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Overview Prepare for the boards with an audience response quizz hosted by Pallimed & Geripal bloggers Review recent, clinically relevant literature on Palliative Care Discover three methods to obtain quality up-to-date information on palliative care
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GI symptoms
HPM 1 Ms. V is a 68 year old with metastatic non-small cell lung cancer, congestive heart failure, and mild renal insufficiency residing in an inpatient palliative care unit for management of bone pain. Her medications include morphine IR, fentanyl patch, furosemide, senna, and Fleet enemas prn. Ms. V did not have a bowel movement in 4 days. Basic labs were ordered for the next morning as well as a two of her prn enemas, although they failed to result in a bowel movement. The labs the next day reveal a serum sodium of 124, potassium of 3. 0, creatinine of 1. 4 (baseline of 1), low calcium of 6. 5, and a very elevated phosphate of 17 mg/dl. What is the most likely cause of her electrolyte abnormalities? a) A medication adverse event b) Tumor lysis syndrome c) Bowel Impaction d) Osteolytic metastases
HPM 1 Ms. V is a 68 year old with metastatic non-small cell lung cancer, congestive heart failure, and mild renal insufficiency residing in an inpatient palliative care unit for management of bone pain. Her medications include morphine IR, fentanyl transdermal patch, furosemide, senna, and Fleet enema’s prn. Ms. V did not have a bowel movement in 4 days. Basic labs were ordered for the next morning as well as a two of her prn enemas, although they failed to result in a bowel movement. The labs the next day reveal a serum sodium of 124, potassium of 3. 0, creatinine of 1. 4 (baseline of 1), low calcium of 6. 5, and a very elevated phosphate of 17 mg/dl. What is the most likely cause of her electrolyte abnormalities? a) A medication adverse event b) Tumor lysis syndrome c) Bowel Impaction d) Osteolytic metastases
HPM 1 - Discussion a) Sodium phosphate preparations (oral and rectal) • Never give to patients with renal insufficiency, heart failure, cirrhosis, or • • elderly frail individuals. May cause intravascular volume depletion and electrolyte disturbances including significant hyperphosphatemia, hypocalcemia, and hypokalemia. Phosphate nephropathy may also occur. b) Tumor lysis • Can cause hyperphosphatemia and hypocalcemia, although mainly with • cytotoxic therapy in patients with a large tumor burden with rapid cell turnover Also associated with hyperkalemia. c) Bowel impaction alone should not cause these electrolyte disturbances d) Osteolytic metastases generally cause hypercalcemia.
HPM 2 Walking into a room at your hospice inpatient unit you see a tired appearing female patient lying in bed with soft moaning, holding her abdomen. She has end stage CHF and no history of cancer. Review of your notes show decreasing oral intake and increased time in bed. Her nurse reports she disimpacted her yesterday after suppositories and enemas were ineffective for worsening constipation. Medications include: Fentanyl 50 mcg patch (on for several weeks); Senna 2 tabs BID; Colace daily Recent enema, and docusate suppository. Exam: Cachectic female; Scaphoid abdomen, hypoactive bowel sounds, formed (but not hard) stool on rectal exam. What is the next best step? A) Write an order for methylnaltrexone 8 mg subcutaneously x 1 now. B) Switch her from a fentanyl patch to a morphine pump so you can better manage her abdominal pain. C) Write an order for octreotide 200 mcg subcutaneously twice daily for three days D) Place an NG and give her polyethylene glycol daily until she has a bowel movement or regains ability to swallow and you can remove the NG tube
HPM 2 Walking into a room at your hospice inpatient unit you see a tired appearing female patient lying in bed with soft moaning, holding her abdomen. She has end stage CHF and no history of cancer. Review of your notes show decreasing oral intake and increased time in bed. Her nurse reports she disimpacted her yesterday after suppositories and enemas were ineffective for worsening constipation. Medications include: Fentanyl 50 mcg patch (on for several weeks); Senna 2 tabs BID; Colace daily Recent enema, and docusate suppository. Exam: Cachectic female; Scaphoid abdomen, hypoactive bowel sounds, formed (but not hard) stool on rectal exam. What is the next best step? A) Write an order for methylnaltrexone 8 mg subcutaneously x 1 now. B) Switch her from a fentanyl patch to a morphine pump so you can better manage her abdominal pain. C) Write an order for octreotide 200 mcg subcutaneously twice daily for three days D) Place an NG and give her polyethylene glycol daily until she has a bowel movement or regains ability to swallow and you can remove the NG tube
HPM 2 - a)Methylnaltrexone=mu-opioid antagonist, effective in 60% of cases for opioid induced constipation. Contraindicated if bowel obstruction or fecal impaction. b)Increasing opioids for pain from OIC is fundamentally not a good strategy c)Octreotide is helpful for bowel obstruction symptoms, not constipation d)She has no indication for an NGT
HPM 3 During a hospice interdisciplinary team meeting, you hear about a 53 year old resident of the local nursing home. He has ALS with bulbar attributes, and is starting to have difficulty swallowing and speaking. He is bedbound most of the day. He has had two episodes of aspiration pneumonia in the last month. His nurse describes the scene with the patient’s wife, Sally, at his side, squeezing his hand with one hand her rosary with the other. He explained to the nurse, “I told Sally that I don’t want a feeding tube. I’ve had a good life and have few regrets. I saw my father-in-law die on a feeding tube and I would not want to go through that, or put my wife through that. But I am Catholic. Our friend at the parish said that I have to ‘do everything’ to prolong my life – especially when it comes to nutrition - or I will go hell. I don’t want to go to hell. ” His wife nods emphatically. During the interdisciplinary care meeting, the chaplain (in his role as teacher) asks you to explain to the team what your understanding of the Catholic doctrine is as pertaining to this patient. What do you say? a)My understanding is that medically assisted nutrition is obligatory for patients who are unable to take food by mouth. b)My understanding is that medically assisted nutrition is morally optional for most patients at the end of life.
