Palliative Care Pearls for the Busy Practitioner I have no - PDF document

10/11/18 Disclosures Palliative Care Pearls for the Busy Practitioner I have no financial disclosures to report. BROOK CALTON, MD, MHS ASSISTANT PROFESSOR OF CLINICAL MEDICINE DIVISION OF PALLIATIVE MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Palliative Care Pearls ¡ Symptom Management ¡ Prognostication Symptom Management ¡ Advance Care Planning ¡ How to Get Help… 1

10/11/18 General Symptom Management Principles Pain — Take a comprehensive approach — “Easier to stay ahead of [symptom], than catch up” ¡ Example: Nausea — It’s often about the way the medication is used, not the medication you choose. ¡ Examples: Neuropathic pain, opioids — Requires frequent follow-up and tinkering — Consider interdisciplinary team/community-based resources The Bio-Psych0-Social Model The Bio-Psych0-Social Model Medications Medical Cannabis (?) Surgery Interventional strategies Dz related mechanisms Exercise, Sleep Bio Bio Biologic mechanisms of Acupuncture psychiatric illness PT/OT Palliative radiation (for CA) Psychotherapy Mindfulness Environmental Relaxation Distress Psycho Social Psycho Social Social support stressors techniques Anger Limiting other Close personal Fear stressors relationships Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 2

10/11/18 Pain Opioid Prescribing Principles — Take a comprehensive approach PRN Dosing ATC Dosing — Focus on function! “PEG” Scale ¡ ADLs, IADLs On a scale of 0-10, over the last week: • What has your average pain been? (0-10) ¡ Hobbies, socialization, exercise How much has your pain interfered with your • enjoyment of life? (0-10) ¡ Concentration, appetite, sleep How much has your pain interfered with your • ¡ Mood, energy, relationships general activity ? (0-10) ¡ Overall health A Few Important Details Opioid Side Effects Side effect Time to Tolerance Drug PO IV Morphine 30 mg 10 mg — Constipation — Never Hydrocodone 30 mg -- — Nausea/vomiting — 7-10 days Oxycodone 20 mg -- — Pruritus — 7-10 days Hydromorphone 7.5 mg 1.5 mg — Sedation — 36-72 hrs Fentanyl See chart 0.1 mg (100 mcg) — Respiratory depression — Extremely rare when Route Peak analgesic Dosing opioids are dosed effect frequency appropriately Oral 60-90 min Q1-4h IV 6-15 min Q15-30min SQ 30 min Q15-30min 3

10/11/18 Constipation — “Better to stay ahead….” — Hydration and activity key, but challenging — Fiber/psyllium problematic https://www.youtube.com/watch?v=9_4Mz — Suppository or enema (avoid Fleets) if > 3-4 days Pv3NJE — For opioid induced constipation: ¡ Avoid Docusate ¡ Start with Senna, then add Miralax, Lactulose, etc ¡ Consider Methylnatrexone for opioid-induced, laxative-refractory constipation Tarumi Y. J Pain Symptom Manage. 2013;45(1):2-13 Mrs. A Dyspnea – A Vicious Cycle 79 yo woman with PMH s/f severe COPD using 4L home O2 c/b two hospitalizations this year for COPD exacerbations. She 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 her disease. If you decide to manage with medication, which might you consider? Start 25 mcg/hr Fentanyl patch 1. 25 mcg Fentanyl with 2mL saline via neb 4x /day prn 2. 3. Start Lorazepam 0.25mg PO BID prn SOB Start Oxycodone 2.5 mg q4h prn SOB 4. 4

