specialist palliative care in esld: an introduction
DESCRIPTION
An overview of concurrent palliative care in serious liver disease including the concepts of generalist vs. specialist palliative care, pain management, psychosocial concerns and advanced communication techniques.TRANSCRIPT
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SPECIALIST PALLIATIVE CARE IN
ESLD:AN INTRODUCTION
KYLE P. EDMONDS, MD
ASSISTANT CLINICAL PROFESSOR
HOWELL PALLIATIVE CARE SERVICE
UCSD HEALTH SCIENCES
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OBJECTIVES
• UNDERSTAND THE ROLE OF PALLIATIVE CARE IN SERIOUS ILLNESS
• AWARENESS OF THE CONCEPTS OF GENERALIST VS. SPECIALIST PALLIATIVE CARE
• NAME THE PREFERRED ADJUVANT PAIN MEDICATION IN ESLD
• DESCRIBE THE DIFFERENTIAL OF ABERRANT DRUG-TAKING BEHAVIOR & A STRATEGY TO SAFELY PRESCRIBE CONTROLLED SUBSTANCES
• EXPLAIN HOW THE CONCEPT OF TIME-LIMITED TRIALS RELATES TO GOALS OF CARE
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YOUR CHALLENGES IN INVOLVING PALLIATIVE CARE?
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THE COMMON ANSWER
Time
Palliative
Care
Routine Medical Care:antibiotics, dialysis, chemotherapy, surgery
“Dying”?
“Nothing more to do”?
“Pt / family request”?
“Really sick”?
“Really, really sick”?
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PROGNOSIS: MOVING TARGET
RAND, 2005.
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PALLIATIVE CARE AS EXPERT PARTNER
AVAILABLE AT ANY AGE AND AT ANY STAGE IN A SERIOUS ILLNESS AND
CAN BE PROVIDED ALONG WITH CURATIVE TREATMENT.
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Time
General / Specialty Palliative
Care
Routine Medical Care
The Course of Illness
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Gastroenterology
Generalist Palliative
CareSpecialist Palliative
Care
•MOA•TACE•Antibiotics
•ondansetron•opioids
•Complex pain•High dose opioids•Limit setting•Hope & Prognostication
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A.R. CASE
• 67 YEAR OLD MALE
• ETOH & HEP C CIRRHOSIS
• JANUARY DX’ED WITH HCC
• SYMPTOMS: FATIGUE AND CHRONIC BACK PAIN ON HIGH DOSE OPIOIDS
• APRIL: TACE
• SYMPTOMS: “SEVERE” PAIN, NAUSEA AND CONSTIPATION
• MAY
• ADMITTED “SEVERE” ABDOMINAL PAIN
• REQUESTING SPECIFIC MEDS AND DOSES
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A.R. CASE
• OVERNIGHT: DECOMPENSATED
• “SEVERE” ABDOMINAL PAIN, “HARD TIME BREATHING”
• TRANSFERRED TO ICU
• PALLIATIVE CARE CALLED
• PATIENT DNAR/FULL CARE
• SEVERE PAIN AND DYSPNEA
• PATIENT DIED NEXT MORNING IN THE ICU
• DPOA: “HE TOLD ME HE WANTED TO DIE AT HOME.”
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HOW COULD WE HAVE HELPED EARLIER?
• EXPERT PAIN MANAGEMENT
• ACUTE ON CHRONIC PAIN
• EVALUATING ABERRANT DRUG-TAKING BEHAVIOR
• PAIN CONTROL W/ HX OF SUBSTANCE ABUSE
• “TOTAL PAIN” ASSESSMENT
• COPING ASSESSMENT / INTERVENTION
• SEVERE DISEASE
• HISTORICAL ALCOHOLISM
• EARLY GOALS OF CARE
• RAPPORT BUILDING
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PALLIATIVE CARE AS EXPERT PARTNER
A TEAM THAT CAN HELP YOUR PATIENTS AND FAMILIES MANAGE THE PAIN, SYMPTOMS,
AND STRESS OF SERIOUS ILLNESS.
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CLASSIFICATION OF PAIN
• PHYSIOLOGIC
• NOCICEPTIVE
• NEUROPATHIC
• MIXED
• TEMPORAL
• ACUTE
• CHRONIC
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WHO LADDER ELEVATOR
1, Pain 1 – 3
2, Pain 4 – 6
3, Pain 7 – 10
Morphine
Hydromorphone
Fentanyl
OxycodoneMethadone
± Adjuvants
Tramadol
A / Hydrocodone
A / Oxycodone
± AdjuvantsAcetaminophen
NSAID’s
± Adjuvants
WHO. Geneva, 1996.
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EXPERT PAIN MGMT
General Principles
(Maximize non-pharm / non-opioid adjuvants)
Initiate at low doses
Dose by pharmacologic principles
Long-acting formulations avoided as much as possible
Monitor decompensated patient for side effects
Kirsch & Passik, 2006.
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FAVORED ADJUVANT
Gabapentin:
Visceral pain, sleep, anxiolysis
Minimal hepatic metabolism
Minimal protein binding
Renal excretion
Dwyler et al., 2014.
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OPIOIDS
Morphine Oxycodone Tramadol
Inc half-life & bioavailability; dec clearance
Elimination is severely impaired
CYP2D6 metabolism to
active M1 form??
22
Grond & Seblotzki 2004.
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OPIOIDS
Consider:
Fentanyl
Short-acting morphine
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“TOTAL PAIN”
Pain
Disease Mgmt
Physical
Psych
SocialSpiritual
Practical
EOL Worry
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DX: ABERRANT DRUG-TAKING BEHAVIOR
• DESPERATION OVER SXS
• AGGRESSIVELY COMPLAINING
• REQUESTING SPECIFIC DRUG
• BUYING OPIOIDS ON STREET
• DOCTOR SHOPPING
• PRESCRIPTION FORGERY
Passik et al. JClinPain. 2006.