HPM 3 During a hospice interdisciplinary team meeting, you hear about a 53 year old resident of the local nursing home. He has ALS with bulbar attributes, and is starting to have difficulty swallowing and speaking. He is bedbound most of the day. He has had two episodes of aspiration pneumonia in the last month. His nurse describes the scene with the patient’s wife, Sally, at his side, squeezing his hand with one hand her rosary with the other. He explained to the nurse, “I told Sally that I don’t want a feeding tube. I’ve had a good life and have few regrets. I saw my father-in-law die on a feeding tube and I would not want to go through that, or put my wife through that. But I am Catholic. Our friend at the parish said that I have to ‘do everything’ to prolong my life – especially when it comes to nutrition - or I will go hell. I don’t want to go to hell. ” His wife nods emphatically. During the interdisciplinary care meeting, the chaplain (in his role as teacher) asks you to explain to the team what your understanding of the Catholic doctrine is as pertaining to this patient. What do you say? a)My understanding is that medically assisted nutrition is obligatory for patients who are unable to take food by mouth. b)My understanding is that medically assisted nutrition is morally optional for most patients at the end of life.
HPM 3 - Discussion a) “The obligation of feeding tubes extends to patients in chronic and presumably irreversible conditions (e. g. , the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. b) Feeding tube is optional for most dying patients: Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.
Nausea Vomiting
HPM 4 Mrs. Dole, a 68 year old with 20 year history of Diabetes Mellitus Type II is referred to Palliative Care from Oncology with Stage III Nasopharyngeal carcinoma. Nausea is the key concern. For last 3 years she has had early satiety but maintained weight. Since initiating chemotherapy, she has had nausea for the first 2 days of her chemotherapy cycle, which then resolves. 1 week after the last round of chemotherapy she required intravenous fluids for dehydration. Now 2 weeks later is having intermittent severe nausea. It can be provoked by sudden changes in body position. She fell once because she lost her balance. Usually she does not vomit, but occasionally does. She describes a feeling of the room spinning associated with the nausea. Of the following options, which drug is most targeted to this patient’s specific nausea type: a) Ondansetron b) Prochlorperazine c) Metoclopramide d) Diazepam e) Meclizine
HPM 4 Mrs. Dole, a 68 year old with 20 year history of Diabetes Mellitus Type II is referred to Palliative Care from Oncology with Stage III Nasopharyngeal carcinoma. Nausea is the key concern. For last 3 years she has had early satiety but maintained weight. Since initiating chemotherapy, she has had nausea for the first 2 days of her chemotherapy cycle, which then resolves. 1 week after the last round of chemotherapy she required intravenous fluids for dehydration. Now 2 weeks later is having intermittent severe nausea. It can be provoked by sudden changes in body position. She fell once because she lost her balance. Usually she does not vomit, but occasionally does. She describes a feeling of the room spinning associated with the nausea. Of the following options, which drug is most targeted to this patient’s specific a) b) c) d) e) nausea type: Ondansetron Prochlorperazine Metoclopramide Diazepam Meclizine
HPM 4 -Nausea Discussion • • • She has vestibular nausea: ? otolith from dehydration vs chemotherapy toxicity Muscarinic blockers – meclizine, scopolamine, promethazine best agents Gastroparesis – metoclopramide – controversial Chemotherapy-induced N/V 5 HT 3 blockers Steroids NK-1 blockers (aprepitant) Not D 2 blockers (2 nd line only) • • D 2 blockers- prochlorperazine, haloperidol – generally first line otherwise
HPM 5 In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice? ” Which one of the following is not a potential scenario to use octreotide? Choose the best answer. a)a 37 year old male with end stage alcoholic hepatitis who starts vomiting blood b)a 90 year old with a severe diarrhea with a history of a rectal tumor and radiation burns to the perineal area c)a 42 year old female with a tense distended abdomen leaking a small amount from a previous paracentesis site. d)a 27 year old male with a malignant wound with copious drainage e)a 31 year old female with abdominal pain from opioid-induced constipation
HPM 5 In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice? ” Which one of the following is not a potential scenario to use octreotide? Choose the best answer. a)a 37 year old male with end stage alcoholic hepatitis who starts vomiting blood b)a 90 year old with a severe diarrhea with a history of a rectal tumor and radiation burns to the perineal area c)a 42 year old female with a tense distended abdomen leaking a small amount from a previous paracentesis site. d)a 27 year old male with a malignant wound with copious drainage e)a 31 year old female with abdominal pain from opioid-induced constipation
HPM 5 - • Octreotide = synthetic somatostatin analog = generalized decrease of secretions throughout the GI tract • Expensive • Primary role is in palliation of n/v in malignant bowel obstructions – diminishes volume of GI secretions – may prevent need for NG intubation • Also decreases splanchnic blood flow and can decrease variceal bleeding in portal hypertension • Can diminish diarrhea – especially secratory diarrhea including radiation enteritis • Some experience showing tumor-related secretions diminish – has a limited role in malignant wound palliation • Octreotide would not be warranted in a patient with opioid-induced constipation, as it could worsen the constipation.
