most common tradition one needs to be aware if is Catholic need for Sacraments of the Sick prior to death. The chaplaincy service at many hospitals is available 24/7 to meet with families and provide support.

4. Is there anyone else who needs to come and say goodbye?

It is useful to ask families whether there is anyone else who would like to say goodbye to their loved one. In addition, families are often unsure what or how much to tell children about their loved one’s dying or whether to let them see them. Asking about this issue allows the family to express their discomfort and ask questions. This is a complicated topic about which social workers often have particular expertise.2

5. What dispositional issues should be discussed with the family?

There are three general options for patients who have been made CMO:

a. The family may wish to stay in the hospital, either with or without hospice. Given that roughly 70% of patients die within 24 hours of having life sustaining treatments stopped in the ICU, this is a reasonable option for the first day. Staying in the hospital for longer periods may not be the best option as the staff have competing responsibilities, hospitals are not set up to focus solely on comfort, and many hospitals have a 2-3 day time limit for in-hospital hospice.

b. For patients who have symptoms and are actively dying, the most appropriate location may be an inpatient hospice unit (either a stand alone unit or located in a long term care facility). These units are staffed by hospice nurses, social workers, and physicians and provide excellent palliative care as well as attention to families’ psychosocial and religious needs. There are a number of these units within Western Pennsylvania.

c. Taking the patient home with hospice may also be a good option for families, provided they have enough support and are willing to have their loved one at home. It is important to remember that when a patient is at home, hospices provide roughly 2-4 hours of care a day depending on the patient’s needs. Thus, the family needs to understand and be willing to provide basic comfort care for their loved one (with direction and guidance from the hospice).

Which options are available and will fit the patient/family needs will vary depending on the patient’s clinical status, the insurance, and family situation. Care managers and social workers in most units are knowledgeable about these issues and can help guide the family about the appropriate choice given their values. Given this, it is important to have them meet with the family shortly after the patient is made CMO. In difficult or complex cases, the palliative care social workers are available for consultation and help.

References:

1. The palliative care service can provide teams with informational brochures that describe the dying process.

2. The palliative care service has reading material that they can provide to the primary service to give to families.

Pallimed Redesign

noreply@blogger.com (Christian Sinclair) — Sun, 13 Mar 2011 04:31:00 +0000

The Cases blog will be acting as a redesign test site for all of the Pallimed blogs since it has been dormant for so many months. No worries fans of great cases, it will soon be back to posting cases every other week.

Expect delays and odd formatting issues Saturday March 12th through the 14th.

Engage with Grace 2010 - Things we are grateful for this year

noreply@blogger.com (Christian Sinclair) — Thu, 25 Nov 2010 06:06:00 +0000

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.

Working Through Moral Distress

noreply@blogger.com (Christian Sinclair) — Thu, 17 Jun 2010 15:54:00 +0000

By Julie Childers, MD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 10, No. 6 - June 2010

Case: Mrs. L was a 95 year old woman who was admitted to the acute care hospital from her nursing home with decreased mental status. She was found to have pneumonia, and though her infection improved with antibiotics, her mental status did not recover and she continued to be only slightly responsive to her family, unable to eat or interact On the sixth day of Mrs. L’s hospitalization, palliative medicine was consulted to help the family with decision-making. By the time the palliative care consultant saw the patient, a temporary feeding tube had been placed, and the family had reached consensus on a trial of artificial feeding to give her a chance to regain strength, though they acknowledged that her prognosis was poor.

The next day, the patient was still unable to communicate, but was moaning and grimacing. She repeatedly tried to cough weakly to clear the copious secretions in her upper airway. The palliative care consultant recommended low doses of intravenous morphine to treat pain and shortness of breath, with a medication to clear secretions. However, Mrs. L’s attending physician was concerned that treating pain with opioids would cause respiratory depression and lead to Mrs. L’s death. The next night, the bedside nurse charted several times that Mrs. L was screaming, but they were only able to give her Tylenol for pain; she required wrist restraints to prevent her from pulling out her feeding tube. The palliative care physician was haunted by the image of the dying 95 year old woman, tied down and denied treatment for her suffering.

Discussion: Moral distress occurs when the clinician knows the appropriate action to take, but is unable to carry it out, and feels forced to give care contrary to her values. It is more often described in the nursing literature, but is beginning to come to the awareness of physicians as well. Moral distress often occurs in end-of-life situations when the decision is made to provide aggressive life-sustaining treatments that are felt to put excessive burden on patients and families.

Clinicians who see patients at the end of life may be particularly vulnerable to moral distress. For those of us who serve as consultants, our involvement in a case is at the discretion of the attending physician. In cases such as Mrs. L’s, we feel constrained by our role as advisors to the consulting physicians and the expectation of professional courtesy towards other physicians’ decisions. When we serve as attending physicians ourselves, our ability to relieve patient suffering may be limited by the family’s preference that every possible life-sustaining measure be taken.

Moral distress is also a common problem in the nursing field, particularly critical care nursing. For clinicians in any of these roles, moral distress arises when the system or other people interfere with our ability to relieve a dying patient’s suffering.
In the nursing literature, moral distress has been shown to contribute to decreased job satisfaction and to burnout. The American Academy of Critical Care Nurses recommends addressing moral distress with a four-step process:

Ask: You may not even be aware that you are suffering from moral distress. Signs of moral distress may include physical illnesses, poor sleep, and fatigue; addictive behaviors; disconnection with family or community; and either over-involvement or disengagement from patients and families.
Affirm: Validate the distress by discussing these feelings and perceptions with others. Make a commitment to caring for yourself by addressing moral distress.
Assess: Identify sources of your distress, and rate its severity. Determine your readiness to act, and what impact your action would have on professional relationships, patients, and families.
Act: Identify appropriate sources of support, reduce the risks of taking action when possible, and maximize your strengths. Then you may decide to act to address a specific source of distress in your work environment.

In Mrs. L’s case, the consultant discussed the case with the interdisciplinary team, receiving support for her concerns. Despite fear of negative repercussions from the primary service, she called the patient’s son herself and gently explained the signs of suffering that Mrs. L was showing. He agreed that his mother should have low-dose morphine. The primary team added this order without any expressed objections to the consultant stepping over her boundaries. Mrs. L died a few days later.

References
1. Weissman, D. Moral distress in palliative care. Journal of Palliative Medicine. October 2009, 12(10): 865-866.

2. The American Association of Critical Care Nurses. The 4 A’s for managing moral distress. (free pdf)

Engage with Grace 2009

noreply@blogger.com (Christian Sinclair) — Wed, 25 Nov 2009 03:17:00 +0000

In consideration of the many family dinners that will occur over the next few days of the Thanksgiving holiday, we are hosting (along with several other medical bloggers) a guest post from Engage with Grace and the One Slide Project. This post will stay at the top of this blog from Tuesday the 24th until Sunday the 29th. You can also join the Engage with Grace group on Facebook.

Have a safe and meaningful Thanksgiving!

Some conversations are easier than others

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.

Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

What Do I Say to My Kids?

noreply@blogger.com (Christian Sinclair) — Thu, 07 May 2009 16:18:00 +0000

By Ellen M. Redinbaugh, PhD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 9, No. 1 - March 2009

(Original PDF)

CASE:
Mr. J was a 39 year-old white married male who came to the hospital for a tissue biopsy and was subsequently diagnosed with advanced adenocarcinoma of unknown primary origin. His disease had progressed to the point where the tumors could not be debulked. The previous week Mr. J had been working full time and leading a very active lifestyle, so his diagnosis and prognosis came as a shock to him and his family. The primary medical team consulted the Palliative Care Team (PCT) to assist with symptom management, discussion of treatment options and goals, and planning of end-of-life (EOL) care.

Once Mr. J became physically comfortable and accepting of his poor prognosis, he voiced concerns about how to talk to his 6 year-old son and 8 year-old daughter about his illness and likely death. The RN for the PCT provided Mr. J with books that aid parents in discussing death and dying with children, and the behavioral medicine specialist with the PCT assisted Mr. J in applying these materials to the conversation he would have with his children.

First, as a means of understanding each child’s developmental level, the behavioral medicine specialist asked Mr. J to simply talk about his two children – how they spent their time, what subjects were they good at in school, and what, if any, exposure they had to the death of a loved one or pet. This discussion naturally led into Mr. J identifying words and concepts about illness and death that his children would understand. Mr. J decided he would say the following to his children, “Sometimes people get sick and the doctors can cure them. Sometimes people get sick and the doctors can’t cure them. The doctors don’t think they can cure me, but I am hoping for a miracle because I don’t ever want to leave you.”

Although his message was brief, Mr. J feared he would emotionally break down when having this conversation with his children. He wanted to be “strong” for them so that they would not be too frightened. To promote his sense of self-control Mr. J practiced his conversation with the behavioral medicine specialist who in turn coached him on breathing techniques that would help him stay in control of his emotions.

The practice helped, but Mr. J still feared that “we’ll all end up crying and that’s not going to any of us any good in the long run.” So then the behavioral medicine specialist worked with him on identifying specific ways in which he was a father to his children, e.g., he helped his children with their homework and he read to them every night before they went to bed. She suggested that after he gives them the bad news and answers their questions, Mr. J might reassure his children that he’s still going to help them with their homework and read to them every night.

