Pallimed: Case Conferences

Excellent point. The Chaplain plays a key role in...

noreply@blogger.com (Christian Sinclair) — Fri, 18 Jan 2013 04:52:44 +0000

Excellent point. The Chaplain plays a key role in challenging situations like this. And Board Certification is a helpful reminder of the professional nature of this support. It is not just as simple as being a nice listener.

Please, all you on the care team -- Call the Board...

noreply@blogger.com (Vcarreiro) — Thu, 17 Jan 2013 23:20:06 +0000

Please, all you on the care team -- Call the Board Certified Chaplain for your patient. Of all the members on the interdisciplinary care team, in palliative care, intensive care and all the medical/surgical units, the chaplain is the one health care clinician who has specialized in spiritual care and that includes addressing issues of moral distress. We help other team members as well as patients and families, by sorting out feelings and perspectives, by searching for meaning and values, and by a well-practiced listening presence.

We use CMO orders in our Tampa hospital. I know a ...

noreply@blogger.com (Cyndi Cramer) — Mon, 21 Mar 2011 01:45:49 +0000

We use CMO orders in our Tampa hospital. I know a search was done before initiating that and the searchers found "many places" that were using this...but I'm afraid I don't have the details...

Great points about semantics David. I had never t...

noreply@blogger.com (Christian Sinclair) — Wed, 16 Mar 2011 15:59:31 +0000

Great points about semantics David. I had never thought that clsoely about
saying/writing things like 'The patient is (a) DNR?' but now with your
comments, it actually looks very objectifying and dehumanizing. I
appreciate your insight and will start to correct some of those habits and
use that in teaching as well.

Good information here, and thank you. I will just...

noreply@blogger.com (David Fisher MD) — Wed, 16 Mar 2011 04:52:01 +0000

Good information here, and thank you. I will just nitpick on my one pet peeve. I never liked the phrase "patient was made comfort measures only" or "patient was made DNR". It is too pejorative, and actually inaccurate, to state things this way, considering that most of these decisions are made with the patient, or a surrogate who is attempting to honor the patient's wishes. As a patient or family member, hearing that someone was "made comfort measures" could imply unilateral decision-making on the part of the clinicians. It could also imply that the patient could have been "made curative care" or even "made to walk again", but the doctors chose a different course. Indeed, I often wish I had more power as a doctor, but I cannot "make" my patient respond to my treatment plan any more than I can "make" their disease progress to the point that comfort measures are the best option. I much prefer saying that "the patient (or family) elected comfort measures only." (In the same vein, I avoid saying that my patient "is a DNR." He or she is a person who has a DNR order.)

Thanks Suzana. A few formatting bugs, and trying ...

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 16:03:53 +0000

Thanks Suzana. A few formatting bugs, and trying to get all the social
widgets integrated but much cleaner and less busy overall I think.

Christian

I would love to see a lot more research in this ar...

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 04:19:57 +0000

I would love to see a lot more research in this area. Even a comprehensive agreed upon grading system would be good so we can all be talking about the same thing.

Great information - thank you!

noreply@blogger.com (Flannery Fielding) — Tue, 15 Mar 2011 03:46:56 +0000

Great information - thank you!

Thanks for sharing your approach to dealing with d...

noreply@blogger.com (Flannery Fielding) — Tue, 15 Mar 2011 03:33:27 +0000

Thanks for sharing your approach to dealing with death rattle - very practical and clearly compassionate. One point from the Cochrane review that I found fascinating: the actual cause of death rattle is, in fact, uncertain. The mechanism as you've explained it (and as many of us do) is presumed, not proven. So, as an additional educational intervention with families, we might addend our explanation with a caveat.

Great new look Christian! Like like like!

noreply@blogger.com (Suzana Makokwski) — Tue, 15 Mar 2011 03:23:40 +0000

Great new look Christian! Like like like!

Thanks for the great reply Suzana.

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 03:16:23 +0000

Thanks for the great reply Suzana.

Since the effect of opioids may be different based...

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 03:14:10 +0000

Since the effect of opioids may be different based on patients previous exposure and tolerance, it depends on the right amount. So the answer to anyone here reading none of this is medical advice. Please talk with your doctor or nurse who can best apprise the situation in front of you.