HPM 6 You visit a patient at home receiving hospice care for cancer. Her pain has been well controlled with long acting morphine 60 mg BID and occasional PRN doses of short acting liquid morphine (10 mg) over the past few weeks: she had been tolerating this well. She has had recent progressive functional decline and is currently at a PPS of 20%. In the last 24 hours the patient has vomited and has been more lethargic and having difficulty swallowing pills. She appears uncomfortable. In your examination you see a very thin patient who appears to be dying with a prognosis in the few days to a week range. The patient’s son is a respiratory therapist at a hospital and is insisting you change the patient’s opioid to a fentanyl patch because “it is less sedating than morphine. ” The best response is: a)Because the patient is cachectic, you tell the family that fentanyl transdermal patches are not indicated because the medication will not be absorbed. b)Agree with the son and convert the patient to a 37. 5 mcg/hr fentanyl patch with oral morphine liquid 10 mg q 1 hour PRN c)Because the fentanyl will not be effective for over 24 hours, continue the long acting morphine sulfate 60 mg BID but give it rectally instead of by mouth d)Suggest starting a morphine infusion via her port at 1. 7 mg/hr basal with a 3 mg q 30 min bolus PRN after talking with the son about his concerns about sedation.
HPM 6 You visit a patient at home receiving hospice care for cancer. Her pain has been well controlled with long acting morphine 60 mg BID and occasional PRN doses of short acting liquid morphine (10 mg) over the past few weeks: she had been tolerating this well. She has had recent progressive functional decline and is currently at a PPS of 20%. In the last 24 hours the patient has vomited and has been more lethargic and having difficulty swallowing pills. She appears uncomfortable. In your examination you see a very thin patient who appears to be dying with a prognosis in the few days to a week range. The patient’s son is a respiratory therapist at a hospital and is insisting you change the patient’s opioid to a fentanyl patch because “it is less sedating than morphine. ” The best response is: A) Because the patient is cachectic, you tell the family that fentanyl transdermal patches are not indicated because the medication will not be absorbed. B) Agree with the son and convert the patient to a 37. 5 mcg/hr fentanyl patch with oral morphine liquid 10 mg q 1 hour PRN C) Because the fentanyl will not be effective for over 24 hours, continue the long acting morphine sulfate 60 mg BID but give it rectally instead of by mouth D) Suggest starting a morphine infusion via her port at 1. 7 mg/hr basal with a 3 mg q 30 min bolus PRN after talking with the son about his concerns about sedation.
HPM 6 • • It is a myth that fentanyl transdermal is ineffective in cachexia Fentanyl is not less sedating that morphine There is no 37. 5 fentanyl patch. 12. 5=12 mcg/hr patch Delay to fentanyl onset would not be a reason to start it if otherwise indicated Most patients prefer to avoid PR meds 37 mcg/hr is a reasonable conversion from morphine based on manufacturer’s recommendation. 2 mg morphine PO=1 mcg/hr transdermal fentanyl rule would suggest a dose of 60 mcg/hr, which would need to be rounded to a patch size. This dying patient is unlikely to regain her swallow, and IV morphine PCA would be a rapid way to achieve and maintain pain relief
HPM 7 JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam. Prior to her hospitalization, she took oxycodone ER 30 mg q 12 h. Currently she is on a hydromorphone IV PCA at 2 mg/hour, with 2 mg q 30 minute boluses. She used 72 mg of IV dilaudid in the last 24 h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe for most of the day: 7 -8/10, and ‘nearly intolerable’ during vest therapy. The best next step is: a)Increase her PCA basal and ‘bolus’ doses by 50% and monitor for 24 hours. b)Add a 5% lidocaine patch to her chest wall over her rib fractures c)Discontinue hydromorphone and switch the patient to another opioid d)Advise the primary team to stop vest therapies
HPM 7 JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam. Prior to her hospitalization, she took oxycodone ER 30 mg q 12 h. Currently she is on a hydromorphone IV PCA at 2 mg/hour, with 2 mg q 30 minute boluses. She used 72 mg of IV dilaudid in the last 24 h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe for most of the day: 7 -8/10, and ‘nearly intolerable’ during vest therapy a)Increase her PCA basal and ‘bolus’ doses by 50% and monitor for 24 hours. b)Add a 5% lidocaine patch to her chest wall over her rib fractures c)Discontinue hydromorphone and switch the patient to another opioid d)Advise the primary team to stop vest therapies
HPM 7 -Opioid Rotation Discussion Indications for opioid rotation are 1) dose-limiting side effects such as sedation, 2) need for a new dosing route (patient cannot swallow), 3) costs/insurance changes, 4) inadequate analgesia despite ‘adequate’ dose-escalation of the current opioid. Morphine, methadone, or fentanyl are all reasonable options for rotation. Some prefer methadone in these sorts of settings: no data. No data at all suggesting the lidocaine patch is effective for pain from fractures
HPM 8 Mr. Smith is a 72 year old patient was admitted to hospital from his nursing home for respiratory distress due to CHF exacerbation. Despite aggressive diuresis attempts, his respiratory distress continued and his urine output remained minimal (~30 ml/day). PMH: heart failure, moderate dementia, renal insufficiency Home medications: furosemide 40 mg po bid, metoprolol 25 mg bid, donepezil 10 mg daily, olanzapine 5 mg qhs. After a conversation with his son (health care proxy) the patient was "made CMO" (comfort measures only) by the hospitalist service and resident team two days ago. He was then started on a morphine drip “titrate by 1 mg as needed for pain or shortness of breath”, his donepezil, olanzapine and diuretics continued, other medications stopped. His intern calls in a panic: “We promised to make him comfortable, that he would die in 2 days, but he is still alive and the family does not know why he is in such pain – even with light touch – crying out & jerking. ” What is your recommendation? a)Stop morphine drip and start fentanyl and lorazepam prn b)Increase morphine and olanzapine c)Increase morphine and add lorazepam prn d)Stop morphine drip and start fentanyl, increase olanzapine