DISCUSSION:
Young children who are informed of their parents’ terminal illness are less anxious than those who are not told , but many terminally ill parents are daunted by this emotionally stressful task. Deciding how to break the news to children is made more difficult when taking into account the developmental level of each child. Palliative Care Teams often have several books available that guide parents through the process of discussing death and dying with their children. Parents’ abilities to apply the information in these books can be further enhanced with a session provided by the behavioral medicine consultant. The individual session allows parents to tailor their approach to their own families and to practice having and controlling very powerful feelings.

References
1. Rosenheim, E., Reicher, R. (1985). Informing children about a parent’s terminal illness. J Child Psychol Psychiatry Allied Disc. 26:995-998.

2. Siegel, K., Raveis, V., Karus, D. (1996). Pattern of communication with children when a parent has cancer. In L. Baider & L. Cooper (Eds) Cancer and the family, pp 109-128. John Wiley and Sons: New York.

Pain vs. Suffering

noreply@blogger.com (Christian Sinclair) — Tue, 21 Apr 2009 04:16:00 +0000

By Rev. Dale Anderson, B.A., M Div.
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 9, No. 1 - March 2009

(Original PDF)

Case: During a weekly Palliative Care Consult meeting, it was discussed that if D, 53-year-old woman with congestive heart failure, did not receive a heart transplant within several weeks to a few months at the most, she would probably die. I felt led to visit her, even though she was not on my normal unit rounds. On the initial visit, D was welcoming when I stopped by her room. After introducing myself as a Protestant staff chaplain, I inquired about her pain. D told me how uncomfortable she was and how she felt so limited by her physical condition. When I asked how she was coping with any other areas of suffering in her life, her lips quivered and her eyes filled with tears as she told of the burdens in her soul…deep, personal stresses in her life that continued to that very day. She had tearfully vented for about an hour, as I reflectively listened and reassured her that every word was confidential and I was there for her to listen, if nothing else.

After hearing her life’s trials, it was important to let her know, as a chaplain and pastor representing Christ’s church, that God could help not only with the treatment of the pain in her heart but also with the trauma of her suffering soul. I prayed for her and the medical team that would work with her and those behind the scenes to care for her, to harvest the new heart and skillfully transplant it into her body; as well as for the opportunity to deal with some of the issues of suffering that were plaguing her. Thankfully, the issues that she was suffering from began to be addressed within her family as the real possibility of D’s death triggered the process of reconciliation. As those issues began to be resolved and forgiveness and harmony blessed her life, hope and new meaning for her life made the anticipated pain of transplant more tolerable. D was sent home with a VAD long enough to appreciate how some of the stress that existed in the home before had dissipated. Within 48 hours D was back in for her heart transplant.

Surgery went very well, and D was out of the ICU with few complications. Yet, once D was on a step-down unit and dealing with post-operative pain in her body and the anxiety and depression that ensues after transplantation, she was troubled by her years of living as a sufferer. It was reassuring when she made her suffering known.

Thankfully, the issues were addressed by those that contributed to her suffering within her family, and positive changes brought meaning back into her life. D did embrace her new life with meaning and purpose, and as she healed from the pain of the transplant, it was made bearable by the liberation from suffering.

This was a process that was not resolved as in our modern media. It was assisted in by others in the Palliative Care Team, the Transplant Team, Unit Staff, Pastoral Care, Providence, and, of vital importance, D’s family members who realized D’s mortality and took ownership of her suffering and their contribution to the dysfunction in their household.

In many of the rooms of the hospital are laminated Comparative Pain Scales with 1 being expressed as :) demonstrating No Pain to 10 being Unbearable/Excruciating Pain. Modern technology addresses this pain well. Suffering of the soul, mind, psyche, what ever terminology you are comfortable with, also needs to be addressed with awareness and compassion. Everyone should participate. According to Thomas R. Egnew, “Suffering arises from perceptions of a threat to the integrity of personhood, relates to the meaning patients ascribe to their illness experience, and is conveyed as an intensely personal narrative.”

While the medical community has established procedures, protocols, and treatment plans that factor in typical emotional responses, suffering is personal, individual and commonly expressed as a narrative that needs the freedom and respect to be presented and the dignity to be acted on to reestablish meaning and significance. Pastoral Care is one piece of the solution, but by far, not the only piece in total patient care.

References:

1. Mayo Clinic on Chronic Pain; Mayo Foundation for Medical Education and Research. Kensington Publishing Corp., NY, NY. 1999

2. Egne, TR. Annals of Family Medicine; Suffering, Meaning and Healing: Challenges of Contemporary Medicine. LICSW. Volume 7 No 2. March/April 2009

Methylnaltrexone for Opioid Induced Constipation

noreply@blogger.com (Christian Sinclair) — Thu, 12 Mar 2009 22:14:00 +0000

Methylnaltrexone Image via Wikipedia

By Tamara Sacks, MD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 9, No. 2 - February 2009

Case

CH is a 56-year-old woman with metastatic breast cancer to bone, liver and brain. She is admitted to the hospital with increasing lethargy and a marked decrease in her oral intake. She has also not had a bowel movement for 10 days. Further interview reveals that she has been on a fentanyl patch 75 mcg for months, senna and colace, and hydrochlorothiazide. Her diuretic is stopped and she is placed on intravenous fluids. Except for dehydration, a metabolic work up is unremarkable. Her exam reveals hypoactive bowel sounds, a scaphoid abdomen with palpable mobile masses, and soft stool in the rectal vault. She is disimpacted. No active bowel movement follows despite suppositories. She is also not able to retain enemas. She has increasing nausea and anorexia. Given her inadequate response to a bowel regimen from below and inability to tolerate an oral regimen, she is dosed with methylnaltrexone subcutaneously x1. She has a large formed bowel movement 2 hours later.

Discussion

Constipation is a well recognized side effect from opioids. Tolerance does not occur. In fact, the dose that can cause constipation is ¼ of an analgesic dose. Opioids exert their constipating effects by decreasing GI motility, gastric emptying, increasing ileocecal valve tone, increasing fluid resorbtion, and decreasing the reflex to defecate.

Methylnaltrexone (MNTX) is a mu receptor antagonist that unlike naloxone does not cross the blood brain barrier as it is a quaternary amine. Naloxone has been used in the past for opioid induced constipation. However, this use has also been associated with opioid withdrawal and decreased pain relief. MNTX was approved for the treatment of opioid induced constipation by the FDA last year. Given its expense, many institutions have tried to limit its use. Our institution has made a Palliative Care consult one of three consultation services that can approve dosing.

The phase three clinical trials that led to approval of MNTX involved patients either enrolled in hospice or as part of a palliative care program, and opioids were thought to be the primary cause of the constipation. They must have been receiving opioids for two weeks and on a stable opioid and laxative regimen for three days.

Enrolled patients had had no bowel movement in greater than 48 hours or had had less than 3 bowel movements the week prior. Bowel obstruction, fecal impaction or other acute abdominal processes were ruled out. In addition, patients with peritoneal dialysis catheters and fecal ostomy bags were excluded. While 80 percent of the patient population had cancer, patients with cardiovascular disease, AIDS, dementia, and COPD were also included. MNTX is administered subcutaneously based on the patient’s weight. After administration of MNTX, greater than or equal to 50% of the study group had a bowel movement within 4 hours. Most patients had a bowel movement within 30-70 minutes. As compared to placebo, the most frequent side effects were abdominal cramping, nausea, dizziness, increased body temperature and flatulence. However, the number of patients who discontinued therapy secondary to side effects was similar to that in the placebo group. No decrease in pain control or signs of opioid withdrawal were noted as compared to the placebo group.

There are many medications and dosage forms that are available for opioid induced constipation. Previously, routes of administration have been oral and rectal. Dysphagia, nausea or decreased mental status can greatly hinder an adequate regimen by mouth. Rectal routes of suppositories and enemas can also be tried. Inability of the patient to participate can limit effectiveness of enemas. In properly selected patients, MNTX may be able to aid in relief of opioid constipation without adversely affecting pain control

References:

1. Thomas, Jay et. al. Methylnaltrexone for Opioid Induced Constipation in Advanced Illness. 2008. NEJM 358 (22): 2332-2343.

2. Yuan, Chun-Su. Methylnaltrexone Mechanisms of Action and Effects on Opioid Bowel Dysfuction and Other Opioid Adverse Side Effects. The Annals of Pharmacotherapy, 2007. 41: 984- 993

Pallimed 2009 Annual Survey

noreply@blogger.com (Christian Sinclair) — Tue, 10 Mar 2009 02:49:00 +0000

SURVEY CLOSED WED MARCH 18, 2009

Results posted on Pallimed Main blog in April

(re-posted from the main Pallimed blog)

Dear Pallimed Readers,

Thanks so much for joining us here at Pallimed. Last January we had our first annual survey to get some more structured feedback from the readers. (Here are the results from the 2008 Pallimed Readers Survey.) This year we ask you for a few minutes to complete this year's survey. (Last year the survey took less then 6 minutes on average.)

