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
BROOK CALTON, MD, MHS ASSISTANT PROFESSOR OF CLINICAL MEDICINE DIVISION OF PALLIATIVE MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
¡ Symptom Management ¡ Prognostication ¡ Advance Care Planning ¡ How to Get Help…
“Easier to stay ahead of [symptom], than catch up” ¡Example: Nausea
¡Examples: Neuropathic pain, opioids
Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007
Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007
Medications Medical Cannabis (?) Surgery Interventional strategies Exercise, Sleep Acupuncture PT/OT Palliative radiation (for CA)
Route Peak analgesic effect Dosing frequency Oral 60-90 min Q1-4h IV 6-15 min Q15-30min SQ 30 min Q15-30min Drug PO IV Morphine 30 mg 10 mg Hydrocodone 30 mg
20 mg
7.5 mg 1.5 mg Fentanyl See chart 0.1 mg (100 mcg)
Constipation Nausea/vomiting Pruritus Sedation Respiratory depression
Never 7-10 days 7-10 days 36-72 hrs Extremely rare when
“Better to stay ahead….” Hydration and activity key, but challenging Fiber/psyllium problematic Suppository or enema (avoid Fleets) if > 3-4 days For opioid induced constipation:
¡ Avoid Docusate ¡ Start with Senna, then add Miralax, Lactulose, etc ¡ Consider Methylnatrexone for opioid-induced,
Tarumi Y. J Pain Symptom Manage. 2013;45(1):2-13
https://www.youtube.com/watch?v=9_4Mz Pv3NJE
1.
2.
3.
4.
Avoid prescribing oxygen to patients who are not
¡ Double-blind RCT 239 outpatients in US, Australia and
¡ Randomized to RA or O2 at 2 LPM x 7 days ÷Instructed to use O2 at least 15 hours/day ¡ No difference between supp O2 vs RA by NC in: ÷Mean AM or PM Breathlessness scores ÷Quality of Life
Abernathy A. Lancet 2010;376(9743):784-93
¡ Pleural effusion, PE, PNA, ascites
Ekstrom M. Ann Am Thoracic Soc 2015; 12(7):1079-92 Bausewein C. Cochrane Database Syst Rev. 2008(2):CD005623
¡ Multifactorial mechanism of action ¡ Low dose safe and likely effective ¡ No studies have found excess mortality associated with opioids
for dyspnea
hospitalizations in the past year. She has difficulty walking a block because of dyspnea. She lives with her son’s family who help with 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. Based on this description, what is the likelihood Ms. A will be alive in 10 years:
1.
10% or less
2.
25%
3.
50%
4.
75%
Helps patients and providers to determine realistic,
Helps patients with life planning Most patients want to know!
Life Expectancy Clinical Decision
¡Usually clearer trajectory
¡Absence of a dominant terminal condition ¡Age + Functional + Cognitive +
Functional Status Comorbid Medical
Cognition Nutrition Polypharmacy Psychological Status Social Support Geriatric Syndromes
Clinical Judgement Life Tables
5 10 15 20 25 70 75 80 85 90 Top 25t h Perce ntile 50t h Percentile Lowest 25 th Perce ntile
Years
Walter LC. JAMA 2001; 285:2750-56
Clinical Judgement Life Tables Prognostic Indices
10/11/18 29
eprognosis.ucsf.edu
Systematic review of 126 articles: 77 directly addressed
Lakin J. JAMA Int Med 2016; 176(9):1380-1387
¡ 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-Stoppelenberg 2014) ¡ More likely to: ÷ 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) ÷ Have caregivers who are satisfied with the quality of their loved
Glaudermans et al. (2015) Fam Practice
§ Systematic review of 10 studies (5 US) among PCPs providing care for patients living in the community or an assisted living § ACP most frequently done with patients with cancer, Alzheimer’s dementia, or other terminal illness § Of patients who died of non-sudden deaths, one-third had ACP § Provider-reported ACP rates higher than patient-reported ones § Lack of systematic approach; hard to judge when to initiate § Patients want to discuss, even if healthy; feel it is responsibility
¡ Fire warning shot ¡ Ask for permission to discuss ¡ Have right people in the room
1.
“Is there anyone you trust to make medical decisions for you if you couldn’t make them yourself?”
2.
“Does this person know you chose them for this role?”
3.
“What have you talked about”
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
Understanding
Prognosis
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
Hopes/Fears/ Values Recommendation
www.polst.org
¡ “ACP includes the explanation and discussion of advance
directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional”
¡ 99497: first 30 min F2F (wRVU 2.40; $85.99) ¡ 99498: each additional 30 min F2F (wRVU 2.09; $74.99) ¡ Include pertinent diagnoses; can bill more than once/yr
http://theconversationproject.org/wp-content/uploads/2016/06/CMS- Payment-One-Pager.pdf
Palliative Care focuses on:
¡ Team-Based care ¡ Symptom management ¡ Excellent communication ¡ Comprehensive care ¡ Bio-psycho-social-spiritual ¡ Family ¡ Continuity
Palliative Care is NOT:
¡ For older adults only ¡ End of Life Care ¡ Hospice Care
CAPC 2015: America’s Care of Serious Illness
¡ “Specialized medical care for people with serious
¡ “An extra layer of support” ¡ “A team that focuses on quality of life and works with
“Patients (and families) aren’t always looking to be "fixed," often they just want someone to listen to them, validate them, and bear witness to their story.”
“People will forget what you said, people will forget what you did, but people will never forget how you made them feel.” – Maya Angelou “Say something empathic and then just shut up!”