Pharmacology does not "stop" just becaus...

noreply@blogger.com (Suzana Makokwski) — Tue, 15 Mar 2011 02:53:44 +0000

Pharmacology does not "stop" just because someone is 'CMO', and efficacy of medications for difficult to manage saliva or pooling of secretions do not change eith. Despite the limit data expressed in the Cochrane study that only reviews literature done on patients who were identified as actively dying, anticholinergics have been studied more broadly in as variety of neurological conditions that mimick the lack of gag reflex at the end of life - such as with ALS and other neurologic conditions.
The research supporting glycopyrrolate, as Bob Arnold writes, is quite substantial, actually. It's pharmacology also gives us more room to increase dose, perhaps leading to increased efficacy. Unlike other anticholinergics available in the US, it is a quaternary amine, hydrophilic, and thus, does not cross the blood-brain-barrier lessening the risk of medication induced delirium.
In the UK there is a quaternary amine version of scolopamine as well.
Repositioning, minimizing excess fluids (in feeding tubes, Ivs) can help, but sometimes we need a little help from Pharm.
A great overall reference is www.palliativedrugs.com - free signup.

Agree with being careful about administering sl me...

noreply@blogger.com (Dslawton) — Tue, 15 Mar 2011 02:45:24 +0000

Agree with being careful about administering sl meds. I think the 0.5ml, which is usually all that is needed, can be given easily by giving a few drops at a time while the patient is lying on their side.

Excellent comment Dslawton. I agree with a lot of...

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 02:27:16 +0000

Excellent comment Dslawton. I agree with a lot of the education points you made. Caution is important though when using PO/SL medications anytime there is evidence of impaired swallowing or noisy secretions/death rattle. If other routes are easily available like IV or subcutaneously (under the skin) then one might consider those, but obviously those are usually only available in a facility like a hospice house.

In regards to the "death rattle" I think...

noreply@blogger.com (Dslawton) — Tue, 15 Mar 2011 02:17:14 +0000

In regards to the "death rattle" I think that educating the family and correct positioning of the patient are key. I would explain to the family what the noise meant by saying that it is simply air passing through the accumulation of saliva at the back of their loved ones throat. I would talk about how as we die the ability to swallow is decreased so we are no longer able to handle all of the secretions that are normally produced. I would instruct them to look for signs of distress instead of focusing on the sound of the gurgling. Look for facial grimacing, picking at badsheets, etc. If the patient seemed breathless then it might be appropriate to administer liquid morphine which would increase their tidal volume and allow them to take a bigger breath thus decreasing their rapid rate. Then I would position the patient on his side with his head down and a towel under his mouth. Doing this facilitated the drainage of secretions. It seems counterintuitive because most want to put the patient's head up but without the ability to swallow that simply promotes pooling which causes the rattle. Rarely did families ever worry about the noise anymore because they could understand what was causing it and they were no longer fixated on it.

I totally thought CMO meant Chief Medical Officer ...

noreply@blogger.com (Christian Sinclair) — Tue, 15 Mar 2011 02:10:01 +0000

I totally thought CMO meant Chief Medical Officer too. I bet having to go see the Chief Medical Officer is not like Comfort Measures Only.

I had not seen CMO until I returned to the east co...

noreply@blogger.com (Suzana Makokwski) — Tue, 15 Mar 2011 01:58:28 +0000

I had not seen CMO until I returned to the east coast after some time away. I was a little confused the first time seeing it, wondering why someone would comment on the Chief Medical Officer in a patient's chart - sometimes associated with a new form of "code status" implying thatNOW the patient had permission to die in the hospital; other times meaning Continuous Morphine Only, as if suddenly morphine became this wonder drug that alleviated all symptoms, all evil. I would explain to people that if that were the case, fellowship and boards in palliative care would be a peace o' cake.
So thanks for the blog, Bob, and for the comment, Christian!

In my limited experience (two large teaching hospi...

noreply@blogger.com (Flannery Fielding) — Tue, 15 Mar 2011 00:49:24 +0000

In my limited experience (two large teaching hospitals in Los Angeles), CMO is a commonly used term - although less commonly implemented. I've heard comfort care only used as well, and I appreciate it as highly descriptive, not overly clinical and easy for families to understand.

