Palliative Care Pearls: Disclosure What Works, What Doesnt Steven - PDF document

Palliative Care Pearls: Disclosure What Works, What Doesn’t Steven Pantilat, MD • I have no disclosures to report Kates-Burnard and Hellman Distinguished Professor of Palliative Care Director, Palliative Care Program and Palliative Care Quality Network Department of Medicine University of California, San Francisco Twitter: @stevepantilat UCSF Palliative Care Program UCSF Palliative Care Program Palliative Care Pearls Supplemental Oxygen for Shortness of What Works, What Doesn’t Breath • Helpful for hypoxemic patients • Oxygen for shortness of breath • No evidence for relief in patients that are • Atropine for rattle not hypoxemic • IV Fluids for dehydration at end of life – Adds discomfort • Docusate for constipation – May prolong dying • Chemotherapy for longevity and quality of life in advanced cancer Abernethy A et al. Lancet . 2010;376:784-93 Cranston JM, et al. Cochrane Database Syst Rev. 2008(3):CD004769 UCSF Palliative Care Program UCSF Palliative Care Program

Palliative Care Pearls Treatment of Shortness of Breath What Works, What Doesn’t • Treat the underlying cause • Oxygen for shortness of breath: only if – Pleural effusion, PE, pna, ascites hypoxemic • Opioids work in all cases • Atropine for rattle – Low dose: morphine 2mg po q3hrs prn • IV Fluids for dehydration at end of life – Safe even in COPD • Docusate for constipation • Sitting upright • Chemotherapy for longevity and quality • Fan and/or fresh air of life in advanced cancer • Cold cloth to face Ekstrom M et al. Ann Am Thoracic Soc. 2015; Bausewein C, et al. Cochrane Database Syst Rev. 2008(2):CD005623 UCSF Palliative Care Program UCSF Palliative Care Program Palliative Care Pearls Treatment of (Death) Rattle What Works, What Doesn’t • Distressing sound in people near end of life • Oxygen for shortness of breath: only if – Likely not distressing to patient hypoxemic • Poor prognostic sign • Atropine for rattle: no – 57 ± 82 hrs (23 hrs median survival) • IV Fluids for dehydration at end of life • Atropine sublingual does not reduce rattle – Neither do any other meds • Docusate for constipation • Turn patient • Chemotherapy for longevity and quality • Limit IVF of life in advanced cancer Heisler et al. JPSM. 2013;45(1):14-22 Lokker et al. JPSM. 2014;47(1):105-122 UCSF Palliative Care Program UCSF Palliative Care Program

IV Fluids at End of Life IV Fluids at End of Life • Significant controversy • Trial of 1000ml/day vs 100ml/day IV • Stopping to eat and drink is normal at end of fluids in hospice patients with advanced life cancer unable to take po fluids • Associated with edema, effusions and • No difference in symptoms, quality of life, ascites or survival • Does not reduce thirst – Median survival 17 days • Management challenge at discharge – Requires IV access • Minimize IV fluids at end of life Bruera et al. J Clin Oncol. 2013;31:111-118. Bruera et al. J Clin Oncol. 2013;31:111-118 UCSF Palliative Care Program UCSF Palliative Care Program Palliative Care Pearls Treatment of Constipation What Works, What Doesn’t • Very important to patients • Oxygen for shortness of breath: only if hypoxemic • Bowel regimen for patients on opioids is • Atropine for rattle: no a quality measure • IV Fluids for dehydration at end of life: no – Bowel stimulants are essential • Docusate for constipation • Senna and docusate are commonly used • Chemotherapy for longevity and quality of life in advanced cancer Dy SM et al. JPSM. 2015;49:773-781 UCSF Palliative Care Program UCSF Palliative Care Program

Treatment of Constipation Treatment of Constipation • Evidence that docusate not helpful • Methylnaltrexone – RCT of senna vs senna and docusate – For stimulant resistant, opioid induced – Senna alone superior constipation • Docusate tastes horrible – Weight-based dosing, subcutaneous – Once daily, every other day – Ruins applesauce • Works quickly when it works • Start with senna • Works half the time – Add polyethylene glycol, lactulose, or sorbitol Hawley and Byeon. J Palliat Med. 2008;11:575-581 Thomas J et al . NEJM 2008;358(22):2332-2343 https://www.youtube.com/watch?v=9_4MzPv3NJE UCSF Palliative Care Program UCSF Palliative Care Program Palliative Care Pearls Chemotherapy at End of Life What Works, What Doesn’t • Goal is to improve quality of life and • Oxygen for shortness of breath: only if extend survival hypoxemic • Considered more helpful in patients with • Atropine for rattle: no better functional status • IV Fluids for dehydration at end of life: no • Chemo in last weeks of life marker of poor • Docusate for constipation: no quality • Chemotherapy for longevity and quality • Study: association of chemotherapy in last of life in advanced cancer 6 months of life with QoL and survival Prigerson HG et al . Jama Oncol 2015; doi:10.1001/jamaoncol.2015.2378 UCSF Palliative Care Program UCSF Palliative Care Program

Palliative Care Pearls Chemotherapy at End of Life What Works, What Doesn’t • Half of patients received chemo in last six • Oxygen for shortness of breath: only if months of life hypoxemic • Patients with good functional status more • Atropine for rattle: no likely to receive chemo • No difference in survival chemo vs none • IV Fluids for dehydration at end of life: no • Chemo associated with worse QoL for • Docusate for constipation: no patients with better functional status at • Chemotherapy for longevity and quality baseline of life in advanced cancer: no • Question chemo in very sick patients Prigerson HG et al . Jama Oncol 2015; doi:10.1001/jamaoncol.2015.2378 UCSF Palliative Care Program UCSF Palliative Care Program Communication about Palliative Care Increased Family Satisfaction Issues • Patients want to talk • Discussions increase patient satisfaction Satisfaction • Absent explicit conversations, patients infer and misunderstand % time family talks Lo et al. Arch Int Med 1986;146:1613-15 Tierney et al. JGIM 2001;16:32-40 McDonagh et al. Crit Care Med 2004;32:1484-88 UCSF Palliative Care Program UCSF Palliative Care Program

Palliative Care Pearls The Golden Questions • Oxygen for SOB only if patient is hypoxemic • “ When you think about the future, what do – Opioids work you hope for? ” • No pharmacologic treatments for rattle are effective- turn the patient • Little benefit to IVF at end of life • “ When you think about what lies ahead, • Stop using colace for constipation what worries you the most? ” • Chemotherapy in last months of life provides little benefit • Communicate with patients about palliative care issues UCSF Palliative Care Program UCSF Palliative Care Program Publication date: life Valentine’s Day 2017 aft er Pre-order at amazon.com t h e diagn osis www.lifeafterthediagnosis.com E xper t Advice on L iving W ell w it h Ser ious I lln ess for Pat ient s an d C ar egivers St even Pan t ilat , M D UCSF Palliative Care Program