Palliative Care:What every 1st year medical

student needs to knowSuzana Makowski, MD MMM FACP FAAHPM

Assistant Professor of Medicine

Slide presentation for 1st year medical students in the Cancer Concepts Course at

UMass Medical School

Overview

• What is Palliative Care?

• What is Hospice?

• How do we care for the dying?

Palliative Care

“an approach that improves

the quality of life of

patients and their families

facing the problems

associated with life-

threatening illness, through

the prevention and relief of

suffering by means of early

identification and

impeccable assessment and

treatment of pain and other

problems, physical,

psychosocial and spiritual.”

WHO definition

Why discuss palliative care?

• “It’s not about killing

Granny; it’s about

keeping Granny alive as

long as possible — with

the best quality of life.”

- Diane Meier, NYTimes

NEJM Study (2010): Early Palliative Care improves longevity and

quality of life for patients with advanced non-small cell lung cancer

http://www.youtube.com/watch?v=XHtHXGhTIC4

What is palliative care?

Not just end-of-life care…

Adapted from Frank Ferris – EPEC-O

Myth: Palliative care = just end-of-life careWe often help patients whose life expectancy is good

Cancer pain management

Cancer pain prevalence

• 50 to 90 percent of oncology inpatients report

breakthrough pain

• 35 percent of community based oncology practices

patients report breakthrough pain

• 1 in 3 patients with active cancer report pain

• 3 out of 4 of patients with advanced cancer report pain

Causes of cancer pain

• Bone metastases

• Visceral metastases

• Immobility

• Neuropathic pain

• Soft tissue

• Constipation

• Esophagitis

• Lymphedema

• Muscle cramps

• Chronic postoperative scar

• Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients with

advanced cancer. J Pain Symptom Manage 1996;12:273-282.

Effects of under treated pain

Physical Emotional Existential

• Increased catabolic demands: poor wound healing, weakness, muscle breakdown

• Decreased limb movement:increased risk of DVT/PE

• Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis

• Sodium and water retention Decreased gastrointestinal mobility

• Tachycardia and elevated blood pressure• Decreased functional status• Increased chronic pain

DepressionAnxietyDecreased intimacySuicidality

Suffering –

“why me?”

Pain Assessment

• Intensity • Location • Quality • Timeline •

Alleviating factors • Meds tried

Pain Quality

Category Cause Symptom Examples

Physiologic Brief exposure to a

noxious stimulus

Rapid yet brief pain

perception

Touching a pin or hot

object

Nociceptive/infla

mmatory

Somatic or visceral tissue

injury with mediators

having an impact on

intact nervous tissue

Moderate to severe pain,

described as crushing or

stabbing

Surgical pain,

traumatic pain, sickle

cell crisis

Neuropathic

Damage or dysfunction

of peripheral nerves or

CNS

Severe lancinating,

burning or electrical

shock like pain

Neuropathy, CRPS.

Postherpetic Neuralgia

MixedCombined somatic and

nervous tissue injury

Combinations of

symptoms; soft tissue plus

radicular pain

Low back pain, back

surgery pain

WH

O p

ain

relie

f lad

de

r

Non-opioid = acetaminophen, NSAID, neuroleptic • Adjuvant = steroid, etc.

Why is this dangerous?

• Mrs. Dolores de Barriga is a 67 year old Peruvian

immigrant with metastatic colon cancer, who has

increasing abdominal pain. She has a colostomy and has

regular bowel movements.

• Her current pain regimen is:

• Morphine ER 15mg twice daily

• Percocet (oxycodone 5mg + acetaminophen 500mg) – 1-2

tablets every 4 hours as needed. She has been taking 2

tablets every 4 hours for the last week.

Opioid Pharmacology

Opioid Pharmacology

Short-acting Long-acting

• Hydrocodone/APAP

• Oxycodone +/- APAP

• Morphine

• Hydromorphone

• Oral transmucosal fentanyl

• Transdermal fentanyl

• methadone

• morphine ER

• oxycodone ER

• Cmax ~ 45 min

• T1/2 ~ 2-4 hours

• Except fentanyl

Cmax and T1/2 vary based on

formulation and drug

A quick quiz

What is the half life (range) for opioids?

• 2-4 hours

How many half lives to get to steady state?

• 4-5

What do you base your scheduled dosing on: Cmax or C?

• t1/2

What do you base your breakthrough dosing on: Cmax or t1/2?

• Cmax

Opioid pharmacology

(except methadone)

• Follow first order kinetics

• Conjugated by liver

• 90-95% excreted in urine

• Dehydration, renal failure, severe hepatic failure

• Decrease interval/dosing size

• If oliguria/anuria

• STOP routine dosing (basal rate) of morphine

• Use ONLY PRN

Why is morphine

contraindicated in

renal failure?

Morphine metabolitesbuild-up disproportionately in renal failure

• Morphine 3-glucoronide

• Not an opioid agonist

• Stimulates the GABA/glycinergic

system

• Can cause neuro-excitation –

agitation, hyperalgesia, myoclonus,

seizures.

