SPECIALIST PALLIATIVE CARE IN
ESLD:AN INTRODUCTION
KYLE P. EDMONDS, MD
ASSISTANT CLINICAL PROFESSOR
HOWELL PALLIATIVE CARE SERVICE
UCSD HEALTH SCIENCES
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
YOUR CHALLENGES IN INVOLVING PALLIATIVE CARE?
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”?
PROGNOSIS: MOVING TARGET
RAND, 2005.
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.
Time
General / Specialty Palliative
Care
Routine Medical Care
The Course of Illness
Gastroenterology
Generalist Palliative
CareSpecialist Palliative
Care
•MOA•TACE•Antibiotics
•ondansetron•opioids
•Complex pain•High dose opioids•Limit setting•Hope & Prognostication
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
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.”
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
PALLIATIVE CARE AS EXPERT PARTNER
A TEAM THAT CAN HELP YOUR PATIENTS AND FAMILIES MANAGE THE PAIN, SYMPTOMS,
AND STRESS OF SERIOUS ILLNESS.
CLASSIFICATION OF PAIN
• PHYSIOLOGIC
• NOCICEPTIVE
• NEUROPATHIC
• MIXED
• TEMPORAL
• ACUTE
• CHRONIC
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.
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.
FAVORED ADJUVANT
Gabapentin:
Visceral pain, sleep, anxiolysis
Minimal hepatic metabolism
Minimal protein binding
Renal excretion
Dwyler et al., 2014.
OPIOIDS
Morphine Oxycodone Tramadol
Inc half-life & bioavailability; dec clearance
Elimination is severely impaired
CYP2D6 metabolism to
active M1 form??
22
Grond & Seblotzki 2004.
OPIOIDS
Consider:
Fentanyl
Short-acting morphine
19
“TOTAL PAIN”
Pain
Disease Mgmt
Physical
Psych
SocialSpiritual
Practical
EOL Worry
20
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.
DDX: ABERRANT DRUG TAKING BEHAVIOR
• TOLERANCE• PSEUDO-
ADDICTION• DRUG DIVERSION• ADDICTION
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
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.
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.
HISTORICAL SUBSTANCE ABUSE
• MEANS OF COPING W/ STRESS
• MORE LIKELY TO RETURN W/ STRESS
• IMPACTS ADHERENCE TO RX REGIMENS
PALLIATIVE CARE AS PARTNER
EXPERT COMMUNICATION FOR CHALLENGING SITUATIONS.
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
“GOALS OF CARE” ≠ CODE STATUS
Goals of
Care
Hopes
Fears
Values
Code Statu
s
Patient/Family Us
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
POTENTIAL GOALS OF CARE
Restorative or Cure
Return to Baseline
Improve Survival
Improve Function
Relieve Symptoms
Allow Natural Death
Adapted from Mulkerin, 2011.
TIME-LIMITED TRIALS
• AGREE EARLY WITH INTERESTED PARTIES ON:• EXACT LENGTH OF
TIME
• SPECIFIC GOALS
• WHAT WILL HAPPEN IF GOALS NOT MET
PALLIATIVE CARE AS PARTNER
PARTNERING WITH YOU FOR BETTER OUTCOMES BY HELPING YOUR PATIENTS TOLERATE CURATIVE TREATMENT.
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”?
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
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
A.L. OUTCOME
• DECREASED OPIOID NEED
• DECREASED ANGER & INCREASED PARTICIPATION IN CARE
• TRANSPLANT
• HOME ON ORAL MEDS W/ PLAN TO WEAN
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.
SPECIALIST PALLIATIVE CARE IN ESLD
KYLE P. EDMONDS, MD
858-534-7079
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