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Principles of Palliative CareA Tasting Menu
Kyle P. Edmonds, MDAssistant Clinical Professor
Doris A. Howell, MD, Palliative Care Consultation Service
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Specialist 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.
Dr. Doris Howell, pediatric oncologist (and all-around pioneer)
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Generalist / Specialist
Palliative Care
Hospice
•Symptom management•Whole person plan of care•No relation to prognosis•Not a philosophy of care
•Funding mechanism•Strictly <6mo prognosis•Home-based•Teaches caregivers
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When to Call?
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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Routine Medical Care
Generalist Palliative
CareSpecialist Palliative
Care
•Fluids•Antibiotics•Etc.
•ACP/GoC•opioids•Ondansetron•Routine MDM
•Complex pain•High dose opioids•Limit setting•Hope & Prognostication•Complex MDM
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When to call
• Patient is seriously ill • AND• You feel uncomfortable w /
• Symptom mgmt• Breaking bad news• Eliciting goals of care• Whole person needs
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General OR Specialty Palliative
Care
Routine Medical CareHospic
eBereaveme
nt
Decision Maker
Goals of Care
Nausea Mgmt
Psychosocial Needs
Care coordination
Prognostication
Bowel Obstruction
Mgmt
Legacy Work
Family Meetings
Hospice Education
POLST
Spiritual Support Mgmt: Vomiting,
Pain, Ascites, Delirium, Anxiety
Care Transitions
1
2 3
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7
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EquipmentTeaching
MedicationsHome AidesVolunteersPrognosisSymptoms
24/7 Access
Preparing Children
Support Groups
Counseling Resources
Dx
Death
Adapted from Landzaat, 2013.
The Course of Illness
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Palliative principles are appropriate for all patients with serious illness
Principle
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Assessing Symptoms
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control
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Whole-person Assessment
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Unfortunately, disease does not exist in a vacuum
Principle:
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Managing Symptoms
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•Nausea has resolved since NGT placed
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• Constant
• Constant + Acute
• Intermittentacute
Time Course
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For acute symptoms, treat with frequent, fast-acting (PRN) meds
Principle:
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For constant symptoms, treat with constant (scheduled) meds
Principle:
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Example: Pain
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•You want to start morphine…
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Plas
ma
Con
cent
ratio
n
0 Time
AbsorptionExcretion
First Order KineticsWhen biological effect
follows plasma concentration
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Plas
ma
Con
cent
ratio
n
0 Time ( hours )
Time to MaximumConcentration ( t Cmax )
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10
1
= time it takes to get to maximum concentration
Cmax MorphinePO / PR
Cmax = 1 hour
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Plas
ma
Con
cent
ratio
n
0 Time
IV
PO / PR60min
Time to MaximumConcentration ( t Cmax )10min
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Plas
ma
Con
cent
ratio
n
0 Time
Cmax
Treating Acute Pain
PO / PR≈ 1 hr
IV~10 min
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For acute pain, dose every C-max with short-acting meds
Principle:
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Aberrant Drug-taking
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•You start morphine PCA 1mg basal, 2mg bolus•Nursing calls: patient requesting Dilaudid, because she’s had it before…
2323
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.
ADDICTED.
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• Low health literacy
• Physiologic dependence
• Receptor heterogeneity
• Chemical coping
• Pseudo-addiction
• Drug diversion
• Substance use disorder
• Addiction
DDx: Aberrant Drug Taking Behavior
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Maintain DDx for drug-related behaviors you don’t like
Principle
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Goals of Care
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•“I want to get back to how I was!”
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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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• Perception of patient/family
• Exploration of life before illness
• Relating patient story to medical situation
• Sources of worry for the future
• Outline the plan concretely
• Notify those who need to know
Goals…How?
Edmonds, Ajayi, Cain, Yeung, & Thornberry. 2014.
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Values
Hopes
Wishes
Personhood
Lifestory
Goals of Care
Medical Options
Patient/Family Us
Ventilator
Pressors
Code Status
Antibiotics
Disposition
The Plan of Care
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The plan of care is a negotiation of GOC & realistic medical options
Principle:
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Sharing Prognosis
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•PMHx of CHF•Needs help around the house and with dressing PTA•Albumin 2.4 g/dL
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Formulating Prognosis: How…?