HPM 8 Mr. Smith is a 72 year old patient was admitted to hospital from his nursing home for respiratory distress due to CHF exacerbation. Despite aggressive diuresis attempts, his respiratory distress continued and his urine output remained minimal (~30 ml/day). PMH: heart failure, moderate dementia, renal insufficiency Home medications: furosemide 40 mg po bid, metoprolol 25 mg bid, donepezil 10 mg daily, olanzapine 5 mg qhs. After a conversation with his son (health care proxy) the patient was "made CMO" (comfort measures only) by the hospitalist service and resident team two days ago. He was then started on a morphine drip “titrate by 1 mg as needed for pain or shortness of breath”, his donepezil, olanzapine and diuretics continued, other medications stopped. His intern calls in a panic: “We promised to make him comfortable, that he would die in 2 days, but he is still alive and the family does not know why he is in such pain – even with light touch – crying out & jerking. ” What is your recommendation? a)Stop morphine drip and start fentanyl and lorazepam prn b)Increase morphine and olanzapine c)Increase morphine and add lorazepam prn d)Stop morphine drip and start fentanyl, increase olanzapine
HPM 8 - Discussion Opioid neurotoxicity in the setting of renal failure/azotemia is the most likely answer. Morphine metabolites (morphine 3 -glucoronide) builds up disproportionately in the setting of renal failure and is a neurostimulant that can lead to agitated delirium, myoclonus, hyperalgesia, and even seizures. Morphine and hydromorphone are the most common culprits. The treatment for this is to rotate off current opioid. Fentanyl is safer option in renal failure. Antipsychotics can worsen the symptoms Benzodiazepines can help treat myoclonus and prevent seizures. References: Robin K Wilson, David E Weissman; Neuroexcitatory effects of opioids: patient assessment, 2 nd ed. EPERC# 057 http: //www. eperc. mcw. edu/EPERC/Fast. Facts. Index/ff_057. htm http: //www. aahpm. org/apps/blog/? tag=boards Smith, H. S. (2009). Opioid metabolism. Mayo Clinic proceedings. Mayo Clinic, 84(7), 613 -24. Is there a Geri. Pal or Pallimed reference too?
HPM 9 BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer. She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilaterally in her lower extremities both proximally and distally. You obtain a stat MRI which shows a T 12 vertebral metastasis and cord compression. In addition to administering glucocorticoids, then next best step is to: • Arrange an urgent radiation oncology consultation for the next day. • Admit her to the hospital, and arrange a stat radiation oncology consultation. • Admit her to the hospital, and arrange a stat spine surgery consultation. • Adjust her pain medications appropriately, and instruct her to contact you immediately if her pain or disability worsens
HPM 9 BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer. She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilaterally in her lower extremities both proximally and distally. You obtain a stat MRI which shows a T 12 vertebral metastasis and cord compression. In addition to administering glucocorticoids, then next best step is to: • Arrange an urgent radiation oncology consultation for the next day. • Admit her to the hospital, and arrange a stat radiation oncology consultation. • Admit her to the hospital, and arrange a stat spine surgery consultation. • Adjust her pain medications appropriately, and instruct her to contact you immediately if her pain or disability worsens
HPM 9 -Cord Compression Discussion Medical emergency New or otherwise suspicious back-pain can be evaluated urgently with a noncontrast MRI of the entire spine. If patients have neurologic symptoms of LE weakness and/or bladder, bowel dysfunction, it is a medical emergency and patients needs stat imaging, steroids, and intervention. Neurologic deficits, once present, can rapidly progress to permanent paraplegia within 24 h. A recent trial indicated better outcomes with immediate surgery vs radiation alone, especially for patients who came in with severe weakness. 84% of patients vs 54% were ambulatory after treatment course with surgery vs radiation without surgery. Actual practice has not necessarily caught up with this, and will depend on local, institutional resources.
HPM 10 Mr. G. Da Salva is a 68 year old construction worker who has metastatic non-small cell lung cancer involving his right femur and pelvis. Medications include: Morphine ER 200 mg bid, Morphine IR 30 -60 mg PO q 2 hours prn, and dexamethasone 8 mg daily. At rest his pain is well managed, 2/10. However, he fears movement due to severe pain and spends most of the day in his recliner, avoiding showering or changing or helping with the meals. He uses approximately 5 doses daily of 60 mg short-acting morphine for this pain but once it starts to work the pain has often spontaneously subsided and he becomes sleepy and confused. Which of the following is LEAST appropriate? a)Take a short-acting morphine prior to a clustering his activities: showering, changing, fixing a meal. b)Add sublingual fentanyl 200 mcg to take prior to his activities. c)Increase his long-acting morphine to 200 mg tid. d)Single-fraction radiation therapy to his pelvis and femur. e)Intrathecal pump with morphine and low-dose bupivacaine.
