45 minutes of suffering (or Anesthesia Grand Rounds on Palliative Care)

on
45 Minutes of Suffering
Anesthesia Grand Rounds
Mike Aref, MD, PhD, FACP
Palliative Medicine Service, IU Health University Hospital
Assistant Professor of Clinical Medicine, Indiana University School of
Medicine

Disclosure of Financial Relationships and
Conflicts of Interest
None

Agenda
• Introduction
• Palliative Care
• Hospice
• Primary Palliative Care
• Goals of Care
• Symptom Management

“Are They Going Palliative?”
• Is a philosophy of care for seriously ill patients, it is
– NOT a place
– NOT a status
– NOT limited by curative intent

Suffering
Goal-of-Care
Palliative Care

Palliative Care
• The area of medicine that deals with
alleviating the physical, mental, spiritual and
familial suffering of patients with chronic,
progressive illness.
• Symptom management and setting goals of
care in “life-limiting” illness.
• Palliative care is concerned with three things:
the quality of life, the value of life, and the
meaning of life.
• “Sufferology”.
Doyle D, Oxford Textbook of Palliative Medicine, 3 ed.

Choosing Wisely
• Don’t delay palliative care for a patient
with serious illness who has physical,
psychological, social or spiritual distress
because they are pursuing disease-
directed treatment.
http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-hospice-palliative-medicine/

Evolving Model of Palliative Care
Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
“Active
Treatment”
Palliative
Care
D
E
A
T
H
D
E
A
T
H
http://www.nationalconsensusproject.org

Evolving Model of Palliative Care
D
E
A
T
H
Comfort-
Focused Care
Psychological and Spiritual Support
Disease-
Focused Care
http://www.nationalconsensusproject.org

And not or
 Of the 151 patients who underwent
randomization, 27 died by 12 weeks and
107 (86% of the remaining patients)
completed assessments. Patients
assigned to early palliative care had a
better quality of life than did patients
assigned to standard care (mean score
on the FACT-L scale [in which scores
range from 0 to 136, with higher scores
indicating better quality of life], 98.0 vs.
91.5; P=0.03). In addition, fewer patients
in the palliative care group than in the
standard care group had depressive
symptoms (16% vs. 38%, P=0.01).
Despite the fact that fewer patients in
the early palliative care group than in
the standard care group received
aggressive end-of-life care (33% vs.
54%, P=0.05), median survival was
longer among patients receiving early
palliative care (11.6 months vs. 8.9
months, P=0.02).

08/27/14 14
Type Goal Investigations Treatments Setting
Active
(Blue)
To improve quality of life with possible
prolongation of life by modification of
underlying disease(s). Ex: Pt. who has
potentially resectable pancreatic carcinoma.
May require immediate symptom control or
need guidance in setting future goals.
Active (eg, biopsy,
invasive imaging,
screenings)
Surgery, chemotherapy,
radiation therapy, aggressive
antibiotic use,
Active treatment of
complications (intubation,
surgery)
In-patient facilities,
including critical
care units; Active
office follow-up
Comfort
(Green)
Symptom relief without modification of
disease, usually indicated in terminally ill
patients. Ex. Pt. who has unresectable
pancreatic carcinoma, no longer a candidate
for or no longer desires chemo or radiation
therapy.
Minimal (eg, chest
radiograph to rule out
symptomatic effusion,
serum calcium level to
determine response to
bisphosphonate
therapy)
Opioids, major tranquilizers,
anxiolytics, steroids, short-
term cognitive and behavioral
therapies, spiritual support,
grief counseling, noninvasive
treatment for complications
Home or homelike
environment
Brief in-patient or
respite care
admissions for
symptom relief and
respite for family
Urgent
(Yellow)
Rapid relief of overwhelming symptoms,
mandatory if death is imminent. Shortened
life may occur, but is not the intention of
treatment (this must be clearly understood
by patient or proxy). Ex. Patient who has
advanced pancreatic carcinoma reporting
uncontrolled pain (8 on a scale of 10),
despite opioid therapy.
Only if absolutely
necessary to guide
immediate symptom
control
Pharmacotherapy for pain,
delirium, anxiety. Usually given
intravenously or
subcutaneously and in doses
much higher than most
physicians are accustomed to
using.
Deliberate sedation may need
to be used and may need to be
continued until time of death.
In-patient or home
with continuous
professional support
and supervision
Victoria Classification of Palliative Care

DO IT!
Palliative care is like intubation, if you think it
needs to be done,

Palliative Care and Hospice
Rosenberg, M et al, Clin Geriatr Med 2013; 29:1–29
Palliative Care
Symptom Management of Life Limiting Illness
End of Life Care/Hospice
Symptom Management and Comfort Care

Hospice and Palliative Care
• Hospice is for
patients who are
expected to die
within less than 6
months.
 Palliative care is for
patients who you
would not be
surprised if they die
within less than 6-12
months.

