PALLIATIVE CARE IN THE ED

Jessica Stetz, MD, MS

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

WHO DEFINITIONOF PALLIATIVE CARE (1 of 3)

Improves quality of life of patients and families facing problems associated with life-threatening illness, through prevention and relief of suffering by early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

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WHO DEFINITIONOF PALLIATIVE CARE (2 of 3)

• Provides relief from pain and other distressing symptoms

• Affirms life and regards dying as a normal process

• Intends neither to hasten nor postpone death

• Integrates psychological and spiritual aspects of care

• Offers a support system to help patients live as actively as possible until death

• Offers a support system to help family cope during patient illness and in bereavement

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WHO DEFINITIONOF PALLIATIVE CARE (3 of 3)

• Uses team approach to address needs of patients and families, including bereavement counseling

• Will enhance quality of life, and may positively influence the course of illness

• Is applicable early in course of illness, in conjunction with other therapies intended to prolong life, such as chemo or RT

• Includes investigations to understand and manage distressing clinical complications

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CHRONIC DISEASE PROCESSES/ LIFE-LIMITING ILLNESSES

• Cancer• CHF• COPD• CVA• ESRD• PVD

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• DM• AIDS• Dementia• ALS

Palliative care

Medicare Hospice Benefit

Bereavement

Disease progression

Diagnosis of serious illness Death

Life-prolonging care

Hospice CareLife-prolonging

care

Old

New

PALLIATIVE CARE PARADIGM

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ADVANTAGES OF PALLIATIVE CARE IN THE ED

• Clarify/change goals of care

• Resolve conflict

• Decompression of ED overcrowding by limiting ICU consults/admissions in patients with advanced disease, improving throughput

• Improve quality of life and quality of death

• Improve patient (and physician) satisfaction with care

• Decrease costs

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TAKE-HOME POINTS

• Treat symptoms

• Communicate

• End-of-life planning

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NEW YORK STATE DNR ORDER

• DNR order in effect only at the point of cardiac arrest

• DNR may be revoked by patient at any time• DNR does not necessarily equal DNI • DNR does NOT mean do not treat

In-hospital DNR forms are not standardizedOut-of-hospital DNR orders are standardized

• Form • Bracelet • Medical orders for life-sustaining treatment (MOLST)

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MEDICAL ORDERS FOR LIFE- SUSTAINING TREATMENT (MOLST)

• Based on POLST (physician orders), developed at Oregon Health & Science University in 1991

• POLST paradigm in effect in 37 states

• MOLST pilot program in New York State in 2006 in 2 counties

• Implemented across New York State in 2008

• Bright pink form

• Placed on patient’s refrigerator

• Honored by EMS

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ADVANCED CARE PLANNING (ACP)

• Often not addressed

• Patients may want to address ACP in ED

• Interviews of 111 consecutively admitted cancer patients 33% had completed advance directive 9% (10/111) reported having discussed end-of-life care

with oncologist Only 23% of remainder (23/101) wished to talk to

oncologist 58% wanted to discuss ACP on hospital admission

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Lamont EB, Siegler M. J Palliat Med. 2000;3:27-35.

PROBLEM LIST

• AMSMass lesionToxic metabolic Infectious

• Dehydration

• Pain

• Multiple myeloma

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SIMULATION CASE

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HEALTH CARE PROXY (1 of 2)Health Care Proxy

(1) I, ____________________________________________________________________________________

hereby appoint _________________________________________________________________________

(name, home address and telephone number)

_____________________________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate Agent

If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby

appoint ______________________________________________________________________________

(name, home address and telephone number)

_____________________________________________________________________________________

_____________________________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions): ______________________________________

___________________________________________________________________________________

(4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary): ___________________________

.

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HEALTH CARE PROXY (2 of 2)(5) Your Identification (please print) Your Name ____________________________________________________________________________ Your Signature__________________________________________________ Date _________________ Your Address___________________________________________________________________________(6) Optional: Organ and/or Tissue Donation I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)■ Any needed organs and/or tissues■ The following organs and/or tissues _____________________________________________________ ___________________________________________________________________________________■ Limitations_________________________________________________________________________If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean

that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature____________________________ Date________________________________________(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or

alternate.) I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of

his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. Date_____________________________________ Date________________________________________ Name of Witness 1 Name of Witness 2 (print)___________________________________ (print)______________________________________ Signature________________________________ Signature___________________________________ Address__________________________________ Address_____________________________________ ________________________________________ ___________________________________________

State of New YorkDepartment of Health

1430 4/08

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LIVING WILL

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A sample living will, copyright by the New York Bar Association, appears at www.nysba.org

NEW YORK STATESURROGATE LIST

• Health care agent (proxy)• Power of attorney• Spouse• Adult child• Parent• Adult sibling• Close friend (with affidavit)

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SIMULATION CASE

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PAIN MANAGEMENT

How do we manage pain

in the setting of hypotension?

