Palliative Care

1. Palliative Care Practice Improvement Series Meeting September 25, 2008 David F. Giansiracusa, M.D. Director, Center for Pain and Palliative Care Maine Medical Center

2. Definition: Palliative Care • Patient- and family-centered care that • Optimizes the quality of life by anticipating, preventing, and treating suffering • Is provided throughout the continuum of illness • Involves: -addressing physical, intellectual, emotional, social, and spiritual needs -facilitating patient autonomy -providing access to information and choice. National Quality Forum

3. Goal of Palliative Care To prevent and relieve suffering and support the best possible quality of life for patients and their families facing life threatening illness regardless of the stage of disease or the need for other therapies. Clinical Practice Guidelines for Quality Palliative Care, National Consensus Project, 2004

4. Palliative Care Programs • Provide assessment and treatment of pain and other symptoms • Help with patient-centered and family-centered communication and decision making • Coordinate care across settings and through serious illness

5. Hospice Care:A Service Delivery System • Palliative care for patients with limited life expectancy and require comprehensive biomedical, psychosocial, and spiritual support as they enter the terminal stage of illness or condition. • Supports family members coping with the complex consequences of illness, disability, and aging as death nears. • Addresses the bereavement needs of family following the death of the patient. National Quality Forum

6. Palliative Care for Quality of Life Bereavement Disease Modifying Therapy Hospice PalliativeCare Acute Chronic Advanced Death Last Hours Diagnosis LTI Life Closure

7. Palliative Care Is Provided by Interdisciplinary Teams • Medicine • Nursing • Social Work • Chaplaincy • Counseling • Nursing assistants and other health care professionals.

8. Pain Present Future Dyspnea Delirium Nausea/ vomiting Anxiety Depression Uncertainty Fear of disability Fear of death Hopelessness Remorse Loneliness Loss of Meaning Control Dignity Relationships Causes of Suffering in Life Threatening Illness

9. Palliative Care Symptom Management: Pain • Carefully Assess: -Patient’s self-report is gold-standard -If patient cannot communication, must rely on family/caregiver report, observation, assumption (previous tx) • Provide Comfort • Improve Quality of Life • Maximize Function

10. Pain Management • Discern cause of pain: underlying disease, complication of therapy, other process such as bladder or bowel distension, neuropathy, rheumatic disorder, PUD • Determine type of pain: nociceptive (somatic, visceral), neuropathic

11. Neuropathic Pain Herpes Zoster Diabetes Stroke Nociceptive Pain Early cancer pain Arthritis Myofascial pain Infection Ischemia Trauma Mixed Pain Syndromes Most common Late cancer pain Lumbar radiculopathy Osteoporosis Types of Persistent Pain

12. Approach to Pain Management • Address treatable causes • Utilize non-pharmacological modalities • Optimize analgesic medications and address side effects • Consider invasive procedures

13. 0 1 2 3 4 5 6 7 8 9 10 Pain Assessment Tools: Intensity Simple Descriptive Pain Intensity Scale 0-10 Numeric Pain Intensity Scale Very Severe None Mild Moderate Severe Worst Possible 0-10 Numeric Pain Intensity Scale None Moderate Worst Possible Visual Analog Scale (VAS) None Pain as bad as itcould possibly be Faces scale reprinted with permission from Patt RB. Cancer Pain. Philadelphia: JB Lippincott Co.; 1993. Jacox A, et al. Management of Cancer Pain: Clinical Guideline No. 9. March 1994. AHCPR Publication No. 94-0592.

14. Pain Management • Often requires multimodality-approach of drug therapy and non-drug strategies • Requires frequent monitoring for response and side effects and for adjustment of therapy

15. Pain Management in the Elderly: Non-pharmacologic Interventions • Cold/warmth • Massage • Exercise/PT • Positioning • TENS • Acupuncture • Cognitive-behavioral therapies: relaxation, guided imagery, music/art therapy, hypnosis, meditation, biofeedback • Socialization, time with pets

16. WHO Analgesic Ladder Pain Relief Opioid for moderate to severe pain + non-opioid +/- Adjuvant Pain Persists or increases Opioid for mild to moderate pain + non opioid +/- Adjuvant Pain Persists or increases Non opioid (NSAID) +/- Adjuvant Pain

17. Morphine is a naturally occurring analgesic“among the remedies that almighty god has given man to relieve his pain and suffering none as efficacious as opium” Sydenham 1690

18. Short Acting: Morphine Oxycodone Hydromorphone Oxymorphone Buccal Fentanyl Sustained Release Morphine: (MS Contin Kadian, Avinza) Oxycodone (Oxycodone CR, Oxycontin) Transderm Fentanyl Long Acting: Methadone Commonly Used Opioid Formulations:

19. Rules of Ones One background and one short acting opioid at a time.

20. Equi-Analgesic Doses of Opioids PO IV Codeine 300 mg Morphine 30 mg 10 mg Hydromorphone 7.5 mg 1.5 mg Fentanyl --------- 100 mcg Oxycodone 20 mg --------- Methadone Chart Fentanyl 25 mcg/hr patch=50 mg oral MS/24hr