It is even shorter then last year's, since we took out some questions! Blame it on the economy, we cannot even afford more questions this year. Drew, Amber, Amy, Tom and I appreciate your feedback very much.

The survey is open for just one week. Please complete it only once. It is the same survey regardless of which blog (Main, Arts, Cases) you access it from.

We will not sell your information. We pledge not to bombard you with survey pop-ups, or separate emails asking you to finish this. It is a voluntary survey.

We are expecting to provide our readers with some feedback from the survey by the end of March.

Thanks,

Christian Sinclair (on behalf of Drew, Amber, Amy, Tom and Pallimed)

Metoclopramide-Induced Gynecomastia

noreply@blogger.com (Christian Sinclair) — Thu, 26 Feb 2009 21:38:00 +0000

By Gordon J. Wood, MD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 9, No. 1 - January 2009

(Original PDF)

Case

Mr BT is a 57 year old man with stage IV laryngeal squamous cell carcinoma, status post radiation and chemotherapy who is now thought to have no evidence of metastases or recurrence. He was followed in a palliative care clinic for chronic musculoskeletal pain and was referred to a new palliative care physician when his prior physician left the practice. Upon presentation to the new physician, the patient complained mainly of painful gynecomastia (excessive growth of breasts in a male) without galactorrhea (spontaneous flow of milk from the nipple) for the past several months. Besides some unrelated knee pain, his examination was remarkable only for bilateral tender gynecomastia. He had not undergone any endocrinological lab studies and a recent PET/CT of the head/neck/chest/abdomen/pelvis was unremarkable. Upon review of his medications, the only possible culprit was metoclopramide which had been started approximately one year prior for nausea. The nausea had since resolved but he was still taking the medication since it was prescribed on a scheduled basis. The metoclopramide was discontinued and several labs were ordered in consultation with endocrinology including testosterone, prolactin, TSH, free T4, FSH, LH, estradiol and HCG. Lab workup was largely unrevealing although most, including the prolactin level, were drawn after the metoclopramide was discontinued. Over the several months following metoclopramide discontinuation the patient’s gynecomastia resolved without any recurrence of his nausea.

Discussion

(Not the patient in this case) Gynecomastia Image via Wikipedia

This case, although relatively simple, is important for two major reasons. First, it reminds us of a rare but significant side effect of a medicine commonly used in Palliative Care. Second, and perhaps more importantly, it highlights the dangers of polypharmacy in the Palliative Care setting.

Metoclopramide is a Dopamine type 2 (D2) receptor antagonist and is used as an antiemetic and prokinetic agent. In addition to these effects, it also reliably increases prolactin levels through its action on the D2 receptor. Dopamine normally inhibits pituitary secretion of prolactin. Metoclopramide administration blocks this inhibition resulting in increased prolactin levels.1 This effect has been used as both a research tool and as a clinical test. Symptomatic gynecomastia from elevated prolactin in patients taking metoclopramide, however, is rare, although it has been reported.² Galactorrhea has also been reported. In fact, metoclopramide has been used to augment lactation in breast-feeding women.³ Upon serologic testing, prolactin levels will generally be elevated in metoclopramideinduced gynecomastia. Discontinuation of the drug generally results in resolution of the symptoms.

Since metoclopramide is generally considered a first line antiemetic and is frequently used in clinical Palliative Care practice, this case serves as useful reminder of this rare but significant side effect. The equally or more important message from this case, however, is the need for careful medication management in this vulnerable population.⁴ Going back to Cicely Saunders, one of the guiding principles of Palliative Care is the scheduled administration of medications to provide continuous symptom control. Recent literature reinforces this concept in the management of nausea and vomiting.⁵ In addition, it is suggested to not only use scheduled antiemetics but to add second and third antiemetics as needed instead of stopping one and starting another. While this method has been shown to provide effective relief of symptoms, it can expose the patient to a high risk of side effects if the practitioner fails to taper the medications after the emetic impulse has resolved. This patient had no recurrence of his nausea with discontinuation of his metoclopramide, suggesting that he could have been spared the development of gynecomastia if the metoclopramide had been tapered earlier.

This case also reinforces one of the most basic but important principles in medicine: symptoms which emerge after initiation of a medication are most likely caused by that medication. Because of the serious and progressive nature of the illnesses encountered in Palliative Care, it can be easy to assume that all clinical deterioration is due to worsening of the underlying disease. This case reminds us of the importance of a solid understanding of medication adverse effects and the need for a constant vigilance for these outcomes. Fortunately for Mr BT, the culprit medication was discovered and the symptoms resolved with discontinuation, thereby allowing him to get back to enjoying his life after what appears to be a very successful initial treatment of his serious underlying cancer.

References:
1. Macullum RW, Sowers JR, Hershman JM, Sturdevant RAL. Metoclopramide stimulates prolactin secretion in man. J Clin Endocrinol Metab. 1976;43:1148-1152.

2. Madani S, Tolia V. Gynecomastia with metoclopramide use in pediatric patients. J Clin Gastroenterol. 1997;24:79-81.

3. Ehrenkranz RA, Ackerman BA. Metoclopramide effect on faltering milk production by mothers of premature infants. Pediatrics. 1986;78:614-620.

4. Bernard SA, Bruera E. Drug interactions in palliative care. J Clin Oncol. 2000;18:1780-1799.

5. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of intractable nausea and vomiting at the end of life: “I was feeling nauseous all of the time…nothing was working”. JAMA. 20087;298:1196-1207

Huntington’s Disease: How Can Palliative Care Help?

noreply@blogger.com (Christian Sinclair) — Thu, 12 Feb 2009 21:24:00 +0000

Dr. George Huntington Image via Wikipedia

By Mamta Bhatnagar, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 11 - December 2008
(Original PDF)

Case

A 43-year-old woman, WM was diagnosed with Huntington’s Disease (HD) in September 1996. In 1997 WM stopped working due to disability related to her disease progression. Since 2004 she was living at a skilled nursing facility where her care had been stable until 4 weeks prior when her choreiform movements intensified, her oral intake declined, and she was unable to rest or sleep due to incessant body movements. Several medication changes at the nursing facility were unsuccessful and she was transferred to an inpatient hospice unit for end-of-life care. On exam the patient appeared younger than her stated age and cachectic. She was non-ambulatory. She had flailing involuntary movements of her arms and legs, which made a comprehensive physical examination difficult. Her speech was unintelligible and skin on her arms and legs showed bruises and open wounds that she sustained when she hit any furniture around her. The patient’s husband and power of attorney’s primary goal was to control her movements and allow her to rest.

Brief overview of Huntington’s disease

HD is a neurodegenerative disorder that is inherited in an autosomal dominant fashion so that each child of an affected patient has a 50% chance of developing the disease. Most patients develop symptoms in their forties and fifties. Symptoms are usually a triad of motor, cognitive, and psychiatric issues. The motor symptoms involve impairment in voluntary movements and appearance of involuntary movements called chorea (hence the name Huntington’s chorea). Impairment in voluntary movements results in loss of manual dexterity, slurred speech, swallowing difficulties, problems with balance, and falls. The motor symptoms worsen in the middle stages followed by rigidity in the late stages of the illness. Cognitive symptoms manifest in the patient’s inability to perform complex tasks with loss of speed and flexibility, progressing to global impairment in the later stages of the disease. Psychiatric symptoms most commonly include depression. Patients may also manifest irritability, anxiety, agitation, impulsivity, apathy, social withdrawal, and obsessiveness.

Treatment

Medications do not alter the progression of HD. Patients are vulnerable to cognitive side effects of pharmacologic therapy. Motor symptoms are usually managed using either neuroleptic agents such as haloperidol and/or benzodiazepines. There are no medications to treat swallowing difficulties or rigidity that occurs later in the disease. Depression is treated with serotonin specific reuptake inhibitors such as sertraline and paroxetine. The mainstay of therapy for HD remains non-pharmacologic management. Padding of furniture and weights on wrists and ankles will help reduce injuries and the amplitude of involuntary movements respectively. As swallowing difficulties progress, the food consistency can be softened and pureed. Eating is usually supervised, and the patient is given time to eat with no distractions. Caregivers should be trained in Heimlich maneuver. Cognitive impairment and difficulties in communication can be eased by giving the patient time to answer and asking closed-ended questions. Establishing routines around the patient and activities that adjust to his or her cognitive level help to decrease anxiety and allow cognitive stimulation. Identifying and avoiding triggers for emotional outbursts and providing family and caregiver supports are measures to help manage behavioral manifestations of the disease.

Survival

Average survival time after diagnosis is 15 to 20 years. Disease course is variable, and every patient is unique, which makes prognostication difficult.