HPM 10 Mr. G. Da Salva is a 68 year old construction worker who has metastatic non-small cell lung cancer involving his right femur and pelvis. Medications include: Morphine ER 200 mg bid, Morphine IR 30 -60 mg PO q 2 hours prn, and dexamethasone 8 mg daily. At rest his pain is well managed, 2/10. However, he fears movement due to severe pain and spends most of the day in his recliner, avoiding showering or changing or helping with the meals. He uses approximately 5 doses daily of 60 mg short-acting morphine for this pain but once it starts to work the pain has often spontaneously subsided and he becomes sleepy and confused. Which of the following is LEAST appropriate? a)Take a short-acting morphine prior to a clustering his activities: showering, changing, fixing a meal. b)Add sublingual fentanyl 200 mcg to take prior to his activities. c)Increase his long-acting morphine to 200 mg tid. d)Single-fraction radiation therapy to his pelvis and femur. e)Intrathecal pump with morphine and low-dose bupivacaine.
HPM 10 -Incident Pain Discussion • Incident pain = related to specific movements and diminishes when movement ceases; pain can rapidly fluctuate, attenuate prior to onset of analgesia from an immediate release opioid • Clustering can help, but still can be a practical challenge • Transbuccal fentanyl has a shorter onset time oral opioids • Increasing the long-acting morphine will sedate him, and is unlikely to help with incident pain much • Radiotherapy may provide durable pain relief • Intrathecal pain medication delivery - lower systemic levels and sedation
HPM 11 Mr. Z is a 87 year old with advanced dementia living in a nursing home. At baseline he cannot recognize family members, is dependent on all ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence. He speaks about 1 -2 intelligible words per day and he has had progressive loss of ability to ambulate. He is now admitted to the hospital after sustaining a hip fracture from a fall. When discussing treatment options for his hip fracture, his wife asks you how long he likely has to live. Given his current state of health, what would be the most appropriate answer: a)Given that he does not meet FAST 7 C criteria his prognosis is likely greater than 6 months b)He meets NHPCO Guidelines for hospice eligibility which means he likely has less than a 6 month prognosis c)Given his advanced dementia and recent hip fracture, his 6 month mortality risk exceeds 50% d)As with most individuals with advanced dementia, his life expectancy is likely weeks to months
HPM 11 Mr. Z is a 87 year old with advanced dementia living in a nursing home. At baseline he cannot recognize family members, is dependent on all ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence. He speaks about 1 -2 intelligible words per day and he has had progressive loss of ability to ambulate. He is now admitted to the hospital after sustaining a hip fracture from a fall. When discussing treatment options for his hip fracture, his wife asks you how long he likely has to live. Given his current state of health, what would be the most appropriate answer: a)Given that he does not meet FAST 7 C criteria his prognosis is likely greater than 6 months b)He meets NHPCO Guidelines for hospice eligibility which means he likely has less than a 6 month prognosis c)Given his advanced dementia and recent hip fracture, his 6 month mortality risk exceeds 50% d)As with most individuals with advanced dementia, his life expectancy is likely weeks to months
HPM 11 -Dementia Discussion a) Hospice eligibility criteria for dementia: • Exceeds Stage 7 c on the FAST and whether they have at least one complication from their dementia. • FAST criteria are not accurate predictors of 6 month mortality. b) NHPCO guidelines relies on the FAST staging • FAST Stage is the highest consecutive level of disability. • Dementia often does not progress in a sequential pattern. c) 6 -month mortality for patients hospitalized with pneumonia or hip fracture • 55% for end-stage dementia patients • 12% for cognitively intact patients d) Individuals with advanced dementia who reside in a nursing home • 6 -month mortality rate is 25% • Median survival in one study of only 478 days
HPM 12 Mrs. A is an 88 year old with advanced dementia who lives in a nursing home. She has at baseline some difficulty with eating as she pockets food in her mouth and occasionally coughs after swallowing. She is now hospitalized for an aspiration pneumonia. In addition to the antibiotics she is on in the hospital, her only other medications include HCTZ for hypertension and a baby aspirin. She has never taken a cholinesterase inhibitor. What is the best next step? a)A trial of both a cholinesterase inhibitors and memantine b)Feeding tube insertion c)Careful hand feeding and good oral care d)Addition of olanzapine to treat her pocketing of food behavior
HPM 12
HPM 12 Mrs. A is an 88 year old with advanced dementia who lives in a nursing home. She has at baseline some difficulty with eating as she pockets food in her mouth and occasionally coughs after swallowing. She is now hospitalized for an aspiration pneumonia. In addition to the antibiotics she is on in the hospital, her only other medications include HCTZ for hypertension and a baby aspirin. She has never taken a cholinesterase inhibitor. What is the best next step? a)A trial of both a cholinesterase inhibitors and memantine b)Feeding tube insertion c)Careful hand feeding and good oral care d)Addition of olanzapine to treat her pocketing of food behavior
HPM 12 -Dementia Discussion a) Dementia drugs: • Marginal improvements in clinically relevant outcomes • Adverse events are common – especially GI upset. • They do not decrease eating problems or risk for aspirations b) PEG tubes • Do not prevent aspiration pneumonia, decrease the risk for pressure ulcers, improve patient comfort, or prolong life. c) Oral care • Shown to decrease incidence of pneumonia, number of febrile days, and death from pneumonia in nursing home residents. d) Antipsychotics • Not been shown to improve eating behaviors in dementia. • Moderate short-term efficacy when treating agitation • Serious side effects that include risk of stroke and death limit their clinical use
HPM 12 – Part 2 The family is concerned that Mrs. A’s aspirations will continue if she continues to be fed by hand in the nursing home. They would like to know about more about the risks of a feeding tube placement. The most appropriate risk to include in the discussion is: a)She will have a 1 in 10 chance of a major surgical complication in the perioperative period, b)She is unlikely to have a tube related complication after the perioperative period c)Once the tube is placed, it would be technically difficult to electively remove the tube d)She will have a 1 in 3 chance of requiring chemical or physical restraints to prevent tube removal
