Providing High-Quality Care in Line with Individualized Patient Goals

1. Current Concepts in Palliative Care Providing High-Quality Care in Line with Individualized Patient Goals Jennifer K. Clark, MD, FAAP Director, Palliative Medicine University of Oklahoma, School of Community Medicine-Tulsa ACP Oklahoma Chapter Scientific Meeting September 28, 2012

2. Disclosures Dr. Clark does not have any financial disclosures.

3. Which is best description of Palliative Care? Holistic care for patients and families choosing hospice care who do not wish to return to the hospital. Comfort care of patients in the last days to weeks of their life. Care of patients who do not want resuscitation or artificial ventilation. Specialized treatment focused on quality of life in patients with a serious illness.

4. Today’s roadmap • Define the tenets of Palliative Medicine as a medical subspecialty • Discuss Palliative Medicine in the US and Oklahoma • Outline pearls of advanced symptom management: Pain and Dyspnea

5. Why?

6. Patient Distress Family Distress Professional Health Care Distress -Providers -System Suffering…

7. What is it? Palliative care is specialized medical care for people with serious illnesses. Palliative care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness ‐ whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Center to Advance Palliative Care

8. What it is NOT….. Palliative Care is not equal to End-of-Life Care, Hospice, “Death & Dying” Palliative Care is not dependent on prognosis Palliative Care is not just for the elderly, it is for patients of all ages Palliative Care Hospice

9. Serious Illness: Group 1: Conditions for which curative treatment may fail. Group 2: Conditions where premature death is inevitable. Group 3: Progressive conditions without curative options, where treatment is exclusively palliative. Group 4: Static, severe neurological conditions -->Cancer, Transplant -->Cystic Fibrosis, HIV COPD, CHF -->Storage diseases, chromosomal abnormalities ALS -->Cerebral palsy, stroke, dementia, TBI Who is it for? Adapted from Association for Children with Life-threatening or Terminal Conditions and their Families, 2003

10. Trajectories of illness… Sudden Death Cancer-like Illness Chronic Illness Frailty Adapted from Lunney, 2003

11. Curative/ Restorative Care Disease Process Dying Process Loss/Grief/Bereavement When to call? Palliative Care

12. Pornography?! • Consultant delivery model… • Addressing the domains of Palliative Care: • Advance decision making and prognostication • Complex symptom management • Psycho-social assessments and interventions • Spiritual/existential

13. Early Palliative Care for Patients with Metastatic Small Cell Lung Cancer Jennifer Temmel, MD, et al New England Journal of Medicine 2010;363:733-742

14. Letting Go What should medicine do when it can’t save your life? by THE NEW YORKER August 2, 2010 LETTING GO What should medicine do when it can’t save your life? By Atul Gwande Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didn’t get into the prognosis—she would bring in an oncologist for that—but Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying.

15. Palliative Care in the US • Demonstrable improved quality of care and cost savings • Surveys show reports of improved pain, symptom management, family satisfaction • Simultaneous models assure earlier referral to hospice leading to improved satisfaction while saving costs Center to Advance Palliative Care

16. Palliative Care in Oklahoma… Oklahoma GRADE: D

18. Which of the following is false regarding prognostication? Physicians, on average, over estimate prognosis by a factor of 5. Accuracy of prognosis is inversely related to the duration of a physician-patient relationship. 95% of patients would not want CPR if life expectancy is estimated at one year or less. Current data has yet to demonstrate an effective prognostication tool

19. Complex Symptoms Pain Non-Pain Dyspnea Delirium Nausea +/- Vomiting Constipation Fatigue Edema • Nociceptive/Somatic • Neuropathic • Visceral

20. Pain • Use the Hierarchy of Pain Assessment Techniques: • Self-report • Search for Potential Causes of Pain • Observe Patient Behaviors. • Surrogate Reporting (family members, parents, caregivers) of Pain and Behavior/Activity Changes • Attempt an Analgesic Trial McCaffery and Pasero, Pain, 2nd Edition - Clinical Manual 1999, Philadelphia: Elsevier Co., pp.423-426

21. Pain N - Number of pains O - Onset: Acute vs. Chronic P - Palliates, potentiates Q - Quality R - Radiation S - Severity T - Timing

22. Pain: Non-pharmacologic Therapies • Behavioral therapy • Spiritual counseling • Physical therapy • Psychotherapy • Splinting • Surgical correction • Cold packs • Meditation • Support groups • Radiation therapy • Acupuncture • Hypnosis • Cultural healing rituals • Heat packs • Prayer • Community resources A Calm, Soothing Environment!