Hospice
 It's a service not a sentence (it's hospice not
house arrest).
 Hospice is a program, not a place.
 Patient's with an estimated life-span of less
than six months who are no longer
candidates for curative therapy are eligible
for services.
 Patient's requiring active symptom
management, who are too tenuous to move,
or are actively dying may be eligible for in-
patient hospice. In these patients death is

 Pain/Symptom Assessment
– Are there distressing physical or psychological symptoms?
 Social/Spiritual Assessment
– Are there significant social or spiritual concerns affecting daily life?
 Understanding of illness/prognosis and treatment options
– Does the patient/family/surrogate understand the current illness,
prognostic trajectory, and treatment options?
 Identification of patient-centered goals of care
– What are the goals for care, as identified by the
patient/family/surrogate?
– Are treatment options matched to informed patient-centered goals?
– Has the patient participated in an advance care planning process?
– Has the patient completed an advance care planning document?
 Transition of care post-discharge
– What are the key considerations for a safe and sustainable transition
from one setting to another?
Weissman, DE, Archives in Internal Medicine 1997;157:733–737
Weissman, DE et al, Journal of Palliative Medicine 2011; 14(1):1-8
Primary Palliative Care Assessment

Palliative Perception
 The patient:
– is not a candidate for curative therapy
– has a life-limiting illness and chosen not to have life prolonging
therapy
– has uncontrolled symptoms
– has uncontrolled psychosocial or spiritual issues
– has been readmitted for the same diagnosis in last 30 days
– has prolonged length of stay without evidence of progress
– has Catch-22 criteria: the indicated treatment of one potentially
fatal problem is contraindicated by another
http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/ Central Baptist Hospital Palliative Care Screening Tool

Hope for the best, plan for the worst.

What are you hoping for?
What worries you the most?
What gives you strength?

Case
• 74 y/o WM with end-stage NASH cirrhosis,
progressive hepatorenal syndrome, active on
transplant list for liver and kidney transplant.
• Patient relocated to Indianapolis for transplant, family
taking turns staying with patient, socially isolated.
• Abdominal pain related to umbilical hernia.

ACTIVE
TRANSPLANT
CANDIDATE
AND
PALLIATIVE
CARE?!?

– Patient
“Every day with liver failure is agony. I’ve
disrupted my family’s life. It will only be worth it if
I get a transplant.”

Course
• Initial consultation to provide support, discuss resources, and connected
patient with transplant social worker.
• Adjusted tramadol for liver failure, recommended low-dose alternative
opiates.
• Recommended surgical evaluation for hernia, which was repaired due to
incarceration.
• Followed patient intermittently as he was admitted for complications with liver
and kidney failure. Explored history, spiritual coping, meaning of disease, and
dealing with suffering of chronic, progressive organ failure.
• Ultimately started to decline, prepared for referral to hospice when organs
became available, currently s/p transplantation of liver and kidneys and
undergoing rehabilitation.

Case
• 21 y/o WF with cystic fibrosis, chronic respiratory failure,
cystic fibrosis induced pancreatic exocrine and endocrine
failure.
• Consulted for symptom management of cystic fibrosis
pain, depression, and anxiety.
• Minimal psychosocial support, history of “non-
compliance”.
• Multiple goals-of-care conversations over the past 17
month period.

THAT’S TOO YOUNG FOR
PALLIATIVE CARE!?!