HPM 12 – Part 2 The family is concerned that Mrs. A aspirations will continue if she continues to be fed by hand in the nursing home. They would like to know about more about the risks of a feeding tube placement. The most appropriate risk to include in the discussion is: a)She will have a 1 in 10 chance of a major surgical complication in the perioperative period, b)She is unlikely to have a tube related complication after the perioperative period c)Once the tube is placed, it would be technically difficult to electively remove the tube d)She will have a 1 in 3 chance of requiring chemical or physical restraints to prevent tube removal
HPM 12 -Dementia Discussion a) Major complications like bowel perforations are rare (1%) b)Tube dislodgement, blockage, and leakage are common (4%-11%). • One in 5 tube-fed residents experiencing a tube related complication necessitating a hospital transfer in the year following insertion. . c) Removal of feeding tubes is not technically difficult. • Pearl: if a feeding tube is inadvertently removed, the stoma site will close in a few hours, so put in a foley catheter to keep it open until a new one can be placed d)Physical and chemical restraints post-feeding tube are common • 1/4 are physically restrained after feeding tube placement • 1/3 are placed on sedating medications to prevent them from pulling out the feeding tube
HPM 13 A 54 yo man with a 7 month history of metastatic bladder cancer presents to the cancer center’s palliative care clinic. He complains of low mood, anhedonia, feelings of guilt, shame, and worthlessness most days for the last 2 months. He says, “Of course I’m depressed – who wouldn’t be? I’ve got a cancer that the doctors tell me is terminal. What good am I to my family? They’d be better off without me. ” The best next step would be to: a)Counsel the patient that he is depressed and recommend a treatment plan for it. b)Ask your team’s social worker to see the patient for grief counseling. c)Provide emotional support and counseling with the patient that what he is experiencing is part of the expected adjustment to having a terminal illness. d)Refer the patient to psychiatry for complicated depression.
HPM 13 A 54 yo man with a 7 month history of metastatic bladder cancer presents to the cancer center’s palliative care clinic. He complains of low mood, anhedonia, feelings of guilt, shame, and worthlessness most days for the last 2 months. He says, “Of course I’m depressed – who wouldn’t be? I’ve got a cancer that the doctors tell me is terminal. What good am I to my family? They’d be better off without me. ” The best next step would be to: a)Counsel the patient that he is depressed and recommend a treatment plan for it. b)Ask your team’s social worker to see the patient for grief counseling. c)Provide emotional support and counseling with the patient that what he is experiencing is part of the expected adjustment to having a terminal illness. d)Refer the patient to psychiatry for complicated depression.
HPM 13 -Depression Discussion • • • Depression is more common in cancer/advanced illness (10 -40%), but is not the norm. Guilt, shame, feelings of worthlessness are not ‘normal’ and patients should be offered help. Mental health referral is important if the patient is willing, but his major problem is depression not grief Complicated depression is not a diagnosis. He has untreated depression, and HPM specialists should be able to initiate appropriate therapy!
HPM 14 The patient agrees to pharmacologic therapy for his depression, and declines offers of counseling/therapy. Your best estimate is that he has 4 -8 weeks to live based on performance status and tempo of decline. Which of the following are appropriate drug approaches for his depression? (choose as many answers as you think correct) a)Methylphenidate b)Ketamine c)Dronabinol d)Sertraline
HPM 14 The patient agrees to pharmacologic therapy for his depression, and declines offers of counseling/therapy. Your best estimate is that he has 4 -8 weeks to live based on performance status and tempo of decline. Which of the following are appropriate drug approaches for his depression? a)Methylphenidate b)Ketamine c)Dronabinol d)Sertraline
HPM 14 -Depression in cancer part 2 Discussion • • • Methylphenidate and other psychostimulants are rapidlyacting, with onset of mood elevation occurring ~immediately (if they are going to be effective at all). Ketamine – emerging interest in its use as an immediately effective antidepressant for terminally ill patients Dronabinol has no defined role as an antidepressant. Most SSRIs take at least 4 weeks to become effective SSRIs are first line treatments for depression in healthy patients and in advanced illness, except when prognosis is short.
I say depression, insomnia, anorexia, nausea – You say: a) Trazodone b) Paroxetine c) Mirtazapine d) Escitalopram I say depression, anxiety, insomnia, neuropathy, You say: a) nortriptyline b) duloxetine c) fluoxetine d) venlafaxine I say activating antidepressants, You say a) fluoxetine b) paroxetine c) buproprion d) citalopram I say depression, anxiety, neuropathic pain, advanced age, You say: a) duloxetine b) nortriptyline c) paroxetine d) mirtazapine
Popquiz 1, 2, 3, 4 I say depression, insomnia, anorexia, nausea – You say: a) Trazodone b) Paroxetine c) Mirtazapine d) Escitalopram I say depression, anxiety, insomnia, neuropathy, You say: a) nortriptyline b) duloxetine c) fluoxetine d) venlafaxine I say activating antidepressants, You say a) fluoxetine b) paroxetine c) buproprion d) citalopram I say depression, anxiety, neuropathic pain, advanced age, You say: a) duloxetine b) nortriptyline c) paroxetine d) mirtazapine
1. 2. 3. 4. Popquiz 1, 2, 3, 4 discussion Mirtazapine has side effects which include drowsiness and weight gain, plus some antiemetic effects TCAs are the only drug class that directly treat all those symptoms (SNRIs like duloxetine and venlafaxine aren’t known to be directly effective for insomnia). Paroxetine can be sedating; citalopram more neutral Duloxetine seems to be better tolerated than TCAs, especially in the elderly. For the boards, would avoid giving elderly TCAs. Mirtazapine’s role in pain is not well defined, especially compared to SNRIs and TCAs.