Back to the Case

Initial attempts to sit the patient in a padded wheelchair and feed her proved unsuccessful. A trial of phenobarbital was initiated to allow her to rest and monitor response. All furniture was removed from her room. Several mattresses were placed on the floor and padding was applied to the walls. Over the course of 3-4 days the patient’s movements subsided, and she was able to stay awake. Her appetite improved, and she drank shakes. Feeding times were unique; one staff member would hold WM in her lap while the other would feed her. Over a period of 2 weeks, WM thrived. Although she was incontinent for bowel and bladder, she would call out to the nursing staff when she needed care. Her room was decorated with her favorite sport team jerseys and family photos. Her husband visited daily and was able to participate in feeding times, and together they watched sports events on TV. WM’s only medications were oral fluoxetine, laxatives, antacids and phenobarbital. While we initiated our treatment plan to relieve distress and attempted palliative sedation therapy as a means to relieve what appeared to be refractory symptoms at the end of life, the patient’s response was so dramatic that we now planned for her care for the next several weeks at a nursing facility. Our objective was to achieve a smooth transition for WM, and we encouraged nursing facility staff to visit the hospice unit and witness her personal care and feeding. The patient was eventually transferred and has continued to be stable at the nursing facility. She has not required any medication adjustments.

References:
1. Aubeeluck A, Wilson E. Huntington's disease. Part 1: essential background and management. Br J Nurs. 2008;17(3):146-51.
2. Rosenblatt A, Ranen NG, Nance MA, Paulsen JS. A Physician's Guide to the Management of Huntington's Disease. Second Edition. Huntington's Disease Society of America 1999.

Staff Coping With Terminal Illness

noreply@blogger.com (Christian Sinclair) — Fri, 30 Jan 2009 03:59:00 +0000

By Justin Engleka, MSN, CRNP, CHPN

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 9 - April 2002
(Original PDF)

Case:

Miss C. is a 28-year-old female with a history of a spinal cord tumor with metastasis to the brain. She was admitted to the hospital for further management of related complications. She had suffered with multiple neurological complications, including paraplegia since 1997. She had endured many procedures, surgeries, treatments, and hospitalizations prior to the Palliative Care Team’s meeting with her on this admission. Her disease had become more extensive. She had recently received chemotherapy, and developed complications likely related to this. When she arrived at the hospital, it was determined that she had suffered an intraventricular hemorrhage. For this reason, she was intubated and placed on the ventilator.

During her hospital stay, she had multiple complicated medical issues: the intraventricular hemorrhage, quadriplegia, infection, hypotension, and delirium. Communication with this patient was difficult and painstaking, but not impossible. Behavioral medicine was recruited to assist with communication efforts and help the family with coping techniques. The Palliative Care Team met with the patient and her family daily to assist them in setting the goals of care. The primary service was an integral part of the communication process. During the previous years of cancer treatments, Miss C. had developed very close bonds with this staff.

Miss C. began to express concerns about the therapies she was receiving. After long, detailed conversations with her, we recommended that some limits be placed on medical interventions such as resuscitation, and blood pressure support. The patient and family agreed. She was successfully discharged to a ventilator facility closer to her family.

Discussion

“Why are you afraid? I am the one who is dying…
But please believe me, if you care, you can’t go wrong…
Death may get to be routine to you, but it is new to me.”
-Anonymous

Dealing with the impending death of a patient is perhaps one of the most difficult tasks that a nurse or physician can encounter. For staff who deal with these types of issues on a day-to-day basis, it can become even more distressing. Traditionally, the intensive care units care for the most critically ill patients. Unfortunately, death becomes an inevitable part of the experience. How each staff member deals with that grief and sorrow varies greatly. It is well acknowledged that the death of a loved one under any circumstance is a tremendous loss for that family. Little is written or spoken about the grief and coping of staff who deal with dying patients on a daily basis. This case illustrates that not all patients who die in the hospital are elderly, frail patients who have lived a full life. Understandably, nurses, doctors, and staff would view this case in a different light. For many of us, we see a young, 28-year-old girl who reminds us of our wives, our sisters, our daughters, or ourselves. 28-year-old women are not supposed to die.

This case also reminds us that we cannot endure the stress and grief alone. While it is important to maintain consistent contact with our patients, we also need to know our limits. Traditionally, nurses are caretakers and nurturers. They typically “vent” about these types of cases with their colleagues and managers. It is also nice to know that there are services within our system for patients, families, and staff. Staff should know that they need to take care of themselves, too. Services like social work, behavioral medicine, palliative care, clergy, and family support services are readily available to consult with staff members about their concerns and grief.

References:
1. Reimer, J.C., Davies, B., & Martens, N. (1991) Palliative Care: The nurse’s role in helping families through the transition of “fading away.” Cancer Nursing, 14(6), 321-327. Vachon, M.L.S.,

2. The stress of professional caregivers in Doyle, D. et al eds. Oxford Textbook of Palliative Medicine, New York, Oxford University Press 1998, 919-929.

Coordination of Care for People at the End of Life

noreply@blogger.com (Christian Sinclair) — Fri, 16 Jan 2009 04:11:00 +0000

By Linda A. King, MD and Nicole Fowler, MHSA

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 8 - March 2002
(Original PDF)

Case:

A 67-year-old man with end-stage congestive heart failure presented to the hospital with worsening respiratory distress and was intubated in the emergency room. Despite a week of intensive efforts, he could not be weaned from the ventilator and remained dependent on intravenous dobutamine for blood pressure support. The ICU staff met with the patient and family to discuss the medical situation and options for care including withdrawal of life support. The patient did not want to continue on long-term ventilatory support nor did he want to die in the hospital. The patient expressed to the care team a strong desire to leave the hospital and to die at home.

A palliative care consultation was initiated to support the patient and family and to assist with a discharge to home. The patient, family, ICU team and palliative care team discussed potential options for discharge and decided on a plan to transport the patient home with ongoing mechanical ventilation and inotropic support. This option allowed the patient to be comfortable at home with his family before removing the ventilator and providing medications for comfort that would likely be sedating. Efforts to carry out this plan were hindered by the reluctance of home care and hospice agencies to participate in this “unusual” and expensive plan that provided little or no reimbursement (i.e. withdrawal of life-support in the home setting while the patient continued on Dobutamine).

Following hours of coordination and planning, the physician from the Palliative Care service and a nurse from the ICU rode home in the ambulance with the patient where they were met by many of the patient’s family and friends and a private duty nurse to support the patient and family. After a few hours of visiting with his loved ones, the patient indicated that he was ready for the ventilator to be withdrawn. Intravenous morphine and ativan were administered until the patient was comfortable, then the endotracheal tube was removed. Additional medication was administered intermittently to maintain adequate comfort and the patient died comfortably at home a few days later. The family expressed their gratitude that the patient’s wish to die at home was achieved.

Discussion

For many patients facing a life-threatening illness, death at home is viewed as a desirable and even essential element of a “good death.” Patients in the hospital expected to die imminently after the withdrawal of life-support do not typically have this option because of the obstacles and lack of payment incentives for coordinating this type of care. Withdrawal of life support in the home can provide patients and families with the opportunity to achieve their goal of dying in the familiar setting of their own home at a lower cost than the average cost of care in an ICU.

However, in our current care system it requires extenuating circumstances and significant coordination and planning to assure that patients and families are well supported and the patient’s comfort is maintained. When the goals of care shift for seriously ill patients from a disease-specific and curative approach to an approach that focuses on comfort, symptom management and other personal preferences for care (such as wanting to die at home), the health care system is often inadequate and discontinuous. One reason, as in our highlighted case, is that “ownership” for this type of coordination does not exist and few providers (home care and others) are willing to assume this role because most insurance programs (such as Medicare) will not pay. Since most care is reimbursed according to location, it is difficult to provide comprehensive services that meet the changing goals of patients as their disease progresses.

Public policies and financial incentives that encourage and reward hospitals, home care agencies, nursing homes and hospices for seamless care need to be established. Surely to compliment our modern care system and life prolonging technologies we should be able to develop a reliable and sustainable system that also relieves symptoms, honors preferences and supports patients and their families at the end of life.

References:
1. Lynn, J. Serving patients who may die soon and their families. JAMA 2002;285: pp. 925-932.

Using Cultural-Specific Music to Alleviate Symptoms of Anxiety and Depression

noreply@blogger.com (Christian Sinclair) — Fri, 02 Jan 2009 05:43:00 +0000

By Erin Hedden, Music Therapy Intern

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 10 - November 2008

Case:

Ms. Z was a middle-aged Colombian woman with pulmonary hypertension and was awaiting a double lung transplant. Her presenting symptoms included extreme shortness of breath with minimal exertion, tiredness, and chest pain. A palliative care consult was requested for support and symptom management for anxiety and depression. She was also very concerned about her bills. She had trouble concentrating, was unable to watch TV or use her laptop, and was constantly tearful. Through palliative care, a consult was obtained for music therapy. In the context of music therapy, her anxious and depressive symptoms were significantly diminished by using music that was specific to her native culture.

Discussion
Music therapy has consistently been demonstrated to help alleviate symptoms of anxiety and depression, especially when the implemented music is a type of music that is preferred by the patient. In fact, a study researching the effects of subject-preferred music found that subjects who listened to their preferred music exhibited an increase in positive mood if their pre-music mood was negative. It also found that subjects listening to preferred music maintained a positive mood if the subjects’ pre-music mood was positive (Wheeler 1985).

