During this hour, well cover: 1. Symptom Management 2. Advance Care - PDF document

Brook Calton, MD, MHS Palliative Care Pearls for the I have no financial disclosures to Assistant Professor of Clinical Medicine Disclosures report. Primary Care Practitioner Division of Palliative Medicine University of California, San Francisco During this hour, we’ll cover: 1. Symptom Management 2. Advance Care Planning Sy Symptom Management 3. How to Get Help

Ms. Billings It’s often about the way the medication is used, not the medication you choose Ms. Billings is a 40 yo woman with colon cancer metastatic to the General peritoneum. She is undergoing palliative chemotherapy. She has been “Easier to stay ahead of [symptom], taking Acetaminophen (3000 mg/day) for her chronic, cancer-related Symptom than catch up” abdominal pain without relief. She wants to be able to take walk her dog around her neighborhood again but pain is too severe. You decide to start Management an opioid – which do you choose? Requires frequent follow-up and 1. Hydrocodone/Acetaminophen 5/325 mg every six hours as needed for Pearls tinkering pain 2. Fentanyl patch 25 mcg/hr Consider interdisciplinary 3. MS Contin 15 mg BID team/community-based resources 4. Oxycodone 2.5-5 mg every three hours as needed for pain The Bio-Psycho-Social Model Take a comprehensive approach Dz related mechanisms Bio Comorbidities Pain Pearls Environmental Distress Psycho Social stressors Anger Close personal Fear relationships Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007

The Bio-Psycho-Social Model Take a comprehensive approach Medications Medical Cannabis (?) Surgery Interventional strategies Exercise, Sleep Focus on function! Bio Acupuncture PT/OT Pain Pearls Palliative radiation (for CA) Psychotherapy • ADLs, IADLs Mindfulness • Hobbies, socialization, exercise Relaxation Psycho Social techniques Social support • Concentration, appetite, sleep Limiting other • Mood, energy, relationships stressors • Overall health Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 Opioid Prescribing Principles PEG Scale PRN Dosing ATC Dosing • On a scale of 0-10, over the last week: • What has your average pain been? (0-10) • How much has your pain interfered with your enjoyment of life? (0-10) • How much has your pain interfered with your general activity ? (0-10)

A Few Important Details Once pain controlled and on Drug PO IV Start with short- stable dosing, can acting as needed Morphine 30 mg 10 mg add long-acting to medications first. Hydrocodone 30 mg -- account for short- Safe Opioid acting usage. Oxycodone 20 mg -- Prescribing Hydromorphone 7.5 mg 1.5 mg Fentanyl See chart 0.1 mg (100 mcg) Pearls Breakthrough Same risk dose should be stratification and Route Peak analgesic Dosing frequency approximately opioid monitoring effect 10% of total daily strategies apply Oral 60-90 min Q1-4h opioid dose. for seriously ill. IV 6-15 min Q15-30min SQ 30 min Q15-30min Ms. Billings (continued) Opioid Side Side effect Time to Tolerance As you prepare to prescribe Ms. Billing’s oxycodone for the first time, Effects • Constipation • Never you should do all of the following except: • Nausea/vomiting • 7-10 days 1. Perform an assessment of Ms. Billing’s opioid misuse/abuse risk • Pruritus • 7-10 days 2. Prescribe Docusate • Sedation • 36-72 hrs 3. Check your state’s prescription drug monitoring program website • Respiratory • Extremely rare (PDMP) to check on prior controlled rx prescriptions depression when opioids are 4. Prescribe a 7- to 10-day supply of oxycodone rather than a full one dosed month supply appropriately

Better to stay ahead… Opioid- • Avoid Docusate Induced • Start with Senna, then add Miralax, Activity and hydration key…and Constipation Lactulose, etc challenging Constipation • Consider Methylnatrexone for Pearls opioid-induced, laxative-refractory Fiber/psyllium can be problematic constipation Something from below if > 4 days Tarumi Y, J Pain Symptom Management, 2013 Mr. Chen Dyspnea: A Vicious Cycle Mr. Chen is a 75 yo man with PMH s/f severe COPD using 4L home O2 c/b two hospitalizations this year for COPD exacerbations. He presents to your clinic with ongoing dyspnea both at rest and with activity. After further history and exam, you believe his DOE is from chronic COPD - not an exacerbation of his disease. If you decide to manage with medication, which might you consider? 1. Start 25 mcg/hr Fentanyl patch 2. 25 mcg Fentanyl with 2mL saline via neb 4x /day prn SOB 3. Start Lorazepam 0.25mg PO BID prn SOB 4. Start Morphine liquid 20 mg/mL 2-4mg PO q6h prn SOB