HPM 15 Mrs. Phillips is a 91 -year-old hospitalized patient who is now actively dying due to end-stage pulmonary fibrosis and asbestosis. She has been well palliated during the last several months at home where she lived independently, until she developed a pneumonia and was hospitalized. Her home medications had not been adjusted in over six weeks. This included: albuterol and atropine nebulizers, dexamethasone 2 mg every morning, 25 mcg/hour fentanyl patch for dyspnea, oxycodone concentrate (20 mg/ml) 10 mg q 2 hours prn dyspnea or pain, senna and Colace. She is on day 7 of oral antibiotics for presumed pneumonia. She is on oxygen 6 liters via nasal cannula. Her last bowel movement was yesterday, and her urine output has been good (250 ml or more daily. ) Yesterday she was still oriented, between periods of increasing fatigue and sleep. She showed signs of mottling and new secretions causing respiratory rattle. A scopolamine patch 1. 5 mg was started for her increased secretions. You are called by the resident who explains to you that this morning Mrs. Phillips is now agitated, moaning, and even thrashing at times. This is causing family and floor nurses distress. He asks you for advice.
HPM 15 Which of the following is appropriate? a) Stop scopolamine b)Start lorazepam c) Increase the fentanyl d)Stop the fentanyl e) Tell family agitation is inevitable. f) Order soft restraints
HPM 15 Which of the following is appropriate? a) Stop scopolamine b)Start lorazepam c) Increase the fentanyl d)Stop the fentanyl e) Tell family agitation is inevitable. f) Order soft restraints
HPM 15 -Delirium Discussion • Delirium common at EOL; ‘terminal delirium’ is a diagnosis of exclusion; at times underlying cause can be easily addressed and treated even near EOL • The most common causes of delirium in this setting, remain constipation, urinary retention, medications, infection, electrolyte abnormalities. • Scopolamine=tertiary amine=crosses BBB = causes delirium • Delirium unlikely from opioids if on a stable, previously tolerated dose • Constipation, urinary retention can be ruled out in this patient. • Lorazepam is not the best option. • Restraints should be avoided. • Family members should be comforted, but not that it is an inevitable part of dying.
HPM 16 Mr. J is 58 year old diagnosed with ALS 6 months ago. He is referred to your clinic by his primary care doctor to help discuss options to treat a progressive weight loss. He currently lives alone in an apartment, is independent of ADLs although he has been having difficulty feeding himself due to proximal arm weakness. He complains that he occasionally bursts out crying or laughing, but denies feeling depressed. His forced vital capacity (FVC) has remained at 70% for the last 3 months. The best treatment to help treat his progressive weight loss? a)Riluzole b)PEG Placement c)Mobile arm supports and modified cutlery d)Non Invasive Positive Pressure Ventilation (NIPPV)
HPM 16 Mr. J is 58 year old diagnosed with ALS 6 months ago. He is referred to your clinic by his primary care doctor to help discuss options to treat a progressive weight loss. He currently lives alone in an apartment, is independent of ADLs although he has been having difficulty feeding himself due to proximal arm weakness. He complains that he occasionally bursts out crying or laughing, but denies feeling depressed. His forced vital capacity (FVC) has remained at 70% for the last 3 months. The best treatment to help treat his progressive weight loss? a)Riluzole b)PEG Placement c)Mobile arm supports and modified cutlery d)Non Invasive Positive Pressure Ventilation (NIPPV)
HPM 16 -ALS Discussion a) Riluzole: • Only available disease-modifying therapy for ALS. • Prolongs median survival in patients with ALS by 2 -3 months compared to patients taking placebo. Does little to improve functional outcomes or bulbar symptoms. There is no evidence to suggest that it is beneficial for weight loss. PEG placement: Should be considered in ALS, although attempt to reverse other common reasons for weight loss is warranted before PEG placement. PEG tubes should be placed before FVC falls below 50%. • b) • • c) Mobile arm supports and modified cutlery • • Difficulty with the mechanics of both cooking and putting food from the plate to the mouth is common and may contribute to weight loss Occupational therapy may help by supplying assistive devices • moderately impaired bulbar function Does not improve weight. d) NIPPV: • Survival benefit and improves quality of life in patients with normal or
HPM 17 Mr G is a 74 year old nursing home resident with coronary artery disease and end-stage renal failure (e. GFR of 12). He is considering starting treatment with dialysis but would like to know more about what life will be like after starting dialysis. What would be the most accurate statement in regards to his prognosis a)His functional status is likely to improve with renal replacement therapy b)His functional status is likely to be maintained at his pre-dialysis level c)He is unlikely to have significant symptom burden if he elects not to initiate dialysis d)The majority of nursing home residents die within one year of starting dialysis
HPM 17 Mr G is a 74 year old nursing home resident with coronary artery disease and end-stage renal failure (e. GFR of 12). He is considering starting treatment with dialysis but would like to know more about what life will be like after starting dialysis. What would be the most accurate statement in regards to his prognosis a)His functional status is likely to improve with renal replacement therapy b)His functional status is likely to be maintained at his pre-dialysis level c)He is unlikely to have significant symptom burden if he elects not to initiate dialysis d)The majority of nursing home residents die within one year of starting dialysis