Since Ms. Z was a Colombian immigrant, there were many times that she had family members and friends with her to both support her and translate some of the more difficult conversations that were in English. Though this author did know rudimentary Spanish, and did successfully implement short phrases, it was the music that became the common language throughout each session.

The first music therapy session was met with much enthusiasm and laughter from Ms. Z’s family and friends. Ms. Z was visibly anxious and nervous as she sat in the corner, but as she began to watch those around her enjoying themselves, her face softened and she smiled from behind her oxygen mask. The two attending interns closed the session having played some of the requested music, but with the momentous assignment to learn many more songs. Countless hours were spent learning songs by one of her favorite artists, Juanes, who is famous in Colombia and other South American and Spanish-speaking countries.

The second session was filled with a myriad of their favorite Spanish songs. They sang every song along with the attending interns, laughing and crying at the same time. Ms. Z was visibly relaxed and at peace. She continued to enjoy music therapy after she got her double lung transplant. Through the implementation of music therapy, her anxious and depressive symptoms were significantly diminished through singing, the use of percussion instruments, and by using her preference of cultural-specific music.

Through singing, she used her lungs—both before and after her double lung transplant. Even when Ms. Z was only able to whisper, she was still stretching her new lungs while “mouthing” the words she knew from memory. It distracted her from the monotony of being hospitalized, from the bills she couldn’t pay, and from her constant medical problems. It fostered a deeper and more meaningful socialization with her loved ones, and helped her to find cultural familiarity within someone else’s culture. Singing also gave her choices: she could participate or watch; she could choose which song she wanted to hear; she could choose which artist she wanted to hear; and she could choose the language with which she wanted to surround herself. It also gave her a sense of ownership and pride that the attending interns learned these songs specifically for her.

Using percussion instruments had its own benefits: it was a less threatening way to participate in the music-making experiences; it gave another series of choices for her to make; and because there was a wide array of South American instruments, it was a physical and tangible connection to her cultural heritage.

Music can help patients to appreciate the beauty and wisdom of their own cultural backgrounds and promote positive feelings within them that can be tapped into when celebrating and coping with life’s highs and lows (Chase 2003). By validating Ms. Z’s culture and bringing it into her hospitalization, music therapy fostered a sense of normalization and familiarity within the hospital walls which to her had previously represented feelings of anxiety and depression.

References:
1. Chase, Kristen M. "Multicultural Music Therapy: A Review of Literature." American Music Therapy Association Music Therapy Perspectives 21 (2003): 84-88.

2. Wheeler, Barbara L. "Relationship of Personal Characteristics to Mood and Enjoyment After Hearing Live and Recorded Music and to Musical Taste." Psychology of Music 13 (1985): 81-92.

Antiobiotic Use in the Dying Patient

noreply@blogger.com (Christian Sinclair) — Fri, 12 Dec 2008 05:59:00 +0000

By David L. Patterson, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 7 - January 2002
(Original PDF)

“They thought that the Titanic was unsinkable. They thought she would last forever.
That’s what some people think about antibiotics”.

Case:

Richard (not his real name), a 72 year old man with metastatic hepatocellular carcinoma, congestive cardiac failure (ejection fraction 14%) and chronic renal impairment was admitted to hospital with possible aspiration pneumonia. Intravenous levofloxacin and clindamycin were commenced. By the 7th day of admission his respiratory status had improved somewhat but he developed diarrhea (six liquid stools in one night).

On the 10th day of admission, his respiratory status had worsened again and a portable radiograph showed new infiltrate. Since extension of his pneumonia could not be distinguished from pulmonary edema resulting from his congestive cardiac failure, the patient was treated with diuretics plus antibiotics (piperacillin/tazobactam). The microbiology laboratory called to say that his C. difficile toxin was positive and that his rectal swab for vancomycin resistant enterococci (VRE) was positive.

By the 16th day of admission, the patient’s condition was clearly deteriorating. Despite supplemental oxygen his oxygen saturation was 84%. He was somnolent and would rouse only to painful stimuli. His BUN had risen to 104. The treating team discussed transfer to the intensive care unit for mechanical ventilation and dialysis. However they noted an advance directive written four months ago, in which the patient stated that he did not wish to undergo mechanical ventilation. Upon discussion with his wife and daughter they frankly noted that his quality of life had been extremely poor and that they did not feel that further aggressive intervention was what Richard would really want. The patient continued on levofloxacin, piperacillin/tazobactam, clindamycin and metronidazole until his death 20 days after hospital admission.

Discussion

Richard’s case raises two questions for discussion. Both relate to antibiotic use.

Clostridium difficile diarrhea

Fecal incontinence due to C. difficile is a miserable experience for the dying patient and their care-givers. Other adverse consequences of C. difficile infection include dehydration, prolonged hospital stay and even toxic megacolon and death. Prior antibiotic exposure is seen in >99% of patients who develop C. difficile related diarrhea. Curtailing unnecessary antibiotic use is the major way in which occurrence of C. difficile can be reduced.

Commonly implicated antibiotics in outbreaks of C. difficile include clindamycin and advanced generation cephalosporins. Increasingly, quinolones (such as levofloxacin) are also found to be associated with C. difficile diarrhea.

In view of the frequent association between clindamycin and C. difficile, clindamycin should no longer be used as a first-line treatment in our hospitals. Metronidazole is usually a good option where an antibiotic with anti-anaerobic activity is required. In some cases of head and neck infection, coverage equivalent to that provided by clindamycin can be by way of ampicillin/sulbactam or ampicillin plus metronidazole.

Quinolones should be reserved for a few specific indications (for example, ventilator-associated pneumonia where a resistant Gram negative bacillus is likely to be implicated, chronic prostatitis, malignant otitis externa). It is not appropriate to use quinolones to “treat” organisms in the urine on the basis of a microbiology report, in the absence of symptoms and without a urinalysis indicating significant pyuria. First line therapy for community-acquired pneumonia is a macrolide and cefuroxime not levofloxacin.

Is antibiotic use appropriate for the dying patient in whom many other components of treatment have been withdrawn or withheld?

C. difficile related diarrhea is just one of the adverse consequences of antibiotic use. A frequently overlooked adverse consequence of antibiotic use is the development of antibiotic resistance. It is well known that many more patients are colonized with antibiotic resistant organisms (such as VRE) than those who are actually infected with them. Colonized patients represent a source of organisms that can be passed from patient to patient. Terminally ill patients with high nursing care requirements represent a high risk for the transmission of antibiotic resistant organisms via the hands of their caregivers.

The ethics of the choice between the interests of present terminally ill patients and the interests of future patients who perhaps have a better prognosis has been recently discussed (Marcus 2001). In patients where antibiotic therapy offers no clinical benefit, and other therapies have been withdrawn or withheld, the balance between advantages and disadvantages of antibiotic therapy is influenced heavily by the “public health” benefit of limiting antibiotic use and avoiding development of a pool of antibiotic resistance. An exception would be use of antibiotics to resolve an infection that is causing painful or distressing symptoms.

Antibiotics are a limited resource. Please use them wisely.

References:
1. Marcus EL, Clarfield AM, Moses AE. Ethical issues relating to the use of antimicrobial therapy in older patients. Clinical Infectious Diseases 2001;33:1697-1705.

Palliative Sedation Therapy

noreply@blogger.com (Christian Sinclair) — Thu, 27 Nov 2008 04:34:00 +0000

By Susan Hunt, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 9 - October 2008

Case:

You are asked to see Mrs. RT, a 44-year old woman with end-stage COPD. She was admitted to inpatient hospice with increased anxiety, hopelessness, and pain “all over.” She says she is tired of being sick and exhausted, and wants to be “put to sleep.” She has heard about “terminal sedation” and is angry it hasn’t been offered. She lives with her husband and adult children who work full-time and is upset they can’t all stay home with her. She experiences dyspnea with activity, and uses a wheelchair, but can independently transfer to bed and toilet. Your exam reveals she is awake and alert, neither delirious by the confusion assessment score (CAM), nor suicidal. She is cachectic, tachypnic, and has generalized muscle atrophy. She lacks signs of infection or localized pain. You estimate her prognosis in months. She takes medications erratically for symptom control.

What is Palliative Sedation Therapy (PST)?

Patients and families sometimes have heard or been told about “terminal sedation,” but it is a frequently misunderstood term and therapy. The term “terminal sedation” suggests the goal of the therapy is hastening death for terminally ill patients, when in fact the goal is symptom relief. Therefore, the term “palliative sedation therapy (PST)” is much preferred since the goal of PST is relief from intolerable and untreatable symptoms, not shortening a patient’s life. An international panel of palliative care experts recently reviewed the medical literature on PST and published their recommendations for standardizing our understanding of this therapy1. They recommend the following definition: “Palliative sedation therapy is the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness.” They emphasize that palliative sedation is distinct from euthanasia while acknowledging lively debate on this issue.

The panel’s position is based on their assertion that hastening a terminally ill patient’s death is not the goal of PST. Other points of difference between PST and euthanasia are the principle of titration to comfort rather than to death, and PST’s reversibility.