I have a question about one of the points in the case study - I followed the link but wasn't able to find the original post, which I presume may have included citations. In the first point in the discussion section, it is stated "The only evidence-based treatment for secretions, or 'the death rattle,' is glycopyrrolate." Having done a fair bit of research on this topic over the past several months, I'm surprised to hear there's an evidence base for using glycopyrrolate over any of the other commonly used anticholinergics. My understanding had been that essentially all of the pharmacologic treatments we use for death rattle are equally ineffective (although not all the researchers involved have chosen to put that spin on it). Is this new data? Can anyone out there point me in the direction of the evidence for glycopyrrolate?

I'm guessing the family was not available? I w...

noreply@blogger.com (caring rn) — Mon, 14 Mar 2011 03:44:53 +0000

I'm guessing the family was not available? I would have caused quite a scene, I believe. I would have called an ethics team person, or hospital attorney, or chief of ICU. There is a tendency to become desensitized to pain and suffering if the whole group is doing the same. These images prevent us from being happy with our work, and sleeping well at night. I have been professional, but outspoken all my nursing life. I'm 68 and still working as a nurse....teaching others to stand up for what is right and have no fear. Have I been "called into the office"? Oh yea. Too bad. Have I reported a neurosurgeon who cursed me out for calling on behalf of his patient? Oh yea. Did I report him? Oh yea. Don't be afraid. We are the patients' advocates...even when others forget that they are, also.

I have never seen the abbreviation CMO meaning com...

noreply@blogger.com (Christian Sinclair) — Sun, 13 Mar 2011 23:49:50 +0000

I have never seen the abbreviation CMO meaning comfort measures only. In the hospitals I have worked at we usually wrote out comfort care only. Is that a common abbreviation or maybe just used in Pittsburgh? What does your hospital use?

Thanks for commenting on your experience Mayopallm...

noreply@blogger.com (Christian Sinclair, MD) — Sun, 13 Mar 2011 10:31:06 +0000

Thanks for commenting on your experience Mayopallmedfellow.

I have yet to prescribe it and I keep looking for situations where I think it will be an issue. It is a bit of a bummer since they really worked closely with hospices to get this drug right for our field. It is not like we get a lot of focused attention for med development in palliative care!

Well the issue for Skilled care in a nursing facil...

noreply@blogger.com (Christian Sinclair, MD) — Sun, 13 Mar 2011 10:31:06 +0000

Well the issue for Skilled care in a nursing facility versus Hospice in a nursing facility for a dying patient is a tough one and the finances of the matter play a big role in it for facility and for family/patient.

When you go skilled the patient/family have less out of pocket expenses since room and board is covered ($150-250/day). But at the same time everyone acts like the patient is going to do rehab, when they likely cannot or do not want to which reinforces the 'maybe he will get better, so we don't have to worry/think about this dying stuff' feelings of staff, patient, and family.

This is a real tough issue that I rarely see talked about in print in the hospice world, but ask any hospice or palliative care team and they will tell you it is a huge bureaucratic nightmare.

Thanks for your comments- I couldn't agree mor...

noreply@blogger.com (Anonymous) — Sun, 13 Mar 2011 10:31:05 +0000

Thanks for your comments- I couldn't agree more. As a hospitalist, care for frail geriatric patients is a mainstay of my job, and helping patients and families make the transition from reflex hospitalization/aggressive procedures to comfort based care when indicated is made SO much more difficult by the complexities of Medicare and nursing homes. The DC Dept of Health today rendered a verdict to this particular nursing facility and my patient's family that yes, DC Law does preclude admission of a patient to an assisted living or independent living facility who has a stage III or IV sacral decub even if the person is in Hospice care and has a family paid caregiver in place 24 hours a day. They say that long term care in their SNF is the only appropriate place, even though there is no further care outside of wet- dry dressing changes for the wound, done just for comfort. I don't know if the DOH is actually going to enforce this, but the nursing home has the answer it wants (to place her in their snf instead of her own independent apartment). I think most other care facilities are more reasonable and look the other way, but I can see this issue affecting other patients as well. I hope our local hospice organizations will tackle this one. This is a terrific web sight by the way, and thanks for your input.

Thanks for the comments Sharon. Over the past few...

noreply@blogger.com (Christian Sinclair, MD) — Sun, 13 Mar 2011 10:31:02 +0000

Thanks for the comments Sharon. Over the past few years I think I am finding less families considering taking a loved one home, even if that is the desired wish of patient and family. There is a concern about being too difficult to give all the proper care at home. I don't know how to measure this trend on a larger scale, but just my experience.

I get excited about cases like this because of all the creative solutions and goodwill that can form as a result of fulfilling someone's dying wish.