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PRINCIPLE OF DUAL EFFECT

• Morphine treats pain (intended effect)

• May lower blood pressure (unintended, but anticipated consequence)

• In fact, symptom control appears to improve survival (more morphine, patients lived longer)

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Campbell M, et al. Crit Care Med. 1999;27:73-77.Campbell M. AACN Adv Crit Care. 2008;19:340-344.

OPIOID PHARMACOLOGY

• Cmax IV = 6 minSC or IM = 30 minPO = 1 hourNOT including extended release

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EQUIANALGESIC DOSING

Agonist Route Equianalgesic dose, mg

Onset, min

Peak effect, min

Duration of effect, hr

Morphine IVPO

1030

5101560

103090120

354

Hydromorphone IVPO

1.57.5

5201530

153090120

3446

Oxycodone PO 20 1530 3060 46

Codeine IMPO

120200

10303045

9012060

4634

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MORE OPIOID PHARMACOLOGY

• Morphine 3:1, oral : parenteral

• Opioids are metabolized in liver, cleared by kidney

• CrCl < 50, decrease dose

• End-stage renal disease, CrCl < 10, give 25% dose

• Geriatric patients, give half dose

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MORPHINE DOSING (1 of 2)

Opioid-naïve, acute pain• Morphine 0.1 mg/kg is standard recommendation• May be inadequate

Slide 24

Bijur P, et al. Ann Emerg Med. 2005;46:362-336.Birnbaum A, et al. Ann Emerg Med. 2007;49:445-453.

MORPHINE DOSING (2 of 2)

Opioid-tolerant (on opioids for 72 hours)• 10% of total daily dose for breakthrough pain

For ex, MS Contin 90 mg BID, MS IR 30 mg Q4• Total daily dose 360 mg PO = 120 mg IV• Breakthrough dose = 12 mg IV

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SIMULATION CASE

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HYPERCALCEMIA OF MALIGNANCY

• Most commonly associated with multiple myeloma, breast cancer, lung cancer

• Increased osteoclastic activity in bone

• Occurs in 20%30% of cancer patients

• Poor prognosis (1-year survival 10%30%)50% die within 30 days, 75% within 3 monthsPrognosis depends on treatment of underlying

malignancy

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SYMPTOMS

• Nausea/vomiting (groans)• AMS (moans)• Abdominal/flank pain (stones)• Weakness/myalgias (bones)• Constipation• Polyuria• Headache

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PRECIPITANTS

Geriatric principle of polypharmacy

• What medications is this patient taking?

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PRECIPITANTS

Geriatric principle of polypharmacy

• Thiazide diuretics Increase calcium reabsorption Decrease calciurias

• Calcium carbonate

• Lithium

• Theophylline

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HYPERCALCEMIA

• Mild < 12 mg/dL

• >14 mg/dL requires treatment

• Hypoalbuminemia Total serum Ca normal Ionized Ca elevated

• Hyperalbuminemia Severe volume depletion or MM Elevated total Ca Normal ionized Ca

• Corrected Ca = 0.8 (4 pt’s albumin) + pt’s serum Ca (mdcalc.com)

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TREATMENT OF HYPERCALCEMIA

• Hydration (RF may require HD)

• Stop agents that increase calcium or decrease calciurias (eg, hydrochlorothiazide)

• Inhibit osteoclastic activity

• Inhibit bone resorption

• Limit enteric absorption

• Treat underlying cause (when possible)

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BISPHOSPHONATES

• Bind hydroxyapatite

• Prevent osteoclastic activity

• Inhibit bone resorption

• Onset of action 14 days; last up to 1 month• Pamidronate

60 mg IV over 4 hr 90 mg IV over 24 hr

• Zoledronic acid 15 mg IV over 15 min

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CALCITONIN

• Naturally occurring hormone

• Inhibits bone resorption

• Increases calcium excretion

• Onset 12 hours, peak 1224 hours

• Salmon calcitonin more potent than human28 U/kg IM/SC q612 hr

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SIMULATION CASE

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GOALS OF CARE AND DISPOSITION

• ICU

• Floor admission

• Discharge home

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HAZARDS OFHOSPITALIZATION (1 of 2)

• Immobilization and deconditioning1 day of bed rest requires 3 days of rehab10% of muscle strength lost each week

• Decreased plasma volume

• Accelerated bone loss

• Sensory deprivationGlasses Hearing aids Dentures

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HAZARDS OFHOSPITALIZATION (2 of 2)

• Barriers and tethers

• Urinary incontinence

• Skin breakdown

• Depression

• Functional decline

• Previous level of mobility difficult to regain

• Unable to remain independent, nursing home placement

Slide 38

Creditor MC. Ann Intern Med. 1993;118:219-223.