What are refractory symptoms?

Refractory symptoms are considered symptoms for which all possible treatments have failed. A patient experiencing refractory symptoms must be differentiated from a patient who has symptoms that are difficult to treat. Refractory symptoms are symptoms that the palliative care physician and team determine cannot safely be relieved by invasive or noninvasive interventions. Expert panel members recommend Cherney’s definition of refractory symptoms: “Refractory symptoms are symptoms for which all possible treatment has failed, or it is estimated that no other therapies exist within the patient’s time-frame or tolerable risk-benefit ratio.”

When is PST considered?

PST is considered for patients with refractory symptoms only after discussions with the patient and/or family, the caregiving team, and the palliative care expert. The most frequent reasons for PST have been refractory delirium or restlessness, dyspnea, pain, and nausea/vomiting. The use of PST or psychological or existential distress is rare, and initiated only under exceptional circumstances. PST is considered only in the last hours to days of life.

Experts recommend a systematic and inclusive process to determine if PST appropriate, which includes the patient, if possible, designated surrogate and caregivers, and addresses the patient’s values, beliefs, and goals. If PST is chosen, then the specific intervention is discussed and reviewed, instituted, and carefully monitored. Decisions about nutrition and hydration are discussed separately from the decision to offer PST.

Medications used for PST include benzodiazepines (usually midazolam), except for delirious patients, phenobarbital, or propofol. Opioids are not recommended for PST because even high doses may not result in sedation.

Since the aim of PST is the relief of refractory symptoms, doses of sedatives are carefully chosen to relieve distress by reducing a patient’s level of consciousness and are not excessive. The degree of sedation can vary from superficial to deep sedation. Initial doses of sedatives should be small enough to allow a patient to communicate periodically.

Refractory symptoms may respond to temporary sedation, since a patient’s ability to tolerate symptoms may be improved following rest provided by sedation. Experts identify three levels of continuous sedation. With mild sedation, the patient is awake, but has a lowered level of consciousness. Moderate sedation results in stupor, so that the patient is asleep, but can be awakened to communicate briefly. With deep PST, the patient is unconscious and unresponsive. PST is frequently monitored and assessed, with attention to the needs and goals of both patient and family.

Back to the Case:

You convene a meeting with the patient, her family, and the palliative care team. After asking open-ended questions and listening to concerns, you offer information about PST but say that you think her symptoms can be treated. You offer medication changes including around the- clock rather than as needed opioids for relief of dyspnea and pain, and a comprehensive treatment plan for her anxiety and depression. Her family finds ways for her to be less isolated, and the hospice team offers additional services and frequent monitoring. Although she is skeptical, she is willing to consider these options as possibly improving the quality of her life.

References:
1. De Graeff A. Dean M: Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendation for Standards. Journal of Palliative Medicine 2007; Vol10 (1); 67-84.

2. Cherny NI. Portenoy RK: Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. Journal of Palliative Care 1994;10;31-38.

Trapped Inside a Failing Body

noreply@blogger.com (Christian Sinclair) — Fri, 14 Nov 2008 05:33:00 +0000

By Rev. Carol Henley, M.Div

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 8 - September 2008

Case:

JD is a 66-year-old African-American female with cardiomyopathy and pulmonary hypertension who has been in and out of the hospital for the past two years. She had biventricular assist devices placed in August, 2007. Since then, she has experienced numerous setbacks and subsequently has been on and off the heart-lung transplant list. Most recently, she went to the OR to have her current LVAD replaced with a smaller unit. The procedure was aborted.

JD is divorced with no children. Prior to hospital admission, she lived alone, independently, in a one-story home. A supportive brother and sister live nearby. She is very sharp, speaks her mind, and has no patience for what she perceives as incompetence or “stupidity.” She expects staff to communicate with her directly and has no tolerance for ambiguity, mixed messages or superficiality. She has alienated several of the staff who don’t meet her expectations.

Over the past couple years, I have visited JD numerous times. In my first visit, she told me where to sit and told me to read certain passages of Scripture to her. (She has taught adult Bible study and has been very active in her church). I went along with her request (i.e., “order,”) and we actually had a stimulating theological discussion. Our visit ended with prayer. After this first visit, she no longer told me what to do. In subsequent visits, she shared her life story. I found that gently kidding around with her diffused her intensity. We spent many visits with her telling me about her life from childhood on, and we’ve shared much laughter. I enjoyed celebrating with her those memories that gave her joy.

In the last few months, her emotional ups and downs have become more pronounced. She was focused on getting a heart-lung transplant, which turned out not to be an option. She faced a surgery with a questionable predicted outcome, knowing she might die on the operating table. That surgery ended up being aborted. I have seen her at all-time emotional lows as well as in periods of bouncing back. Spiritually, she says she knows that God is with her; she has “no doubts” about that. She also says she must make all decisions, including life and death decisions, on her own – without God’s help.

Intervention:

The anchor in all my visits with her is prayer—prayer for guidance for her in decision making, prayer that lifts all her specific concerns and joys to God. We always hold hands in prayer, which she anticipates and appreciates. The healing aspects of this relationship are consistency and love. In the time we spend together, JD has shared precious, sometimes outrageously funny memories of her life. I have lifted up these memories to God in prayer with her, sometimes in a humorous way. My hope is that rather than compartmentalizing her spirituality she will allow God more and more into her decision making, that she will let God carry the weight of her burdens. This seems to be difficult for her, since she is so fiercely independent.

More and more, she seems now to be dealing with the prospect of her earthly life ending. While she remains trapped in a failing body with future prospects dim, she is now looking at her life with a sense of “well done, thou good and faithful servant” (Matthew 25:21) which is the ultimate healing.

Discussion:

Addressing quality of life is essential for patients with prolonged hospital stays. Patients on LVADS or BIVADS are physically restricted. While the body may be restrained, the mind is free to roam. Well-being must be viewed holistically, with emotional and spiritual needs being addressed. One researcher found that patient coping strategies include family support, religious convictions, and diversional activities, and that best way to support these patients is to establish a trusting relationship, foster independence and incorporate humor into their care. (Savage)

References:

1. Savage, Laura, RN, MSN (2003) Quality of Life among Patients with a Left Ventricular Assist Device: What is New? AACN Clinical Issues 2003 Feb. 14 (1) pp.64-72.

2. Savage, Laura, RN, MSN (1999) Life With a Left Ventricular Assist Device: The Patient’s Perspective American Journal of Critical Care Vol. 5, No. 5, pp. 340-343.

Finding a Language, Creating a Space

noreply@blogger.com (Christian Sinclair) — Fri, 17 Oct 2008 04:47:00 +0000

By David Barnard, Ph.D.

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 4 - October 2001
(Original PDF*)

Case:

Mr. L.O. was an elderly Russian immigrant to Canada, admitted to the Palliative Care Unit of a Canadian hospital with advanced rectal cancer. When L.O. was first presented to the multidisciplinary team, his major problems were identified as persistent rectal pain and anxiety. The initial workup of the pain suggested a neuropathic component, and adjustments were made to L.O.’s medications. His complaints of pain and anxiety persisted over the next several days.

L.O. then began to experience terrifying nightmares. Even during the day, when he was awake, he would have what he called “flashes” of frightening imagery, but the nightmares were the worst. L.O. was so fearful of them that he resisted falling asleep as much as he could. The images were horrific, often violent, with L.O. sometimes being the victim of the violence, sometimes the perpetrator. A CT scan was ordered to investigate the possibility of brain metastases as a contributing factor.

At the same time, the attending palliative care physician had a long interview with L.O., in which they explored the content of the nightmares in depth. L.O. was an amateur artist, and the physician suggested that he might sketch the images in his dreams, or, if not the exact images, some rendering of how they made him feel. L.O. did this. Subsequent conversations revealed that L.O. was estranged from his children; the main reason that he needed to be in the Palliative Care Unit was that none of his children cared enough about him to support him while he lived at home. L.O.’s sketches showed a small figure—himself—cowering at the bottom of a deep pit, with another figure standing far above, looking down.

The physician suggested that L.O., who had become physically well enough for a weekend pass, bring some of his previous paintings back with him to the Palliative Care Unit. Within a few days, the sound of hammering could be heard from L.O’s room. He was hanging his pictures, 15 or 20 in all. Most were landscapes, but there were also a portrait of a lovely young woman, and a winter scene, all in black and silvery white, of a snow- and ice-lined brook leading into a dark woods. The next morning L.O. reported that he had dreamed of eating a chicken dinner.

Discussion:

Two features of this case are striking. The first is the necessity of combining medical and psychosocial approaches to L.O.’s nightmares and overwhelming anxiety. Both the CT scan and several psychoactive medications were appropriate and helpful. But it was the in-depth exploration of the content of the imagery, and even more, the suggestion that L.O. use his art to capture his emotional state in drawings, that appeared to unlock the insights and emotions that lay beneath the anxiety and terror. The physician succeeded in helping L.O. find a language to express himself more effectively and concretely than he had been able to do at a purely verbal level. The physician found a form of expression that “fit” the patient, even though that form was somewhat unconventional.