• ePrognosis.org
• myPCNow.org
Covinsky et al., 2011.
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Prognostic Awareness
• Higher when:• Less time to live• Cognitively intact• At peace with life• Not depressed
Fisher et al., 2015. Jackson et al., 2013.
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Goals: Require Time
Steinhauser et al., 2000.
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…Prognosis: How?
• Control symptoms, alleviate worries
• Ask permission
• Use SPIKES protocol
• (Hedge if you like)
• Give ranges• Days-to-weeks• Months, less-than-six• Years
• Celebrate when they live longer!
36
Hope is not fragile
• More than medicine• “I hope”• Positive future• Patient
• The subject of• Relatedness
•Focus on Life
Adapted from Table 1: Eliott & Olver, 2006.
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Formulating & sharing prognosis is the standard of care
Principle
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“Just do everything”
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•You broach the concept of hospice with her
•“Oh no, doctor I still have HOPE to get stronger and have more chemo…•“I want to do EVERYTHING possible!”
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DDx for “Do Everything”
• Affective• Abandonment (Don’t give up on
me)• Anxiety (I don’t want to leave my
family)
• Cognitive• Incomplete understanding• Wanting reassurance
• Spiritual• Vitalism (I value every moment of
life)• Faith in God’s will (Only He can
decide)
• Family• Family conflict (My husband will
never let me go)• Children or dependents (I don’t want
to bother my children)
Quill et al., 2009.
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Align, Reassure, Reframe
• “Hoping for the best and planning for the worst”
• Align with patient
• Explore & reframe “everything”
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“Do everything” is a statement of emotion to be explored, not a medical directive
Principle:
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Realistic Communication
•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•Chemo on hold•Increasing dependence•Prognosis: months, less than 3
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Crucial Conversations©
• A discussion between people where• Stakes are high• Opinions vary• Emotions run strong• Outcome greatly impacts lives
Patterson, Grenny, McMillan & Switzler. 2002.
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Crucial Conversations©
• 3 ways to handle• Avoid• Face & handle poorly• Face & handle well
Patterson, Grenny, McMillan & Switzler. 2002.
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Crucial Conversations©
• Why they can go poorly• Biology: fight-or-flight• No warning• No rehearsal• Self-defeating behavior
Patterson, Grenny, McMillan & Switzler. 2002.
46Multiple Goals Theory of Communication
Action Mill. 2014.
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Communication: Palliative Consults
• More accurate prognostic understanding1
• Addressed QOL2
• Contained more “pessimistic” cues2
1. Temel et al., 2011.2. Gramling et al., 2012.
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Anxiety = Not always bad
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Reality sometimes need to cause anxiety for good decision-making.
Principle:
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Maladaptive Coping…
• Cognitive• Cognitive delay• Medically naïve• Extremes of age
• Emotional/Psychological• Emotional reactivity• Serious mental illness• Substance abuse history
• Social/Cultural• High degree of mistrust• Collectively-focused• Defer to authority• Those who believe only option
is a miracle
Roeland, Cain, Onderdonk, Kerr, Mitchell, & Thornberry. 2014.
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Relying on your expertise
Roeland, Cain, Onderdonk, Kerr, Mitchell, & Thornberry. 2014.
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Tailor your communication approach appropriately
Principle
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Howell Palliative Care Consultation Services
• Multi-disciplinary teams• Licensed Clinical Social Worker• Nurse Practitioner• Fellowship-trained physician• Pharmacist
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• Palliative principles are for all patients with serious illness
• Acute symptoms PRN meds
• Constant symptoms scheduled meds
• Maintain DDx for drug-related behaviors you don’t like
• The plan of care is a negotiation of goals of care & realistic medical options
• “Do everything” is a statement of emotion
• Reality sometimes needs to cause anxiety
• Tailor your communication approach
Principles
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“Palliative Care is a team of specialists who help with symptoms, coping with serious illness &
planning for the future.”
How to describe us?
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Principles of Palliative CareA Tasting Menu
Kyle P. Edmonds, MDAssistant Clinical Professor
Doris A. Howell, MD, Palliative Care Consultation Service