HOSPICE CARE

• System of care for terminally ill patientsWith estimated prognosis <6 months

• Relieve suffering and improve quality of life for patients with advanced illness and their families

• Offered simultaneously with all other appropriate medical treatment

• 98% provided at home

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MEDICARE HOSPICE BENEFITAS OF 2007

• > 4700 US hospice programs

• > 1.4 million Americans utilized

• 90% hospice recipients were over age 65

• 85% hospice provided by Medicare

• Many ED patients could benefit from hospice

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BENEFITS OF HOSPICE CARE

• 24/7 access to on-call RN• Home visits• In-patient and respite visits when needed• Social worker, chaplain/religious support, home

visits• Payment for medications related to hospice• 98% provided at home• Bereavement for family for 13 months• Medicare still pays for care not related to hospice

(eg, broken arm)

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ED HOSPICE REFERRAL

• Would you be surprised if the patient died in the next 6 months?

• Florida pilot program — presented at SAEM meeting 2009

• University of Florida at Jacksonville

• Direct referral to hospice decreased ED congestion, improved patient satisfaction

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HOSPICE PATIENTSMAY LIVE LONGER

In a March 2007 study, hospice patients lived an average of 29 days longer than non-hospice patients

• Retrospective statistical analysis of 4500 patients with CHF, 5 types of cancer

Slide 43Connor SR, et al. J Pain Symptom Manage. 2007;33:238-246.

HEALTH CARE ECONOMICS

• 30% of annual Medicare costs is spent on 5% of beneficiaries who will die that year

• 1/3 of that 30% is spent in the last month of life

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END-OF-LIFE (EOL) CONVERSATIONS MAY DECREASE COSTS

• A longitudinal multi-institutional study of 603 pts with advanced cancer and their caregivers interviewed and followed up through death

• 188 (31.2%) reported EOL discussions at baseline

• Mean aggregate costs were $1876 for patients who reported EOL discussions vs. $2917 for patients who did not (P =.002)

• Higher costs equaled worse quality of death in final week as reported by caregiver (more mechanical ventilation, resuscitation, admission to and death in the ICU)

Slide 45

Zhang B, et al. Arch Intern Med. 2009;169:480-488.

IF PALLIATIVE CARE AWARENESSIN THE ED INCREASES:

• Improved symptom control

• Greater patient/physician satisfaction

• Fewer end-stage patients admitted to ICUDecreased ED congestion

• More humane clinical care and more rational financial outcomes

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TAKE-HOME POINTS

• Treat symptoms

• Communicate

• End-of-life planning

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ACKNOWLEDGEMENTS

• Brian Gillett• Cat Tubridy• Che Ward • Ed Porosnicu• John Adelaine

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BIBLIOGRAPHY• Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new Subspecialty, new

opportunities. Ann Emerg Med. 2009;54:94-102.• Chan GK. End-of-life models and emergency department care. Acad Emerg Med. 2004;11:79-86.• Lamont EB, Siegler M. Paradoxes in cancer patients’ advanced care planning. J Palliat Med.

2000;3:27-35.• Quest TE, Bone P. Caring for patients with malignancy in the emergency department: patient-

provider interactions. Emerg Med Clin North Am. 2009;27:333-339.• Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from

mechanical ventilation: a prospective study. Crit Care Med. 1999;27:73-77.• Campbell M. Treating distress at the end of life: the principle of double effect. AACN Adv Crit

Care. 2008;19;340-344.• Bijur P. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the

majority of patients. Ann Emerg Med. 2005;46:362-336.• Birnbaum A, Esses D, Bijur PE, Holden L, Gallagher EJ. Randomized double-blind placebo-

controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med. 2007;49:445-453.

• Creditor M. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-223.• Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice

patient survival among patients who die within a three-year window. J Pain Symptom Manage. 2007;33:238-246.

• Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med. 2009;169:480-488.

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