23. Pain: Pharmacologic Therapies • WHO Pain Ladder • Non-Opioids • Opioids • Adjuvants

24. 3 2 1 Pain: Pharmacologic Therapies W.H.O. Analgesic Ladder Strong opioid +/- adjuvant Weak opioid +/- adjuvant Pain persists or increases Non-opioid +/- adjuvant

25. Non-Opioids • Acetaminophen • NSAID’s • Aspirin • Tramadol (Ultram®)

26. Principles of Opioid Use Stanford Faculty Development Center: www.growthhouse.org/stanford • No ceiling effect • Give orally when possible (PO/SL) • If oral meds are not tolerated, subcutaneous administration is equivalent (and preferable to) intravenous opioids • Most oral/SubQ opioids last for 4 hours • Assess and reassess for side effects

27. Principles of opioid use • Start with a short-acting opioid agent – assess for efficacy, tolerability. • For opioid-naïve, start with 5 - 10 mg PO q4 hours PRN • After 24 – 48 hours, may eventually convert to long-acting regimen • There is no ceiling dose

28. Principles of opioid use • Consider a long-acting opioid plus a breakthrough agent for spikes: • Long acting dose is typically ½ of the previous 24h opioid use. Continue breakthrough dose…typically 10-20% of total daily long acting dose • Predictable spikes - Short-acting agent prior to event • Unpredictable spikes - Short-acting agent readily available

29. Principles of Opioid Use • MANAGE EXPECTATIONS… • Select the drug that works best for the patient that offers the best side-effect profile • Rotate to a new opioid if failure occurs • Patients will tell you

30. Table does not consider incomplete cross-tolerance Opioid Conversion Table

31. A Case of Pain Mrs. Smith is a 62 year old female with newly diagnosed breast cancer. She has undergone resection and is starting radiation. Since discharge from the hospital, Mrs. Smith has had ongoing pain at the surgical site and she is concerned about it worsening with the radiation. H & P demonstrate that there is no other concerning causes of the pain. She has been taking the prescribed Norco 7.5/325 every 4h for the last three days with little relief…

32. What is the next step? Refill the Norco at current dose. Refer back to patient breast surgeon. Calculate 24 hour needs, and start a long acting opioid. Start oxycodone at 5mg Q4h.

33. It’s just a bit of math… Mrs. Smith is taking 45mg of Norco per day. 45mg of Norco is roughly equivalent to 70mg of Morphine or 45mg of Oxycodone. Take up to half of the daily requirement and start a long acting agent. MSContin 15mg BID or OxyContin 10mg BID Breakthrough dose is roughly 10-20% of total long acting dose. Roxanol 5mg Q4h or Oxycodone 5mg Q4 or continue Norco

34. Dyspnea • "a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." • Dyspnea is often caused by complex interactions between physiological, psychological, social, and environmental factors, and may result in secondary physiological and behavioral responses. American Thoracic Society

35. Dyspnea Treatment Restorative Measures Palliative Measures Environmental: Handheld fan drastically reduces sensation of breathlessness Galbraith, JPSM, 2010 Positioning Pharmacologic: Opioids (oral and parenteral) are the drugs of choice for palliation.Palliation of dyspnea with opioids is often achieved with lower doses of opioids than are usually required for palliation of pain. Start low and go slow, in opioid naive patients. Abernathy, BMJ, 2003 Rehabilitation • Identify and treat the reversible causes of dyspnea: • Edema • Bronchospasm • Infection • Anemia • Muscle weakness • Neurologic impairment • Etc.

36. Closing thoughts… • Palliative Care is standard of care for those patients with serious illness…of any age and at any stage. • Palliative Care offers: Prognostication, advance care planning, complex symptom management, psycho-social intervention, spiritual support • Basic pain control and dyspnea management are simple interventions that can make a world of difference in patient suffering.