Palliative Medicine and Hospice – When Comfort is the Goal

Michelle Schultz, MDDirector of Palliative MedicineSSM St. Mary’s Health CenterMichelle_Schultz@ssmhc.com

Objectives

•Summarize the benefits of palliative care and hospice care for patients with advanced illness

•Describe basic principles of medical management of chronic pain

•Apply pain management strategies for elderly patients seeking comfort in advanced or terminal illness

What is Palliative Care?

Medical care for people with serious illnesses Focused on providing relief from pain, symptoms

and stress Improving QOL for patient and family Provided by a team of doctors, nurses and other

specialists who work with a patient’s other doctors to provide extra layer of support

Appropriate at any age or stage of a serious illness Can be provided together with curative treatment

Conceptual Shift for Palliative Care

Palliative Care Improves Care in 3 Domains

1. Relieves physical and emotional suffering

2. Improves patient-professional communication and decision-making

3. Coordinates continuity of care across settings

The Palliative Medicine Team

•Physicians•Nurses•Social Workers•Chaplains

Working together to improve quality of life and decrease family stress

What Does the Palliative Medicine Team Do?

•Helps to relieve pain and other symptoms• Provides support throughout all phases of

chronic illness • Facilitates discussions about goals of care•Helps make decisions with respect to

healthcare wishes • Enhances communication with the healthcare

team•Discusses options for care in the hospital and

beyond• Provides community resources

Goals of Care

• Cure of disease• Prolongation of life• Maintenance or improvement in Quality of life• Relief of suffering• Maintaining control• Staying at home• Minimizing burden on family• A good death

Identifying Goals to Hope For

•False hope may deflect from other important issues▫Unfinished business▫Foregoing aggressive unpleasant measures▫Accepting hospice care

•Redirect from unrealistic to realistic goals

Honest Communication about Prognosis and Treatment Options

Palliative Care Reduces Hospital Costs

How? –Talking with patients and families and

treating physicians about what is happening and their realistic options leads to more conservative choices.

–Allows provision of higher quality care in appropriate, often less costly, settings.

Demand for Palliative Care

•What Patients and Families want…▫Pain and symptom control▫Avoid inappropriate prolongation of the

dying process▫Achieve a sense of control▫Relieve burdens on family▫Strengthen relationships with loved ones

▫ Singer et al, JAMA 1999;281:163-168▫ Steinhauser et al, Ann Int Med 2000;132:825-32

…And What They Get

• Half of patients had moderate-severe pain >50% of last 3 days of life

• 38% of those who died spent >10 days in ICU, in coma or on a ventilator (Unable to say goodbye)

National Data on the Experience of Advanced Illness in 5 Teaching Hospitals (9000 pts/median survival 6 mo.)

Is Palliative Care the Same Thing as Hospice?

How Does Palliative Care Differ from Hospice?

• Hospice care provides palliative care for those in the last weeks to months of life under a Federal Medicare Benefit. Complex treatments like chemotherapy, dialysis and hospitalizations are usually excluded.

•Non-hospice palliative care is appropriate at any point in a serious illness. It can be provided at the same time as life-prolonging treatment and is not dependent on prognosis.

Palliative Care vs. HospicePalliative Care Hospice

Relief of suffering Treat pain & other sx Team approach Family support Inpatient Mostly Sometimes

Outpatient Sometimes Mostly

Regulated by CMS Prognosis <6mo. mandatory

2 MDs certify terminal

Pain among hospitalized patients with serious illness

% of 5176 pts reporting moderate to severe pain between days 8-12 of hospitalization

▫ Colon cancer 60%▫ Liver failure 60%▫ Lung cancer 57%▫ MOSF + cancer 52%▫ MOSF + sepsis 52%▫ COPD 44%▫ CHF 43%

▫ Desbiens JAGS 2000;48:S183-186

WHO 3-step Ladder

1 mild1 mild

2 moderate2 moderate

3 severe3 severe

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

Tramadol

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

Tramadol

± AdjuvantsASA

Acetaminophen

NSAIDs

± Adjuvants

ASA

Acetaminophen

NSAIDs

± Adjuvants

Opioid Pharmacology

•Duration of effect of “immediate-release” formulations (except methadone)▫3–5 hours po ▫shorter with parenteral bolus

•Steady state after 4–5 half-lives▫(24 hours)

THERAPEUTIC RANGE

PRN Dosing

TIME

Conc.