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DDX: ABERRANT DRUG TAKING BEHAVIOR
• TOLERANCE• PSEUDO-
ADDICTION• DRUG DIVERSION• ADDICTION
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PSYCHOSOCIAL CONSIDERATIONS
Alcohol or Substance Abuse
Hx “chemical coping”
Perceiving judgment / blame
Alexithymia (not “in tune”)• Symptom assessment challenging• Need alternative ways to assess
5
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PALLIATION IN HISTORICAL SUBSTANCE ABUSE
Limit-setting
Use adjuvant medications whenever possible
Use non-drug adjuvants (relaxation, distraction, biofeedback)
Clinic risk stratification / procedures
Multidisciplinary assessments
Involve addiction specialists
34
Passik et al. 2006.
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OPIOID RISK TOOL FOR SCREENING
• STRATIFY PATIENT OPIOID ABUSE RISK BASED UPON
• FAMILY HX OF SUBSTANCE ABUSE
• PERSONAL HX OF SUBSTANCE ABUSE
• AGE
• SEX
• HX OF PREADOLESCENT SEXUAL ABUSE
• PSYCH D/O
Chou et al. JClinPain. 2009.
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HISTORICAL SUBSTANCE ABUSE
• MEANS OF COPING W/ STRESS
• MORE LIKELY TO RETURN W/ STRESS
• IMPACTS ADHERENCE TO RX REGIMENS
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PALLIATIVE CARE AS PARTNER
EXPERT COMMUNICATION FOR CHALLENGING SITUATIONS.
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GOALS OF CARE COMMUNICATION
• NORMALIZE DISCUSSION
• “HOPE FOR THE BEST & PLAN FOR THE WORST”
• PROGNOSTICATION NOT ASSOCIATED W/ LOSS OF HOPE
• COMMON PITFALL: ASSUMING HOPE ONLY = CURE
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“GOALS OF CARE” ≠ CODE STATUS
Goals of
Care
Hopes
Fears
Values
Code Statu
s
Patient/Family Us
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GOALS OF CARE
PERCEPTION OF CURRENT HEALTH
EXPLORE LIFE BEFORE PRESENT ILLNESS
RELATE PAST AND PRESENT
SOURCES OF WORRY OR CONCERN
OUTLINE THE PLAN
NOTIFY IMPORTANT PEOPLE
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POTENTIAL GOALS OF CARE
Restorative or Cure
Return to Baseline
Improve Survival
Improve Function
Relieve Symptoms
Allow Natural Death
Adapted from Mulkerin, 2011.
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TIME-LIMITED TRIALS
• AGREE EARLY WITH INTERESTED PARTIES ON:• EXACT LENGTH OF
TIME
• SPECIFIC GOALS
• WHAT WILL HAPPEN IF GOALS NOT MET
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PALLIATIVE CARE AS PARTNER
PARTNERING WITH YOU FOR BETTER OUTCOMES BY HELPING YOUR PATIENTS TOLERATE CURATIVE TREATMENT.
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A.L. CASE & QUESTIONS
• 65YOM W/ ETOH / HCV ESLD LISTED FOR TX
• HX OF IVDA AND METHADONE MAINTENANCE
• A/W AMS D/T HYPONA AND HEPATIC ENCEPHALOPATHY
• PAIN OUT OF CONTROL, THREATENING TO LEAVE AMA D/T OPIOID LIMITATIONS = “ADDICTION”?
• 6MG OF IV DILAUDID IN 24 HOURS (120MG OME)
• TEARFUL, ANGRY = “DEPRESSED”?
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A.L. PALLIATIVE ASSESSMENT• COMPLEX PAIN
• NO ABERRANT DRUG-TAKING BEHAVIOR
• NOT DEPRESSED
• GRIEVING: “ACUTE GRIEF OVER LOSS OF FUNCTION”
• UNCERTAINTY: “WONDERING HOW HIS LIFE WILL UNFOLD”
• COPES THROUGH SPIRITUALITY & INTERACTION W/ PEOPLE
• GOALS
• PAIN CONTROLLED
• TRANSPLANT
• HOME
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A.L. PALLIATIVE RECOMMENDATIONS
• CHANGE HYDROMORPHONE TO PO
• GABAPENTIN 300MG AT HS (SLEEP, PAIN, ANXIETY)
• EXPLORED GUIDED IMAGERY & JOURNALING
• ENCOURAGED NURSING TO MAKE FREQUENT VISITS
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A.L. OUTCOME
• DECREASED OPIOID NEED
• DECREASED ANGER & INCREASED PARTICIPATION IN CARE
• TRANSPLANT
• HOME ON ORAL MEDS W/ PLAN TO WEAN
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PALLIATIVE CARE
• A TEAM THAT CAN HELP YOUR PATIENTS AND FAMILIES MANAGE THE PAIN, SYMPTOMS, AND STRESS OF SERIOUS ILLNESS.
• AVAILABLE AT ANY AGE AND AT ANY STAGE IN A SERIOUS ILLNESS AND CAN BE PROVIDED ALONG WITH CURATIVE TREATMENT.
• EXPERT COMMUNICATION FOR CHALLENGING SITUATIONS.
• PARTNERING WITH YOU FOR BETTER OUTCOMES BY HELPING YOUR PATIENTS TOLERATE CURATIVE TREATMENT.
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SPECIALIST PALLIATIVE CARE IN ESLD
KYLE P. EDMONDS, MD
858-534-7079