Admission and increased mortality
Cohort Number %
Died in ED 205 / 76,060 0.27
Died within 30 days of discharge
from ED
111 / 59,366 0.19
Died within 30 days of being
admitted from ED
876 / 16,489 4.6
Emerg Med J. Aug 2006; 23(8): 601–603

Death does not respect age
http://www.medicine.ox.ac.uk/bandolier/booth/Risk/dyingage.html

Median Death Age in Cystic Fibrosis
BMJ 2011;343:d4662

For select candidates, lung transplantation
improves survival and quality of life.
The five-year survival post-transplant is about
50%
www.eperc.mcw.edu/EPERC/FastFactsIndex/265-Palliative-Care-for-Patien

SUFFERING DOESN’T RESPECT AGE EITHER*

Symptoms
• Cough
• Dyspnea
• Fatigue
• Pain
www.eperc.mcw.edu/EPERC/FastFactsIndex/265-Palliative-Care-for-Patien
worsen as lung
disease
progresses
}

Pain
Pediatrics 1996; 98(4):741 -747

DECREASE SUPPORT INCREASE MORTALITY

Socioeconomics and Mortality
BMJ 2011;343:d4662

– Patient
“I get scared when there are more than two or
three people in the room, so I just say ‘yes’ to
their questions so they leave.”

Course
• Pulmonary service sought to limit opiate usage due to concerns of
abuse and transplant eligibility, pain control was improved by starting
and titrating pregabalin and venlafaxine.
• Worked on strategies for coping with managing her disease, such as
teaching her to use a day planner, having health department inspect
home for mold, healthcare representative declaration, and POST
form.
• Often we conveyed concerns to the pulmonary team because her
anxiety was exacerbated by the number of team members on
pulmonary service and changing faces of the team.
• She has since died of complications of cystic fibrosis.

Do-Not-Resuscitate not Do-Not-Treat!
• “DNR orders only preclude resuscitative
efforts in the event of cardiopulmonary
arrest and should not influence other
therapeutic interventions that may be
appropriate for the patient.”
JAMA. 1991;265(14):1868-1871.

“Out-of-hospital” DNR
IC 16-36-5-1
"Cardiopulmonary resuscitation" or "CPR"
Sec. 1. As used in this chapter, "cardiopulmonary resuscitation" or "CPR" means
cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation,
including:
(1) cardiac compression;
(2) endotracheal intubation and other advanced airway management;
(3) artificial ventilation;
(4) defibrillation;
(5) administration of cardiac resuscitation medications; and
(6) related procedures.
The term does not include the Heimlich maneuver or a similar procedure used to expel
an obstruction from the throat.
As added by P.L.148-1999, SEC.12.
My attending physician has certified that I am a qualified person, meaning that I have a
terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure,
resuscitation would be unsuccessful or within a short period I would experience repeated
cardiac or pulmonary failure resulting in death.
I direct that, if I experience cardiac or pulmonary failure in a location other than an
acute care hospital or a health facility, cardiopulmonary resuscitation procedures be
withheld or withdrawn and that I be permitted to die naturally. My medical care may
include any medical procedure necessary to provide me with comfort care or to alleviatewww.in.gov/legislative/ic/2010/title16/ar36/ch5.html

What’s a DNR?
DNR
• A: DNR
• B: Limited or Full
• “If you find 'em dead,
leave 'em dead.”
DNR with comfort
measures
• A: DNR
• B: Comfort Measures
• “When they're dying,
dignity, peace, and
comfort we’re trying”

ARTIFICIAL NUTRITION AND HYDRATION

Benefits of Artificial Nutrition and Hydration
• Physiological support for temporary inability
to swallow or to use their gastrointestinal tract
due to otherwise reversible conditions.
• Artifical nutrition and hydration (ANH) may
prolong life and allow a more accurate
assessment of the patient's chance of
recovery.
• For patients with chronic disabilities who are
unable to take in adequate nutrition by mouth
and who enjoy the life they lead, ANH is
physiologically and qualitatively useful.
Nutr Clin Pract. 2006 ;21:118-125

Supportive not curative
• ANH alone, while sometimes supportive,
does not cure or reverse any terminal or
irreversible disease or injury.
• Multiple studies have consistently failed to
show meaningful clinical benefit from ANH in
terminally ill patients.
• A review of 70 published, prospective,
randomized trials of nutrition support among
cancer patients failed to demonstrate the
clinical efficacy of nutrition support for such
patients. Nutr Clin Pract. 2006 ;21:118-125
Nutr Clin Pract.1994;9:91– 100

Stop or don’t start ANH
• ANH support by either the enteral or
parenteral route to terminally ill patients
suggests increased suffering without
improved outcome.
• ANH, whether provided by “feeding tube” or
vein, is often associated with significant
complications, including bleeding, infection,
physical restraints such as tying the patient
down, and in some cases a more rapid death.
• TPN does not alleviate hunger JAMA.1999 ;282:1365– 1370
J Gerontol.1998 ;53:M207– M213
Lancet.1997 ;349:496– 498
Appetite. 1989;13(2):129-41

Curative and Palliative
J Palliat Med. 2012; 15(1):106-14

Curative or Palliative?
• Morphine
– No mortality benefit.
• Oxygen
– No mortality benefit (unless hypoxic).
• Nitrates
– No mortality benefit.
• Aspirin
– OK, now we start decreasing mortality (anti-platelet effects onset
of action is 2 hours, analgesic effect is 10-15 minutes).

