Vol. 43 No. 2 February 2012 337Schedule With Abstracts

Research objectives. To determine the benefit ofadministering oxygen to patients who are neardeath.

Method. A double-blinded, repeated measuresobservation with the patient as his/her owncontrol is underway. The Respiratory DistressObservation Scale (RDOS) measured presenceand intensity of distress at baseline and at everygas or flow change. Medical air, oxygen, and noflow were randomly alternated every 10 min-utes with patients who were near death (Pallia-tive Performance Scale (PPS)d30%), at riskfor respiratory distress, and with no distress attesting. Each patient had two encounters undereach condition yielding six encounters perpatient.

Result. Twenty-six of 40 targeted patients havebeen tested. Patients were 62% female, 42%white and 58% African-American, and age 60-97 years. Patients had heart failure (26%),chronic obstructive pulmonary disease (38%),pneumonia (38%), or lung cancer (8%). The av-erage PPS was 18.8 � 0.9%. An internal consis-tency coefficient (a ¼ 0.85) for RDOS wasachieved. Repeated measures analysis of vari-ance revealed no differences in respiratory com-fort under changing gas and flow conditions.Oxygen saturation (SpO2) changed significantlyacross gas conditions (p ¼ .046). Significancewas found in the relationship of SpO2 to PPS(p ¼ .04).

Conclusion. Declining oxygen saturation is ex-pected, naturally occurring, and does not signifyrespiratory distress. The n-of-1 trial of oxygen inclinical practice is appropriate in the face of re-spiratory distress.

Implications for research, policy, or practice.The routine application of oxygen to patientswho are near death is not supported.

High Flow Nasal Oxygen Use in PalliativeCare (311-B)Allan Ramsay, MD, Fletcher Allen Health Care,Burlington, VT. Ursula McVeigh, MD, Universityof Vermont, Burlington, VT.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Recognize how high-flow nasal oxygen deliv-

ery devices can be used in respiratory failure.

This will include a discussion of how to de-velop a policy for institutional use of high-flow nasal oxygen in the non-critical caresetting.

2. Recognize how to withdraw high-flow nasaloxygen in the palliative care patient. Out-comes of a case series and medical manage-ment of non-invasive ventilator support willbe discussed.

Background. Non-invasive positive pressure ven-tilation (NPPV, BiPAP) is often used as a bridgetherapy in palliative care patients who developrespiratory failure and want to avoid intuba-tion. NPPV decreases the work of breathingin alert patients and reduces respiratory muscleeffort during inspiration. High-flow nasal oxy-gen has been used in newborn respiratory dis-tress for several years and is now also beingused in the adult population as a secondmethod of non-invasive ventilation support.HFNO is much better tolerated than BiPAPfor most patients. We will present a series of pa-tients who were started on HFNO and palliativecare was consulted to assist in withdrawal of thisventilation support.

Case Description. We will present seven patientswho received HFNO and were weaned off thisventilation support by the Palliative Care Ser-vice. Diagnostic categories for these patients in-cluded congestive heart failure, interstitialpulmonary fibrosis, pulmonary hemorrhage,small cell lung cancer, and lymphangitic pulmo-nary metastatic disease. Opiate and sedation reg-imens required to withdraw these patients fromHFNO support will be reviewed. Only two pa-tients survived their HFNO therapy, both hadpartially reversible conditions that lead to respi-ratory failure. The high mortality rate of patientsrequiring HFNO lead to the development of aninstitution policy for transitioning to comfort-di-rected care.

Conclusion. High-flow nasal oxygen is a newtechnology for adult patients with non-hyper-capnic respiratory failure. Patients who haveadequate ventilation and respiratory effort tol-erate this therapy better than BiPAP. Thoughnon-invasive, the use of HFNO makes a patientventilator dependent. When HFNO is with-drawn it is similar to withdrawal of invasive ven-tilation support, however the patient on HFNOis more likely to be fully aware and awake.The palliative care team must be prepared to

338 Vol. 43 No. 2 February 2012Schedule With Abstracts

control dyspnea and anxiety to avoid end-of-lifesuffering.

Effective Treatment of Post-HerpeticNeuropathy With Scrambler Therapy,Patient-Specific Neurocutaneous ElectricalStimulation (311-C)Thomas Smith, MD, Johns Hopkins Health Sys-tem, Baltimore, MD. Giuseppe Marineo Univer-sity of Rome Tor Vergata, Rome Italy. PatrickCoyne, MSN APRN FAAN, Virginia Common-wealth University, Richmond, VA. PatriciaDodson, MA BSN RN CCRC, Virginia Common-wealth University, Richmond, VA.(All authors listed above for this session have dis-closed no relevant financial relationships withthe following exception: Marineo received a roy-alty from CTTC for his role in intellectual prop-erty (patent).)

Objectives1. Recognize the incidence and severity of post-

herpetic neuralgia.2. Recognize the effectiveness of patient-spe-

cific neurocutaneous electrical stimulationwith Scrambler Therapy.

Background. Post-herpetic neuropathy (PHN)or post-shingles pain affects at least 7%-19% ofshingles patients with increasing frequency byage. To date, no therapy has been uniformly ef-fective in either preventing or treating PHN.Therapies such as gabapentin, tricyclic antide-pressants, or pregabalin plus transcutaneouselectrical nerve stimulation (TENS) reducepain in about one-third of patients but haveside effects and require ongoing treatment.Scrambler therapy has been effective for refrac-tory chemotherapy induced peripheral neuropa-thy and refractory neuropathic pain.

Research objectives. To determine the effective-ness of Scrambler Therapy on PHN.

Method. Each person was treated for 30-45 min-utes as an outpatient for 10 working days. Thepatients in Italy were treated with ScramblerTherapy on the randomized trial, and patientsin Virginia were treated on an open access trial,MCC 13098. All patients gave informed writtenconsent and all studies were approved by the rel-evant ethics board.

Result. We treated 10 patients with long stand-ing established PHN and observed a dramaticreduction in pain. The patient mean age was

54 � SD 13 years, 6 men and 4 women, witha mean duration of PHN for 15.6 months(range, 2.5-48 months) without satisfactory reliefdespite conventional drugs.

Conclusion. Average pain score rapidly dimin-ished from 7.64 � 1.46 at baseline to 0.42 �0.89 at one month, a 95% reduction, with con-tinued relief at 2 and 3 months. Patientsachieved maximum pain relief with less than5 treatments. Most patients were able to stopor reduce their pain medicines completely.Five of 10 patients had complete disappearanceof pain which has continued. As in other trialsof Scrambler Therapy, no side effects wereobserved.

Implications for research, policy, or practice.Scrambler therapy appears to be quickly anddramatically effective for refractory PHN.

Palliative Care in Nursing Home Settings:An Educational Intervention For NursePractitioners (312-A)MariJo Letizia, PhD, Loyola University Chicago,Maywood, IL.(Letizia has disclosed no relevant financialrelationships.)

Objectives1. Describe the planning and implementation

of an innovative online palliative care educa-tional program involving an academic/indus-try partnership.

2. Identify results of the educational program,including improvement in knowledge and re-ported confidence in delivering palliativecare.

3. Discuss lessons learned, including onlinetechnological and operational challengesand successes.

Background. The nursing home is a major set-ting for death and dying in the U.S., yet palli-ative care approaches are underused in thesefacilities. Nurse Practitioners working in nurs-ing homes are well-suited to provide this carebut most have not been formally educatedabout this specialty practice. This session de-scribes the development, implementation,and evaluation of an online Palliative Carecourse to better prepare NPs across the coun-try to direct and deliver high-quality palliativecare to patients and families in nursing homesettings.