Overmedicated

PAIN

Routine dosingImmediate-release preparations

•Codeine, hydrocodone, morphine, hydromorphone, oxycodone, tramadol▫dose q 4 h for oral agents, q 3 h for IV▫Adjust dose daily

• mild / moderate pain 25%–50%• severe pain 50%–100%

• Adjust more quickly for severe uncontrolled pain

Extended-release preparations

• Improve compliance•Better pain relief▫Sleep through the night

•MS Contin, Oxycontin – dose every 12 hours▫Adjust dose q 2–3 days (once steady state

reached)•Fentanyl Patch - dose every 72 hours▫Steady state in ~24 hrs▫Advantages: Compliance, swallowing

problems•Methadone – dose BID▫See below

The Sea of Pain

Breakthrough dosing

•Use immediate-release opioids▫10% - 15% of 24-hr dose prn▫May dose q 1-2 hours in extreme

cases•Do NOT use extended-release opioids

prn

Changing opioids . . .• Equianalgesic table

• Transdermal fentanyl▫ 25-mg patch » ~60 mg morphine/24 h

• Methadone Non-linear dosing conversion – use dosing table

PO/PR (mg) IV/SC/IM (mg)

60 Codeine 30

15 Hydrocodone -

4 Hydromorphone 0.75

15 Morphine 5

10 Oxycodone -

. . . Changing opioids

•Cross-tolerance▫Start with 50%–75% of published

equianalgesic dose more if pain less if adverse effects

Converting to MS Contin

• Calculate total daily dose of each opioid• Convert to oral morphine equivalent ▫MEDD

• Divide by 2• Add 10% - 15% of 24o morphine dose as

immediate release q 3o prn

Methadone

•Synthetic opioid•Used to treat addiction and chronic pain•Schedule II▫Addiction: Prescribers must register with

DEA for that purpose▫Pain: Any prescriber with Schedule II

privileges •Safety concerns▫<5% of opioid prescriptions but ~33% of

opioid-related deaths

Methadone Advantages

▫Low cost▫High oral bioavailability▫Naturally long acting - may dose QDay or

BID▫Steady analgesic effect▫Blocks NMDA receptors – efficacious in

neuropathic pain▫Lack of active metabolites▫No dose adjustments in renal impairment

Methadone Disadvantages

•Stigmatization•Complex pharmacology

Dose conversion ratios are complex and vary based on current opioid dosage

Long variable half life (6 – 190 hours) can lead to drug accumulation, sedation,

confusion, and respiratory depression, especially in the elderly or with rapid dose adjustment

• Prolongs QT interval – may lead to fatal arrhythmias (torsades de pointe)

•Not recommended for breakthrough pain

Methadone Caveats

• Elimination half life longer than its duration of action• Precise opioid dose ratio for methadone is unknown• Equianalgesic dosing in not linear:▫Dose varies inversely with the previous oral morphine

equivalent dose• Drug interactions at CYP 450(3A4, 2D6):▫ Inhibitors ↑ methadone level = toxicity▫ Inducers ↑clearance = pain

CYP Inhibitors and Inducers

Inhibitors Inducers

Macrolides (erythromycin, azithromycin)

Anticonvulsants (phenobarbital, phenytoin)

Imidazoles (ketoconazole) Rifampin

SSRIs (paroxetine, fluoxetine) Corticosteroids

Antiviral drugs (ritonavir)

Benzodiazepines (lorazepam)

Quinolones (ciprofloxacin)

Acute alcohol ingestion Chronic alcoholism

Dosing Methadone: Overview

1. Determine the oral morphine equivalent daily dose (MEDD)

2. Select the initial methadone dose based on the oral MEDD

3. Stop the previous opioid and start methadone4. Utilize immediate-release opioid for

breakthrough pain▫ Switch to an opioid different than the one

used previously if toxicity experienced▫ Do not use methadone for breakthrough pain

Methadone Dosing Table

Dose Ratio*

31-99mg 4

100-180mg 6

181-240mg 8

241-300mg 10

Calculated Oral MEDD Dose Ratio

<30 mg 2:1

31-99 4:1

100-299 8:1

300-499 12:1

500-999 15:1

>1000 20:1

American Pain Society – Methadone Guidelines• Careful patient selection▫ Baseline EKG - Assess QTc▫ Drug interactions – avoid if other QT-prolonging

medications

• Patient Education about risks• Low starting dose• Opioid naïve patients▫ 2.5 mg q 8 h starting dose

• Slow titration - no more than every 5 days• Buprenorphine as alternative for patients with

opioid addiction and prolonged QTc

“Follow Directions: How to Use Methadone Safely”