Total Symptoms
Pain
• Physical problems (multiple)
• Anxiety, anger and depression—
elements of psychological distress
• Interpersonal problems — social
issues, financial stress, family
tensions
• Nonacceptance or spiritual
distress
Dyspnea
• Physical symptoms
• Psychological concerns
• Social impact
• Existential suffering
Curr Opin Support Palliat Care. 2008; 2(2):110-3

Quality has quantitative benefit
 Poor pain control is associated with
delayed wound healing.
 After bypass surgery, depressive
symptoms are associated with infections,
impaired wound healing, poor emotional
and physical recovery.
 Interventions to reduce the patient's
psychological stress level may improve
wound repair and recovery following
surgery. McGuire L, Ann Behav Med, 2006;31(2): 165-72
Doering LV, Am J Crit Care, 2005;14(4): 316-24
Broadbent E, Psychosom Med, 2003; 65(5): 865-9

Start Smart
• What type of pain are we managing?
• What was their level of function and regimen prior to
this hospitalization?
• Why not PO? (IV keeps you in the hospital)
• What is your patient’s goal?
• What is the plan and is everyone in agreement?

Opiates…
• Do not cure anything (at best they are neuro-
hormonal-psychiatric scaffolding)
• Are poor choice for neuropathic pain
• Have abuse / “self-medicating” potential
• Have social stigma

Dose Units Medication Route Real World
15 mg morphine PO
15 mg hydrocodone PO
10 mg oxycodone PO
4 mg hydromorphone PO
5 mg morphine IV
0.75 mg hydromorphone IV
50 mcg fentanyl IV
Dose Equivalents

WHO Analgesic Ladder
Canadian Family Physician 2010; 56(6):514-517

Ascending the Ladder
• Morphine
– Initial loading dose of 0.1 mg/kg
– Subsequent dosages of 0.025 to 0.05 mg/kg every 5 minutes
• Hydromorphone
– Initial loading dose of 0.015 mg/kg hydromorphone
– Subsequent dosages of 0.0075-0.015 mg/kg every 5-15
minutes
• Fentanyl
– Initial loading dose of 1-1.5 µg/kg
– Subsequent dosages of 0.25-0.5 µg/kg every 15 minutes
75 kg 90 kg
Loading Dose PRN Loading Dose PRN
morphine 7.5 mg 2-4 mg 9 mg 2.5-5 mg
hydromorphone 1 mg 0.5-1 mg 1.5 mg 0.75-1.5 mg
fentanyl 75-100 µg 20-50 µg 100-150 µg 25-75 µg
http://www.medscape.com/viewarticle/720539

Patient Controlled Analgesia
• If analgesia is reached with 3 bolus doses,
the patient controlled analgesia (PCA)
equivalent is approximately:
Q12min dose 4° lockout
morphine 0.8-1 mg 16-20 mg
hydromorphone 0.15-0.25 mg 3-5 mg
fentanyl 20-30 µg 400-600 µg

Descending the Ladder
• PCA can probably be weaned if one
vial is enough for > 24 hours.
• Wean IV doses by 10-33% per day.
• Wean PO dose by 25-50% per day
until 1-2 tablets Q4H of “low” dose
medication then wean dosing
interval:
✓ Q6H-Q8H-Q12H-QHS
✓ 16 “doses”
http://paincommunity.org/blog/wp-content/uploads/Safely_Tapering_Opioids.pdf

Day Frequency morphine (mg)
hydromorphone
(mg)
fentanyl (mcg)
1 Q2H 30 4 300
2 Q2H 20 3 200
3 Q2H 15 2 150
4 Q2H 10 1.5 100
5 Q2H 7.5 1 75
6 Q4H 30 8
oxycodone (mg)
20
7 Q4H 15 4 10
25% 50%
Example Opiate Wean