21. Methadone Conversion

22. Opioid Dose Titration • Start with PRN short acting opioid • Add long-acting opioid in dose equal to 75-100% of 24 hour dose of PRN opioid consumed • Continue PRN opioid in dose of 10-15% (5% in frail elderly) of 24 hour dose of long-acting opioid every 1-2 hours

23. Opioid Side Effect Management: • Constipation • Nausea • Dry mouth • Sedation • Respiratory depression • Delirium

24. Preventing and Treating Opioid Side Effects • Start bowel regimen-stool softener and laxative on all patients when starting opioids • Anticipate sedation/cognitive changes: fall precautions, assistance with mobility • Consider 5 day course of anti-emetic: -dopamine antagonist: haloperidol, prochlorperazine, metoclopramide -5 HT-3 antagonist: ondansetron

25. Opioid Side Effects: Sedation • Eliminate other etiologies • polypharmacy • CNS pathology • metabolic dysfunction • Consider psycho-stimulants if appropriate • Methylphenidate (Ritalin) • Dextroamphetamine (Dexedrine) • Increased drowsiness and weakness are common in the final days before death

26. Rationale for Changing Opioids: • Intolerance: -sedation -persistent nausea/vomiting -pruritus -urinary retention • Difficulty with compliance/adherence • Renal function impairment: morphine metabolites

27. Incomplete Cross Tolerance • A patient tolerant to the effect and side effects of one opioid may not be equally tolerant to the effects and side effects of another opioid • When switching opioids, after calculating the equivalent conversion, reduce the new opioid by 25-50%

28. Neuropathic Pain • Due to injury to peripheral nerves, spinal cord, central nervous system • Common illnesses: cancer, AIDS, diabetes mellitus, alcoholism, herpes zoster, amputation, stroke, chemotherapy, radiation tx, surgery • Characterized by burning, lancinating, tingling, shooting, electrical or pins-and-needles associated with numbness

29. Adjuvant Medications • Helpful for neuropathic pain syndromes: diabetic neuropathy, postherpetic neuralgia, trigeminal neuralgia • Lidoderm (5% Lidocaine patch, up to three for 12-24 hours a day); lidocaine infusions • Gabapentin or other anti-convulsants • Opioid analgesics • Tramadol • Tricyclic antidepressants (desipramine or nortriptyline) or noradrenergic/specific seritonergic uptake inhibitors (Dworkin RH, Backonja M, Rowbotham MC et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003; 60:1524-1534.)

30. Antidepressant Analgesics for Neuropathic Pain: • For burning, tingling pain: • Tricylic antidepressants: -Analgesic in days to weeks, anticholinergic-delirium and urinary retention, cardiac toxicity -desipramine or nortriptyline 10-25 mg qhs,- minimal anticholinergic or sedating effects • Serotonin-noradrenaline uptake inhibitors: duloxetine (Cymbalta), venlafaxine (Effexor) (Onghena P el al. Pain, 1992;49:205-219; Bradley RH et al. (Venlafaxine) Am J Ther.2003;10:318-323; Raskin J et al.(Duloxetine) J Palliat Med 2006:9:29-40.)

31. Anticonvulsant Adjuvants for Neuropathic Pain Gabapentin (Neurontin) -100 mg po qd to TID -increase dose every 1-3 days -usual effective dose 900-1800 mg/d, maximum may be >3600mg/d -tolerance to drowsiness develops in days -adjust for renal failure (CrCl 30-59: 400-1400mg/d; CrCl 15-29: 100-300 mg/d; CrCl <15: proportionate decrease Pregabalin (Lyrica) -50 mg po BID to 300 mg BID

32. Topical Analgesics • Lidocaine 5% patches (12-24 hour/day safety (PHN, PDN, low back pain) • Capsaicin (0.025% and 0.0.75%) • Antipressants (Zonalon-doxipen HCl)-PHN, PDN, mucositis, pain of intermittent urinary bladder catheterization. • Topical opioids-pressure ulcers (10 mg morphine, mucositis-2% morphine) • (Argoff C. Topical Local Anesthetics; McCleane G. Topical Opioids; McCleane G. Nitrates, Capsaicin, and Tricyclic Antidepressants; in Clinical Management of the Elderly Patient in Pain. Haworth Press, NY, 2006)

33. Treatment of Bone Pain • Non-steroidal anti-inflammatory drugs • Steroids • Opioids • Bisphosphonates • Radiation • Neuropathic treatment

34. Palliative Care Symptom Management: Dyspnea • Etiologies: -Pulmonary: tracheal, bronchial obstruction; edema; pneumonia; lymphangitic spread; pleural effusion; pulmonary embolus; interstitial disease; pneumothorax; neuromuscular disease - Cardiac: ischemia; heart failure; superior vena cava syndrome; pericardial disease -Anemia: -Acidosis:

35. Management of Dyspnea • Treating reversible causes: diuretics, bronchodilators, thoracentesis, radiation therapy, blood transfusion • Comfort measures: blowing air over face, oxygen for hypoxemia, opioids in low doses (ie. Morphine elixir 2.5-5 mg po q4 hrs titrated to relief discomfort of shortness of breath, tx of anxiety with benzodiazepine (lorazepam 0.5 mg po q4-6hr)

36. Nausea and Vomiting: Mechanisms/Pathways • Chemoreceptor Trigger Zone: drugs- opioids, digoxin, antibiotics, NSAIDS; Chemotherapy; metabolic-hypercalcemia, uremia, hyponatremia • Higher Cortical Structures -elevated ICP-tumor, bleed, infection; conditioned, anxiety • Vestibular Apparatus -movement • Vagal Afferent Nerve -mucosal irritation, constipation, gastroparesis, gastric outlet or SBO, distension or infiltration of a viscus

37. Treatment of Nausea and Vomiting: VOMIT (1) eperc • V-vestibular: -receptors: cholinergic, histaminic -meds: Scopolamine patch, promethazine • O-obstruction by constipation: -receptors: chol, histaminic, ?5HT3 -meds: senna; octreotide-cramps, secretions

38. Treatment of Nausea and Vomiting: VOMIT (2) • dysMotility of upper gut: gastroparesis -meds: metoclopramide • Infection, Inflammation: -receptors: cholinergic, histaminic, ?5HT3 -meds: promethazine (Phenergan), cyto-protective (PPI, H2 blockers) • Toxins stimulating the chemoreceptor trigger zone: -receptors: dopamine 2, 5HT3 -meds: prochlorperazine, haloperidol, olanzapine, ondansetron

39. Palliative Care: Communications • Understand who the person is (ABCDE)-attitudes, beliefs, context, decision making, environment • Assessment of physical and psychosocial symptoms • Determine what patient and family know about patient’s condition • Determine how much patient wishes to be told • Convey information • Advanced care planning (advanced directives, surrogate, goals and sites of care) • Closure at the end of life • Bereavement

40. Psychological and Spiritual Assessment • Evaluate what strengths and vulnerabilities patients bring to their illness experiences • Assess the meaning patients ascribe to their illness Block SD JAMA 2001:85(22):2898

41. Psychosocial Assessment (1) • Meaning of illness: “How have you made sense of why this is happening to you?” “What do you think is ahead?” • Coping style: “How have you coped with hard times in the past?” “What have been the major challenges you have confronted in your life?” (Block SD. JAMA 2001)

42. Psychosocial Assessment (2) • Social support network: “Who are the important people in your life now?” “How are the important people in your life coping with your illness?” • Stressors: “What are the biggest stressors you are dealing with now?” “Do you have concerns about pain or other kinds of physical suffering?” “About your and your family’s emotional coping?” (Block JAMA)

43. Psychosocial Assessment (3) • Spiritual resources: “What role does faith or spirituality play in your life?” • Psychiatric vulnerabilities: “Have you experienced periods of significant depression, anxiety, drug or alcohol use, or other difficulties in coping?” “What kinds of treatment have you had and which have you found helpful?” (Block JAMA 2001)

44. Psychosocial Assessment (4) • Economic circumstances: “How much concern are financial issues for you?” • Patient-physician relationship: “How do you want me, as your physician, to help you in this situation?” “How can we best work together?” (Block SD. JAMA 2001)

45. Common Psychiatric Disorders in Dying Patients • Depression • Anxiety • Delirium (Block SD. Psychological considerations, growth, and transcendence at the end of life. JAMA 2001;285(22):2898-2905)

46. Depression in Terminal Illness • Not normal, Under-diagnosed, Under-treated • Major depression in about 25%, increases with advanced disease • Impairs quality of life: impairs capacity for pleasure, meaning, connection; amplifies pain and other symptoms; causes family anguish; is a risk factor for suicide (Block JAMA 2001)

47. Indicators of Depression • Emotional symptoms (most reliable)* -Hopelessness -Helplessness -Worthlessness -Guilt -Suicidal ideations *Neuro-vegetative symptoms common in dying patients (Block JAMA 2001)

48. Treatment of Depression • Combination of supportive psychotherapy, patient and family education, and stimulants and/or antidepressants • Medication: -Methylphenidate (Ritalin) 2.5 mg q8am and noon, increase q2-3 days-max. of 30 mg/d -SSRI’s (may take 4-6 weeks for effect) ie. Sertraline (Zoloft) 25-200 mg/d (Block JAMA 2001)

49. Anxiety and Fear • Significant anxiety in about 25% patients with life-threatening illness • Contributors to anxiety: substance abuse and withdrawal, pain, corticosteroid therapy, delirium • Assessed: “What are you afraid of?” “What do you imagine dying will be like?” “Where do these worries come from?” “What is hardest for you?”

50. Treatment of Anxiety and Fear • Ongoing exploration and support • For persistent, high levels: -low dose benzodiazepines (clonazepam 0.5 mg BID) -behavioral modalities-relaxation training, meditation -SSRI’s -Neuroleptics