10/11/18 Dyspnea - Symptom Relief Dyspnea – Role of Oxygen — Treat the underlying cause — Avoid prescribing oxygen to patients who are not ¡ Pleural effusion, PE, PNA, ascites hypoxemic. — Medication education ¡ Double-blind RCT 239 outpatients in US, Australia and — Positioning UK with life-limiting illness, refractory dyspnea, and PaO2>55mHg — Breath training ¡ Randomized to RA or O2 at 2 LPM x 7 days — Fan and/or fresh air ÷ Instructed to use O2 at least 15 hours/day — Pulmonary rehab ¡ No difference between supp O2 vs RA by NC in: — Acupuncture in COPD ÷ Mean AM or PM Breathlessness scores ÷ Quality of Life Ekstrom M. Ann Am Thoracic Soc 2015; 12(7):1079-92 Abernathy A. Lancet 2010;376(9743):784-93 Bausewein C. Cochrane Database Syst Rev. 2008(2):CD005623 Medications for Dyspnea — Opioids first-line, better for dyspnea at rest vs DOE ¡ Multifactorial mechanism of action ¡ Low dose safe and likely effective Prognostication ¡ No studies have found excess mortality associated with opioids for dyspnea — Anecdeotal but no sufficient evidence for inhaled opioids — Benzos as adjunct if anxiety 5

10/11/18 Mrs. A (continued) Prognostication – Why It’s Important — Helps patients and providers to determine realistic, Ms. A is a 79 yo woman with COPD, on 4L O2, with two hospitalizations in the past year. She has difficulty walking a block achievable goals of care and proceed with interventions because of dyspnea. She lives with her son’s family who help with consistent with goals iADLs but she is independent in ADLs. She has a previous 50 pack year history of cigarette use but she hasn’t smoked in 10 years. “If your heart stops, do you want electrical shocks and Based on this description, what is the likelihood Ms. A will be alive in 10 years: chest compressions to try to get your heart beating again?” 10% or less 1. 25% 2. — Helps patients with life planning 50% 3. — Most patients want to know! 4. 75% Prognostication – Why It’s Hard Clinical Decisions Influenced by Life Expectancy — Younger patients (often with cancer): Life Clinical Decision Expectancy ¡ Usually clearer trajectory <4-6 weeks Methylphenidate over SSRI for depression — Older adults: <6 months Discontinue statins <6 months Refer to hospice ¡ Absence of a dominant terminal condition <1-2 years Nonoperative management of AAA ¡ Age + Functional + Cognitive + <2-3 years Tight BP control in diabetes unlikely to Multimorbidity prevent stroke, MI <5 years Bio-prosthetic heart valve over mechanical <9 years Discontinue tight blood sugar control in diabetes 6

10/11/18 Multiple Domains Independently How should we prognosticate? Impact Prognosis — Functional Status — Comorbid Medical Conditions Clinical — Cognition Judgement — Nutrition Life — Polypharmacy Tables — Psychological Status — Social Support — Geriatric Syndromes Great Variation in Life Expectancy How should we prognosticate? for People of Similar Ages 25 Life Expectancy for Women 20 Top 25t h Perce ntile Clinical 50t h Percentile 15 Years Judgement Years Lowest 25 th Perce ntile 10 Life Tables 5 Prognostic 0 Indices 70 75 80 85 90 Age (Years) Walter LC. JAMA 2001; 285:2750-56 7

10/11/18 29 eprognosis.ucsf.edu Age Sex BMI General Health Status PMH Cig Use 10/11/18 Hospitalizations ADLs/iADLS 10 year mortality risk: Your Guess 87% 8

10/11/18 Discussing Prognosis — Ask for permission and preferences for how information is relayed — Use ranges Advance Care Planning — “In other people in a similar situation to you….” Advance Care Planning Unique Opportunity in Primary Care — Systematic review of 126 articles: 77 directly addressed — An ongoing process of discussing care preferences primary care, 26 addressed specific populations, 23 and making care plans between patients (and their addressed general topics caregivers) and providers Strengths Weaknesses • Continuity • Deficits in knowledge, — Should include discussion of person’s priorities, • Duration skills, and attitudes beliefs, and values AND prognostic information • Trust • Discomfort with — May or may not lead to completion of advance • Ability to coordinate prognostication directive across settings • Lack of clarity about the • Unique ability to have appropriate timing and — Both physicians and patients think it’s important these in an iterative initiation of manner conversations Lakin J. JAMA Int Med 2016; 176(9):1380-1387 9