National Cancer Institute: Last Days of
Life (PDQ®)
• “Many patients fear uncontrolled pain during the final
hours of life, while others (including family members
and some health care professionals) express concern
that opioid use may hasten death. Experience
suggests that most patients can obtain pain relief
during the final hours of life and that very high doses of
opioids are rarely indicated. Several studies refute the
fear of hastened death associated with opioid use. In
several surveys of high-dose opioid use in hospice and
palliative care settings, no relationship between opioid
dose and survival was found.”
• The goal is to provide symptom management,
specifically of pain and dyspnea, not to cause death.
http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/page2

Continuous Opioid Infusions
• Fentanyl start at 50 mcg/hr and titrate by 25
mcg/hr every 15 minutes
• Hydromorphone start at 1 mg/hr and titrate
by 0.5 mg/hr every 15 minutes
• Morphine start at 5 mg/hr and titrate by 2.5
mg/hr every 15 minutes

Opiate-Induced Bowel Dysfunction
Prophylaxis
• Non-pharmacological
– Oral hydration
– Physical activity
– Privacy/scheduled visit to commode
• Pharmacological
– Scheduled senna (stimulant laxative), hold for diarrhea
– Scheduled bisacodyl (stimulant laxative), hold if bowel
movement in the past 24°
– Scheduled MOM (or lactulose if kidney disease) or
polyethylene glycol (osmotic stool softener), hold if bowel
movement in the past 48°
– Do NOT use bulk producers (i.e. fiber)
– Consider adding mineral oil (lubricating stool softener)
http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf

Case
• 23 y/o WF with chronic abdominal pain, nausea, and
food aversion secondary to multiple surgeries for
hereditary pancreatitis and complications thereof.
• Non-malignant abdominal pain managed with
progressive increases in opiates, now on high-dose
opiates, 200 mcg/hr fentanyl patch with 4-8 mg of
hydromorphone as needed every 2-3 hours
• Mother strong advocate for patient.
• Consulted for pain management.

CDC Grand Rounds, January 13, 2012 / 61(01);10-13

Course
• Basal opiates increased and discharged home
• Patient seen on subsequent hospitalizations for other
complications, e.g. line infection, portal vein
thrombosis. Abdominal pain continues to worsen.
• Having built a relationship with patient, discussed
concerns that opiates were worsening her pain.
Agreeable to weaning off opiates.

Narcotic Bowel Syndrome
Chronic or frequently recurring abdominal pain that is treated with acute
high dose or chronic narcotics and all of the following:
• The pain worsens or incompletely resolves with continued or
escalating dosages of narcotics.
• There is marked worsening of pain when the narcotic dose wanes
and improvement when narcotics are reinstituted (“Soar and
Crash”).
• There is a progression of the frequency, duration and intensity of
pain episodes.
• The nature and intensity of the pain is not explained by a current or
previous gastrointestinal diagnosis*
*A patient may have a structural diagnosis (e.g., inflammatory bowel
disease, “chronic pancreatitis”) but the character or activity of the
disease process is not sufficient to explain the pain.
Clin Gastroenterol Hepatol. Oct 2007; 5(10): 1126–1122.

Case
• 72 y/o WM with metastatic pancreatic cancer, admitted
for pain control.
• Patient has been on rapidly escalating doses of
morphine. Delirious, in his lucid moments he weeps,
morphine has been aggressively increased. In the past
24 hours he developed intermittent jerking of his limbs.
• Consulted for pain management.

Opiate-Induced Hyperalgesia
• Increasing sensitivity to pain stimuli (hyperalgesia).
Pain elicited from ordinarily non-painful stimuli, such as
stroking skin with cotton (allodynia).
• Worsening pain despite increasing doses of opioids.
• Pain that becomes more diffuse, extending beyond the
distribution of pre-existing pain.
• Presence of other opioid hyperexcitability effects:
myoclonus, delirium or seizures.
• Can occur at any dose of opioid, but more commonly
with high parenteral doses of morphine or
hydromorphone and/or in the setting of renal failure.
www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_142.htm

Course
• Patient was switched to fentanyl, but at 75%
equianalgesic dose.
• Pain controlled, delirium improved, myoclonic jerks
resolved.
• Patient died on in-patient hospice.

THANK YOU
Questions? Concerns? Comments?

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