The second feature concerns the possibility of creating a living space in the Palliative Care Unit where L.O. could work his way to a feeling of peace and safety, despite his estrangement. This use of the inpatient palliative care service would almost certainly be impossible in the United States, with our minimal lengths of stay and our restrictive utilization review requirements. L.O. died in this Canadian palliative care unit many days after his physical and emotional symptoms had been brought firmly under control. But the inpatient environment remained critical to his spiritual well-being. Even though the Canadian health care system faces some of the same economic pressures as that in the U.S., the possibility still exists there for more flexibility to respond to the broadest range of patient or family need, compared to the limits imposed by hospice and palliative care financing in the U.S.

References:

1. Pratt A, Wood M (eds). Art Therapy in Palliative Care. London: Routledge, 1998.

2. Lynn J. Serving patients who may die soon and their families: The role of hospice and other services. JAMA, 2001, 285:925-932. (No open access pdf)

3. Raphael C, Ahrens J, Fowler N. Financing end-of-life care in the USA. Journal of the Royal Society of Medicine, 2001, 94:458-461. (Open access PDF avail from Journal and PubMed Central)

(CS: Minor formatting edits for readability)

One Man’s Journey Toward Deactivating His Implantable Cardioverter-Defibrillator

noreply@blogger.com (Christian Sinclair) — Fri, 03 Oct 2008 03:35:00 +0000

By Ellen Redinbaugh, Ph.D.

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 4 - September 2001
(Original PDF*)

Case:

Mr. C, a 68 year old widower with an implantable cardioverter-defibrillator (ICD) placed five years previously, was admitted to the hospital after his ICD discharged several times in one day. Each discharge was associated with severe pain, loss of consciousness, and heightened anxiety about experiencing future discharges. Evaluation of the ICD firing confirmed refractory ventricular tachyarrhythmias consistent with Mr. C.’s end-stage heart failure. Trials of anti-arrhythmic medications proved unsuccessful. The frequency of ICD discharges could not be reduced without deactivating the device (which would cause imminent death), yet leaving the ICD active would prolong Mr. C’s suffering.

When his primary medical team informed him about his medical condition and prognosis, Mr. C showed ambivalence about deactivating his ICD. He clearly stated to his health care team that he “did not want to live under these circumstances” and that “shutting off this pacemaker may be the best thing for me.” However, he did not like being left alone for fear his heart would stop and no one would be available to resuscitate him. His primary medical team consulted the Palliative Care Team (PCT) to discuss end-of-life options and goals with the patient and family. The PCT treated Mr. C’s anxiety with clonazepam and relaxation training, “supported” his ambivalence, and assisted with his discharge planning.

As the PCT continued working with Mr. C, it became apparent that Mr. C experienced tremendous remorse for “what I put my family through 20 years ago after my wife died.” Although his family openly stated that all was forgiven, Mr. C could not accept their reassurances – “I wish I could make it up to them.” The PCT initiated an intervention where Mr. C talked about his family members one at a time, and he described his happiest memory, what he appreciated, and what he loved about each one. His thoughts were written down, and the family was trained to continue the exercise until all family members were done. Mr. C was discharged with home hospice, and his family completed the PCT intervention at home. The day after Mr. C finished his individualized sentiments, he requested to have his ICD turned off. A representative from the ICD manufacturer came to Mr. C’s home and deactivated the ICD. Mr. C died two hours later in the comfort of his home and surrounded by his family.

Discussion:

ICDs are used to treat people at risk for sudden death due to ventricular tachycardia or ventricular fibrillation. They deliver an electrical charge to the myocardium during an arrhythmic event, and the “shock” allows the ventricle to resume a normal rhythm1. ICDs allow many people to enjoy a prolonged life without significant compromise to quality of life, but in cases of end-stage heart disease ICDs can cause significant physical suffering simply by doing their “job” - repeatedly normalizing arrhythmic events. Patient quality of life is further compromised by the severe anxiety associated with the fear of receiving a future shock2.

For patients with end-stage heart disease, deactivating the ICD can be a sound medical, ethical, and legal decision for them - albeit a difficult one. For Mr. C, his ambivalence about turning off his ICD was driven by his need for reconciliation with his family. Once this was achieved he calmly and peacefully made his decision to die. His case suggests that end-of-life decision making can be difficult for patients, and they may need time and guidance in completing their relationships with their loved ones before they can make the medical decision that is best for them.

ICDs can be deactivated in different ways depending on the urgency of the situation. In cases requiring immediate action (e.g., a patient is actively dying of end-stage cancer and his ICD fires causing the patient to go into convulsions), pacemaker magnets placed over the device deactivate it within seconds. In less urgent cases, the manufacturer and/or the electrophysiology service can assist with ICD deactivation. For patients at the end-of-life, turning off an ICD is similar to withdrawing a ventilator: the patient (or surrogate) has elected for comfort measures in lieu of aggressive medical care.

References:

1. Braun, TC, Hagen, NA, Hatfield, RE, Wyse, DG (1999). Cardiac pacemakers and implantable defibrillators in terminal care. Journal of Pain and Symptom Management, 18, 126-131. (No open access PDF)

2. Dunbar, SB, Warner, CD, Purcell, JA (1993). Internal cardioverter debrillator device discharge: Experiences of patients and family members. Heart Lung, 22, 494-501. (Open access PDF)

3. Quill, TE (1996). A midwife through the dying process: stories of healing and hard choices at the end of life. Baltimore, MD: Johns Hopkins University Press.

An Isolated Patient Who Wants to Die at Home

noreply@blogger.com (Christian Sinclair) — Fri, 19 Sep 2008 03:30:00 +0000

By Justin Engleka, M.S.N., C.R.N.P.

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 1, No. 2 - August 2001
(Original PDF*)

Case:

Mary was a 58 year-old woman who was admitted to the hospital for management of a wound infection. Her past medical history included severe peripheral vascular disease, and she subsequently had bilateral, above-the-knee amputations. Her stumps were very necrotic, and did not respond well to antibiotic therapy. To further complicate her story, a routine imaging scan found suspicious lesions on both her lung and liver. This finding was highly suspicious for metastatic cancer since she also had a smoking history, significant weight loss and decreased appetite. Mary’s primary physician encouraged her to pursue a cancer workup, but she refused. She also decided that she did not want to pursue any other aggressive medical therapies that may prolong her life. Her only goal was to go back to her apartment where she could die in peace. The palliative care service was asked to become involved to help with discharge planning.

Since Mary previously lived alone, this was going to be a very difficult task. During her hospital stay, she became increasingly delirious, and it was clear that she would not be able to return home. We attempted to contact all of her relatives to recruit help. No one was able to take responsibility for her care at home, even with hospice assistance. So we attempted to make her hospital stay as pleasant as possible while these complicated issues were sorted out. We recruited a volunteer to sit with her several times per week to keep her company. Her delirium and agitation improved with the use of antipsychotics. Her pain had also improved after careful titration of her opiate and adjuvant medications. We also paid for a beautician to visit her here in the hospital. Mary was ultimately discharged to a local skilled nursing facility. To ensure continuity, our medical student on service wrote a letter to the attending physician there. We included some of the details of the care that we provided. We suggested that it would be very appropriate to provide Mary with some “luxuries” that would normally be contraindicated in her care such as milkshakes or ice cream.

Discussion:

Patients who do not have family or caregivers can create very challenging situations for hospital staff. Under usual conditions, palliative care extends the focus of care to family and friends of the dying patient. Family members are encouraged to create a home like environment in the hospital. Family photos, favorite music, or a blanket from home can make a hospital stay more pleasant. Patients that are alone often miss the comforts of home. According to Ferrell & Coyle, 2001, the discipline of palliative care provides physical, psychological, social and spiritual support to help the patient adapt to the anticipated decline, associated with advanced, progressive, incurable disease. Palliative care also alleviates isolation through a commitment to non-abandonment, ongoing communication, and sustaining relationships. The role of the volunteer and the medical student in this case was crucial. Volunteers are an integral part of the hospice and palliative care philosophy and approach. Beyond extending the available personnel, volunteers put a truly human, non-professionalized face on the provision of care.

References:

1. Ferrell, B.R., and Coyle, N. Textbook of Palliative Nursing. 2001. Oxford University Press, New York, 684.

2. Mount, B.M. Volunteer support services: A key component of palliative care. Journal of Palliative Care, 1992, 8(1):59-64. (no open access pdf)

Subscribe to Comments Only!

noreply@blogger.com (Christian Sinclair) — Fri, 19 Sep 2008 03:00:00 +0000

Have you ever wondered what other people might be saying about a particular subject you see on any of the three Pallimed blogs? But to actually remember to go back and check the post is something you never get around to doing?

Well for Pallimed readers who subscribe via RSS* we now have a Comments Only Feed that will keep you up on the latest conversations on the posts. Each Pallimed blog (Main, Arts, and Cases) has its own individual subscription link in the left hand column.

Pallimed: Main Comments Only Feed (About 5-10/week)

Pallimed: Arts Comments Only Feed (About 2-4/week)

Pallimed: Cases Comments Only Feed (About 1-2/month)

We rarely get spam comments 2-3/month and we delete them within 2-4 hours usually, so this should not be a big deterrent. The 'Comments Only' subscription is not available for email subscribers at this time, but if you would like an email subscription option then email me directly or post a comment.