Dyspnea – Role of Oxygen Dyspnea Pearls • Treat the underlying cause • Pleural effusion, PE, PNA, ascites • Medication education • Positioning • Pacing • Breath training • Fan and/or fresh air • Pulmonary rehab • Acupuncture in COPD Ekstrom M. Ann Am Thoracic Soc 2015; 12(7):1079-92 Bausewein C. Cochrane Database Syst Rev. 2008(2):CD005623 Abernathy A. Lancet 2010;376(9743):784-93 • Opioids first-line • Multifactorial mechanism of action • Low dose safe and likely Medications effective Advance Care Planning for Dyspnea • Anecdotal but no sufficient evidence for inhaled opioids • Benzos as adjunct if anxiety

Unique Opportunity in Primary Care • An ongoing process of discussing care preferences and making care plans • Systematic review of 126 articles: 77 directly addressed primary care, 26 between patients (and their caregivers) addressed specific populations, 23 addressed general topics and providers • Should include discussion of person’s Strengths Weaknesses Advance Care • Continuity • Deficits in knowledge, priorities, beliefs, and values AND • Duration skills, and attitudes Planning prognostic information • Trust • Discomfort with • May or may not lead to completion of • Ability to coordinate prognostication advance directive across settings • Lack of clarity about the • Both physicians and patients think it’s • Unique ability to have appropriate timing and these in an iterative initiation of conversations important manner Lakin J et al. JAMA Int Med 2016. Audience Poll Benefits of ACP In my practice, I aim to have advance care planning conversations with: 1. None of my patients • Patients who have advance care planning or EOL conversations with their provider are: 2. All my patients over 65 years old • Less likely to: • Receive intense interventions (mechanical ventilation, CPR, ICU death, feeding tubes) (Zhang et al. 2009, Teno et al 2008, Wright et al. 2008, Brinkman- 3. My patients who are terminally ill Stoppelenberg 2014) • More likely to: 4. Both 2 and 3 • Receive outpatient hospice and be referred to hospice earlier (Zhang et al. 2009, Wright et al. 2008) • Have their wishes known and followed (Detering et al. 2010; Houbin 2014) 5. All my patients regardless of age • Have caregivers who are satisfied with the quality of their loved one’s death (Detering et al. 2010)

For me, the biggest barrier in having ACP Practices in Primary Care conversations about serious illness/end-of-life with my patients is: § Systematic review of 10 studies (5 US) among PCPs providing care for patients living in the community or an assisted living 1. Knowledge (of how to have the conversation) § ACP most frequently done with patients with cancer, Alzheimer’s dementia, or other terminal illness 2. Time Audience Poll § Of patients who died of non-sudden deaths, one-third had ACP § Provider-reported ACP rates higher than patient-reported ones 3. Money (I can’t or don’t know how to bill) § Lack of systematic approach; hard to judge when to initiate § Patients want to discuss, even if healthy; feel it is responsibility of provider to 4. Personal Discomfort - Fear of Taking Away bring up Hope or Damaging the Relationship Glaudermans et al. (2015) Fam Practice 5. None, this stuff is easy! www.prepareforyourcare.org ACP Best Practices in a Busy Practice Pre-Work Separate Visit Identify Surrogate Fire warning shot Assign pre-work “Is there anyone you trust to make medical decisions (a.k.a. Ask for permission to for you if you couldn’t make prepareforyourcare. discuss them yourself?” org) “Does this person know you Have right people in chose them for this role?” the room “What have you talked about?”

ACP– Hosting the Conversation ACP – Hosting the Conversation Hopes/Fears/ Values Understanding of Illness Recommendation Prognosis https://www.ariadnelabs.org/areas-of-work/serious-illness-care/ https://www.ariadnelabs.org/areas-of-work/serious-illness-care/