•FDA educational materials•Designed to educate both consumers and

healthcare professionals •Brochures, fact sheets, and posters are

available for download or order at the SAMHSA website

• http://www.dpt.samhsa.gov/methadonesafety/print_materials.aspx

Pain poorly responsive to opioids

• If dose escalation adverse effects▫Use alternative route of administration (intrathecal) opioid (“opioid rotation”)

▫Add adjuvant▫Try a non-pharmacologic approach

Adjuvant analgesics

•Medications that supplement primary analgesics▫May themselves be primary analgesics Acetaminophen, NSAIDs

▫May have different primary indication Anticonvulsants, antidepressants

▫Use at any step of WHO ladder

Burning, tingling, neuropathic pain• Anticonvulsants▫Gabapentin, Pregabalin▫Carbamazepine, Phenytoin

• Tricyclic antidepressants (TCAs)▫Amitriptyline, desipramine

• SNRI▫Duloxetine

• Corticosteroids• Lidoderm Patch• Capsaicin Cream

Cannabinoids

•Work synergistically to allow lowered opioid dosing

•Marginal benefit for central pain and spasticity associated with multiple sclerosis

•May reverse opioid-associated hyperalgesia

•Prevention and treatment of chemotherapy-induced neuropathy

Strouse TB: J Pall Med 2015;18:7-10

Importance of Pain Management in Elderly• Rapidly growing segment of the population• Prevalence of pain increases with age• May go unreported due to belief that it is a

normal part of aging• Consequences▫ Impairment in ADLs, ambulation, stamina▫Requirement for higher level of caregiving

Prevalence of pain in Elderly

• Pain in elderly cancer patients

• 66% of geriatric Nursing home patients have chronic pain

• 34% of these unrecognized by their physician

Age Untreated Pain

65-74 21%

75-84 26%

>84 30%

Pain Assessment

• Location (1°, referral pattern)

• Quality• Timing• Severity• Radiation

• Modifying factors• Impact on function• Effect of prior

treatments• Patient perspectives

The patient’s self report is the single most reliable indicator of pain!

Supplemental Pain Assessmentin Elderly• Cognitive function• Depression Screen• Functional Status• Gait/Balance• Loss of sensory/visual/auditory acuity

American Geriatric Society’s Indicators of Pain

• Facial expressions• Verbalizations/vocalizations▫ Crying/Moaning/Groaning

• Touching/rubbing area• Change in gait or posture• Changes in interpersonal interactions• Changes in activity patterns or routines• Mental status changes• Change in functional status• Withdrawal• Agitated behavior

• Seek reports from caregivers and family

Items 0 1 2

Breathing NormalOccasional labored

breathing.Short period of

hyperventilation.

Noisy labored breathing.Long period of

hyperventilation. Cheyne-stokes

respirations.

Negative Vocalization

NoneOccasional moan or

groan. Low level speech with

a negative or disapproving quality.

Repeated troubled calling out.

Loud moaning or groaning.

Crying.

Facial expression

Smiling, or inexpressive

Sad. Frightened. Frowning.

Facial grimacing.

Body Language

RelaxedTense. Distressed pacing.

Fidgeting.

Rigid. Fists clenched. Knees pulled up. Pulling or pushing away.

Striking out.

ConsolabilityNo need to

consoleDistracted or

reassured by voice or touch.

Unable to console, distract or reassure.

Pain Assessment IN Advanced

Dementia- PAINAD (Warden, Hurley, Volicer, JAMDA, 2003)

Multidisciplinary Approach to Treatment•Pharmacotherapy•Physiotherapy•Psychosocial support• Interventional procedures

Factors Leading to Poor Compliance in Elderly

•Compromises in ▫Communication skills▫Cognitive function

•Cost•Polypharmacy

• KISS: Keep it Simple Stupid

Pharmacokinetic Changes

• Altered drug distribution▫ Increased body fat and decreased muscle mass

Lipophilic drugs (e.g. fentanyl, lidocaine) will have increased duration of action