This post will be cross-posted to all three Pallimed Blogs. My apologies in advance for readers who see it multiple times.

*Really Simple Syndication.

Delay, Scheduling, Boards, Comments

noreply@blogger.com (Christian Sinclair) — Fri, 19 Sep 2008 02:03:00 +0000

Delay
Case Conferences are back after a month hiatus. Technically on a every 2 week schedule, only one post was skipped, but it just feels like a long time. So never fear, we are not leaving, there is still so much to post!

Scheduling
Case Conference posting will be moving to Thursday evenings to avoid crowding with Arts & Humanities (usually Monday evenings) and because the main Pallimed blog rarely posts on Thursday evenings. Still every two weeks for Case Conference posts.

Boards
The Case Conferences are a great tool for studying for the palliative medicine boards. I would encourage you to go to the UPMC Institute for Enhanced Palliative Care so you can get some of the archived cases.

Comments
We have a lot of readers but very few comments, so please feel free to add your two cents, anonymously or identified. And check out the new Comments Only subscription.

When Depression Isn't Depression:Understanding Hypoactive Delirium

noreply@blogger.com (Christian Sinclair) — Wed, 20 Aug 2008 03:38:00 +0000

By Kevin Patterson, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 7 - August 2008
(Original PDF*)

Case:

Mr. R is a 65-year-old man who retired as a high-level executive at a large business. He had been hospitalized with worsening pulmonary fibrosis and had ultimately received a double lung transplant. Following transplant, Mr. R suffered multiple complications over a period of three months. In these months, Mr. R was a participant in his own care during times of relative medical improvement. Yet his primary team noticed at the present admission that, he seemed to be withdrawn and was not engaging well with physical or occupational therapy. The team also noted that he had more difficulty concentrating when they went into the room to see him. The team expressed concern that the stress of a prolonged hospitalization was getting to him and/or that Mr. R might be suffering from depression.

The team requested a palliative care consult and, as the psychiatrist on the service, I was asked to see Mr. R. When I first examined him, I indeed found him to be quiet and withdrawn and not at all the "go-getter" that his wife described. When the palliative care doctor had initially seen the patient, she was concerned that he appeared to be confused at times, and my examination bore this out. Mr. R was lethargic and would drift in and out of sleep while we talked. With a little prodding, he revealed that he had noticed a "problem" with his thinking and frequently found himself to be unsure of where he was and why people were coming in and out of his room. He denied any hallucinations or paranoia.

Discussion:

It is very common for doctors to identify hyperactive delirium in patients. Hyperactive delirium is the disturbance in thinking that results from physical illness, medications, or various other etiologies and is characterized by a previously stable individual becoming disoriented, agitated, paranoid, and hallucinatory. It frequently results in a disturbance on the medical unit, and is therefore usually diagnosed. Far more common, but less frequently noticed (estimates run from 32-66% missed) is the condition known as hypoactive delirium. Hypoactive delirium is also a disturbance of consciousness wherein the patient's mental status waxes and wanes, but it frequently manifests with symptoms more like those observed in Mr. R: patients become withdrawn, display less motivation, have lower energy, and are quietly confused.

It is not uncommon for patients with this symptom set to be mistaken for depressed or even as simply lacking the motivation to improve medically. The incidence of delirium among hospitalized patients has been estimated at around 10%. Among patients nearing the end of life, these numbers increase to approximately 60%. It is known that untreated delirium results in increased morbidity and mortality in the 6 months following a hospitalization. Identifying and treating hypoactive delirium is therefore an important component of improved quality and length of life for palliative care patients.

The treatment for both hyperactive and hypoactive delirium is the same: identification and treatment of the underlying cause, and short-term use of antipsychotic medications to reduce disruptive symptoms. Mr. R was started on risperidone 0.25mg twice a day with additional doses available as needed. Within two days of starting this regimen, he was interacting more with his providers, reengaging in rehab, and having conversations with his wife that both of them found to be more successful. Mr. R. never endorsed symptoms that would suggest depression. He was better able to communicate his needs and participate in his care.

References:

1. Casarett D, et al. Diagnosis and management of delirium near the end of life. Ann Int Med 2001; 135 (1): 32-40. (open access pdf)

2. Rea RS, et al. Atypical antipsychotics versus haloperidol for treatment of delirium in acutely ill patients. Pharmacotherapy 2007; 24 (4): 588-94.(no open access pdf)

The Differential Diagnosis of Opioid Poorly-Responsive Cancer Pain

noreply@blogger.com (Christian Sinclair) — Tue, 05 Aug 2008 04:51:00 +0000

By Robert Arnold, MD and Tamara Sacks, MD

Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center

Vol 8, No. 6 - July 2008
(Original PDF*)

Case:

Mrs. Smith is a 52-year-old woman with metastatic lung cancer diagnosed two months ago when she developed chest wall and right arm pain. Since then she has seen her primary care physician, an oncologist, and a palliative medicine physician. Her opiate dose was escalated from nothing to 200 micrograms of fentanyl without any pain relief. She was admitted to the hospital two days ago for uncontrolled pain and placed on a hydromorphone PCA. She is currently using 10mg/hr (continuous and bolus), still rates her pain as a 10 out of 10, and has developed nausea.

She describes her pain as a throbbing of the right chest wall and numbness, burning, and tingling down her right arm. Her physical exam is consistent with a lower brachial plexopathy. Her radiographic studies reveal metastases to the sternum and ribs and a right upper lobe mass invading the brachial plexus.

Given the patient is currently using almost 5 grams of oral morphine equivalents a day with no relief and probable opioid induced nausea, what is the next step?

Discussion:

While cancer pain can be relieved in 80-90% of patients using the WHO analgesic ladder, this case raises the question of what should be done when a patient’s pain is uncontrolled even on very high opiate doses. In this discussion, we will assume the pain is caused by tumor rather than distress from psychological causes (delirium, anxiety, addiction) or spiritual/existential suffering.

A key question is whether the patient has ever been responsive to opiates for this condition. If the answer is yes, the increased pain should lead to a search for a worsening of the underlying disease or a new cause of pain. Prior to concluding that a patient’s pain is not opioid responsive, one needs to make sure that the patient has had an adequate trial. The dose should be increased until the patient has pain relief or unacceptable toxicities develop. Aggressively treating the opiate’s side effects may improve the analgesic window. Control of the patient’s vomiting, hyperalgesia, myoclonus, delirium or drowsiness may make it possible to increase the opiate dose to an effective level. In addition, a Cochrane review suggests that rotating from one opiate to another may help decrease side effects and widen the therapeutic window. In addition, recent studies have shown that for patients with opioid responsive pain and uncontrolled side effects, an epidural pump leads to better pain management and is cost-effective.

If analgesia is still ineffective, one can add a drug that produces independent analgesic effects. For example, this patient seems to have both bone and neuropathic pain syndromes. The former may respond to steroids, non-steroidals, or biphosphonates, the latter to topical lidocaine, antidepressant, or antiepileptic drugs. While the strongest evidence supports tri-cyclic antidepressants, gabapentin, and serotonergic neuroepinephrine reuptake inhibitors for the treatment of neuropathic pain, one may have to try five or six agents (including agents such as clonidine, intravenous lidocaine, or mexelitine) to get a significant decrease in pain. A combination of these may also be needed. One should systematically add a co-analgesic and increase the dose until the maximal dose, pain relief, or intolerable side effects occur. A medication should be continued if it results in at least a 50% decrease in pain.

One should also consider non-pharmacological analgesic interventions. Acupuncture and behavioral interventions have been shown to help with pain syndromes. Radiation to the patient’s sternum and ribs may help with bone related pain, while a regional nerve block may help the neuropathic component. In addition radiopharmaceuticals such as samarium, can be considered in patients with pain secondary to diffuse bone metastases.

In very difficult cases, one may need to try and enhance the opiate’s analgesic effect. Drugs that antagonize the NMDA receptor, for example, have both direct analgesic effects or may reverse opiate tolerance, resulting in better pain management. The three drugs that are most commonly used are ketamine, methadone, and dextromethorphan. The use of these drugs should only be done with a pain or palliative care consultation.

While opiate unresponsive pain is not that common, it is very frustrating. Systematically approaching the problem will ensure that one develops the best treatment plan.

References:

1. Mercadante S, Portenoy RK. Opiate Poorly Responsive Cancer Pain Parts 1-3 Journal of Pain and Symptom Management 2001 Vol. 21 #1 page 144-150; Vol. 21 #2 page 255-264; Vol. 21(4) #3 page 338-354.

2. Smith, TJ, Staats, PS., Deer, T., et al. (2002). "Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug related toxicity, and survival." J Clin Oncol 20(19): 4040-9.

3. Fallon, M. (2008). "When morphine does not work." Support Care Cancer 2008: 16(7):771-5.

Acknowledgments: We appreciate input from David Weissman who helped us think through and provide part of the algorithm for this article.