• Morphine 6-glucoronide

• Active metabolite that acts as an

opioid agonist – especially against the

mu-opioid receptor

Palliative Care

• Same “rules” apply

• CMO ≠ Continuous Morphine Only

Optimal symptom management

• Goals of care based

• Not problem based

Personalized healthcare

• Bio-psycho-social-spiritual approach

• Interdisciplinary

Whole-person care

Myth: Palliative care = “no more treatment”We assess the values & goals of a patient, designing care around them

Massachusetts facts

On an average day in Massachusetts:

144 people die

A few childre

n

1 infant

Some middle aged

Most over 75

MA: 67% want to die at home

MA: only 24% die at home

Hospice care: 1 way to help stay home

• In the United States, hospice is a form of care provided to

patients whose life expectancy is 6 months or less.

• It is generally provided in the patient’s home, but can be

received in nursing homes, hospices houses, etc.

• It is a Medicare benefit (that many other insurances

cover)

• Its approach is to help people live as well as possible, for

the time they have left: alleviating symptoms, reaching

goals, supporting family, addressing spiritual needs.

• As long as a person’s prognosis remains 6 months, the

benefit does not run out.

• A patient may be “full code”, “DNR/DNI” – according to

their goals and preferences on hospice.

Hospice Home Palliative (VN)

Requires Prognosis <6months

(Not required: code status,

primary caregiver)

Home-bound only

Must show improvement

Services Nurse, social worker,

chaplain, volunteer, home

health aide

Nurse, PT/OT

DME* All covered Not covered

Meds Covered if associated with

dx

Not covered

Hours 24/7 Regular business hours

Other Bereavement for family up

to 13 months after death

None

*DME = durable medical equipment (bed, oxygen, commode, etc.)

from Second City

Much of our practice is for patients nearing end-of-life

Caring for the dying

What we know

• Until recently, only 10% of medical students had any

courses on how to care for dying patients.

• Practicing non-abandonment is tough when we don’t

know what to do.

• Know the signs and symptoms of dying and means to

treat them.

• Address fears, anticipate problems

• Sir William Osler: To cure sometimes, to alleviate

often, to comfort always.“

“

Physiology of dying with cancer

• Cancer Cachexia/Anorexia

• Metabolic demands of cancer outpace that of the body

• Malnutrition: protein and fat depletion

• Loss of intravascular oncotic (osmotic) pressure due to low

albumin and other proteins

• “third spacing” of fluid to abdomen, lungs, subcutaneous

tissue

How does this differ from starvation?

Physiology of dying

• Decreased perfusion of brain

• Increased fatigue, somnolence

• Poor control of bowel and bladder

• Change in respiratory pattern (late)

• Decreased reflexes, including gag and

swallow – leads to pooling of saliva in back

of throat

• Decreased cardiac output

• Poor peripheral perfusion: skin breakdown

• Decreased perfusion of the kidneys (low

intravascular volume/pressure, low cardiac

output) leads to pre-renal azotemia

Signs/Symptoms

• Decreased

energy

• Increased sleep

• Respiratory

pattern changes

• “Terminal

secretions”

• Skin breakdown

• Peripheral

“mottling”

Pain • Breathlessness • Bleeding

Retching • Hallucinations • Seizures

What signs/symptoms might she experience?

• Dolores returns

• she is now pancytopenic

due to bone marrow

involvement

• plts now 5,000/mcl,

• Hct 12%,

• WBC 2,000/mcl

Pan = all

Cyto = cell (usually referring to blood cells)

Penia = poverty

Where could she bleed?

• Brain

• Seizures, brain stem herniation

• Mucosa

• Nose bleeds, vaginal bleeds

• Lungs

• Dyspnea, hemoptysis

• GI tract

• Hematemesis, aspiration of blood,

bloody stool

• Retroperitoneal

• Back pain

What to do once you can no

longer transfuse blood? – Be

prepared

• For bleeds you can see:

dark blue towels, surgicel

or topical thrombin for

nose/mucosa

• Benzodiazepam for

seizures

• Opioid and benzo of

phenobarbitol for

hemoptysis, pain, etc.

Some

help:

• Sir William Osler:

• Eric Cassell:

“

“ “

“

Summary

• Most physicians practice Palliative Care every day

• Palliative care includes any care that enhances quality of

life (QOL) – regardless of its effect on longevity (it may

prolong life!)

• Prognostication is hard, but important. It helps patients

plan, achieve goals that they can reach.

• Palliative care can help patients at any stage of a serious

illness, while hospice is available for patients whose

prognosis is on average 6 months.

How to learn more

• EPEC (Education on Palliative & End-of-Life Care)

• Lois Green Learning Community

www.loisgreenlearningcommunity.org

• Get Palliative: www.getpalliativecare.org

• Pallimed Connect