▫Decreased body water (diuretics, dehydration) Hydrophilic drugs will have higher plasma concentrations

resulting in increased side effects▫Poor nutrition/decreased albumin effects protein-

bound drugs (increased free drug) NSAIDS, antiepileptics

▫Drug half life increased for benzodiazepines and tricyclics

• Declines in renal and hepatic function affect clearance

American Geriatrics Society Pharmacotherapy

Recommendations - 2009•Acetaminophen should be considered as initial

and ongoing therapy because of good safety and efficacy profiles

•NSAIDS should rarely be considered in highly selected patients with extreme caution▫Risks of renal, GI and cardiovascular toxicity▫Use with PPI▫Patients on ASA for CVD should not use

ibuprofen

American Geriatrics Society Pharmacotherapy

Recommendations - 2009•Opioids should be used for patients with

continuous or frequent pain with poor QOL▫Regularly assess for and anticipate adverse

effects and adjust accordingly▫Use around the clock scheduled dosing to

achieve steady state▫Provide breakthrough doses for those on long-

acting opioids▫Cautious use of methadone

American Geriatrics Society Pharmacotherapy Recommendations - 2009

•Adjuvants for neuropathic pain▫Use lowest dose and titrate slowly▫Provide adequate therapeutic trial before

changing▫Avoid tricyclic antidepressants (TCAs) due to

high frequency of adverse anticholinergic and cognitive effects

▫Consider topical agents for localized pain Lidocaine for neuropathic pain Topical NSAIDS, Capsaicin, menthol for non-

neuropathic pain

Case 1 – DeborahInpatient Palliative Care Consult

• 52 yo lady with metastatic cervical cancer to retroperitoneal and para-aortic lymph nodes failing chemotherapy and radiation

• Hospitalized March 23, 2014 with 10/10 pain in the right flank, right lower quadrant, right groin radiating down right leg with burning quality

• Also complained of n/v, anorexia, wt loss and constipation (no BM x 7 days)

• Right hydronephrosis and elevated creatinine

Case 1 (Cont.)

• Rx Ketoralac 15 mg IV q 6 hrs and Hydromorphone 2 mg IV q 3 h prn pain (total 9 mg) with good relief within 24 hours

• Changed to Hydromorphone 2 mg PO q 3 h prn without relief

Doing the Math

• IV Hydromorphone: PO Morphine 20:1• Hydromorphone 9 mg iv = Morphine 180 mg PO

• Morphine 60 mg PO: Fentanyl patch 25 mcg/h q 72 h

• Fentanyl 75 mcg/h q 72h

• Breakthrough dose (1/6 of 24 h dose)• 30 mg PO morphine = 8 mg PO hydromorphone

Deborah’s regimen

• Fentanyl patch 75 mcg/h q 72 h• Hydromorphone 8 mg PO q 2 h prn• Lidoderm patch to right flank and right leg• Gabapentin 300 mg q 8 h• Dexamethasone 4 mg PO Qday• Prochlorperazine 10 mg ac and qhs• Senna-s 2 tabs bid• Dulcolax tab prn constipation

Hospice course

• Excellent response initially – gained weight, went camping

• June 14 – Increased Fentanyl patch to 100 mcg/h and Hydromorphone 1-2 tabs q 2 h prn

• Nov. 1 – Increased Fentanyl patch to 125 mcg/h q 72 h

• Dec. 1 – Increased Fentanyl patch to 175 mcg/h q 72 h and Hydromorphone 10 mg/ml 10-20 mg SL q 2 h prn pain

• Died 12/7/14

Case 2 - Michael

•68 yo man with lung cancer and paraspinal mass invading ribs and spine

•Progressive disease despite chemotherapy and radiation therapy

•Elected hospice care from home•Pain 8/10, continuous, throbbing

Case 2 - Michael• Previous pain regimen▫MS Contin 60 mg q 12 h▫MSIR 15 mg q 3 h prn breakthrough pain▫Taking 8 doses of per day with little relief

• Having myoclonic jerks and visual hallucinations

Conversion to Methadone• Oral MEDD▫ MS Contin = 240 mg/day (120mg x 2)▫ MSIR = 120mg/day (15mg x 8)▫ Total oral MEDD = 360 mg/day (240mg + 120mg)

• Initial methadone dose▫ Dose ratio from table (300 – 499 mg MEDD) = 12▫ Initial methadone dose = 30 mg/day (360÷12)▫ Methadone 15 mg every 12 hours

• Breakthrough medication▫ 10-15% of 24 h morphine dose ≈40-60 mg▫ Morphine 20 mg/ml 2-3 ml q 2 h prn pain

Adjuvants

• Dexamethasone 4 mg Q day• Lidoderm Patch to site of pain

• TENS unit• Massage therapy

One week later

•Averaging 4-5 breakthrough doses/day•~180 mg MEDD•Same dosing ratio (12) ~15 mg

methadone• Increased Methadone to 20 mg q 12 h

•Pain level currently 3/10