HPM 17 -ESRD Discussion a) Nursing home patients who start dialysis do poorly • Within 3 months after the start of dialysis, 61% die or had a decrease in functional status as compared with their functional status before dialysis. • By 12 months, almost all (87%) nursing home residents had died or had a decrease in functional status after starting dialysis. b) Only 39% had the same functional status that they had before dialysis. c) Last month of life for those who elect not to undergo renal replacement therapy: • • Associated with high symptom burden similar to that of advanced cancer. Common symptoms include lack of energy, itching, feeling drowsy, shortness of breath, difficulty concentrating, pain, lack of appetite, and swelling of arms/legs. d) 58% of nursing home residents die one year after initiating dialysis
HPM 18 George Condi is a 68 y/o male is admitted to ICU for respiratory crisis and found to have renal cell carcinoma with a 13 cm mass in the R upper abdomen. He has severe pain, and dyspnea with large R sided pleural effusion. With drainage of effusion his dyspnea is improved; a tunneled pleural catheter is placed, and he is discharged to home hospice with a PPS of 50. The next day his wife calls saying she can’t manage the catheter and she is in tears because his pain is 6/10 and he is more short of breath. “You promised me it wouldn’t be like this!” She wants to take him to the emergency room for IV furosemide and a pulmonologist visit. The best approach is to: a)Arrange for a hospice nurse to meet the patient in the emergency room to disenroll him from hospice b)Set up in home continuous care to manage his catheter c)Immediately prepare a respite stay d)Admit the patient to a qualified skilled nursing facility for General Inpatient stay for pain control
HPM 18 George Condi is a 68 y/o male is admitted to ICU for respiratory crisis and found to have renal cell carcinoma with a 13 cm mass in the R upper abdomen. He has severe pain, and dyspnea with large R sided pleural effusion. With drainage of effusion his dyspnea is improved; a tunneled pleural catheter is placed, and he is discharged to home hospice with a PPS of 50. The next day his wife calls saying she can’t manage the catheter and she is in tears because his pain is 6/10 and he is more short of breath. “You promised me it wouldn’t be like this!” She wants to take him to the emergency room for IV furosemide and a pulmonologist visit. The best approach is to: a)Arrange for a hospice nurse to meet the patient in the emergency room to disenroll him from hospice b)Set up in home continuous care to manage his catheter c)Immediately prepare a respite stay d)Admit the patient to a qualified skilled nursing facility for General Inpatient stay for pain control
HPM 18 -Hospice GIP Discussion a) The family needs are symptom management and training about catheter care. ED is not best place of care for this. b) Continuous care could be a reasonable choice if the issue were only the catheter. The requirement for skilled care is the same as for gip and it is a good option for a patient who really does not want to be in a facility but in this case the patient’s intensive symptom need may need 24 hour nursing care and continuous care is not entirely provided by nursing level care c) Respite should be planned, or for caregiver breakdown when there is not a skilled care need d) GIP: In this case, the patient has severe dyspnea and pain and is requiring both catheter drainage of an effusion and rapid titration of opioids to control his symptoms in a manner that his care givers are not capable of providing currently. GIP is to provide skilled care for the patient that cannot be provided in the home. Documentation for GIP based on pain must include: Frequent evaluation Frequent medication adjustment Aggressive interventions to control the pain • • •
HPM 19 George is admitted to GIP status in a skilled nursing facility with 24 hour RN availability. He has had a marked decline since he was seen 2 days ago. The hospice nurse is asking whether the plan should be to send him back home after the symptoms are controlled. The social worker doesn’t want to bring that up because it might upset the wife and because it might give George false hope. The entire Interprofessional group thinks he might die in the next week or two. You reply that: a)Since he’ll likely die in 7 -10 days, it will be fine to continue on General Inpatient Status for imminently dying criteria so discharge discussions don’t need to be raised b)Due to the wife’s burden of caregiver distress, the patient will be maintained on General Inpatient Status for caregiver breakdown so discharge discussions don’t need to be raised c)Once admitted to General Inpatient Status, one of the goals must be transition to a lower level of care d)Since General Inpatient status should only last 7 days, discharge discussions will start after the first 3 days to let the family have some relief.
HPM 19 George is admitted to GIP status in a skilled nursing facility with 24 hour RN availability. He has had a marked decline since he was seen 2 days ago. The hospice nurse is asking whether the plan should be to send him back home after the symptoms are controlled. The social worker doesn’t want to bring that up because it might upset the wife and because it might give George false hope. The entire Interprofessional group thinks he might die in the next week or two. You reply that: a)Since he’ll likely die in 7 -10 days, it will be fine to continue on General Inpatient Status for imminently dying criteria so discharge discussions don’t need to be raised b)Due to the wife’s burden of caregiver distress, the patient will be maintained on General Inpatient Status for caregiver breakdown so discharge discussions don’t need to be raised c)Once admitted to General Inpatient Status, one of the goals must be transition to a lower level of care d)Since General Inpatient status should only last 7 days, discharge discussions will start after the first 3 days to let the family have some relief.
HPM 19 -Hospice GIP Discussion a) There is no GIP status for ‘imminently dying. ’ There must be some symptom that requires management b) CMS has clarified that GIP should only be used based on the patient condition and should not be used due to caregiver “breakdown”. (CMS Quarterly Provider Update April 2007, http: //www. cms. hhs. gov/quarterlyproviderupdates/downloads/cms 1539 p. pdf) c) Direct wording from quarterly. The goal may not be achievable, but needs to be a part of planning and discussion. d) There is no specified time limit to GIP status, although some fiscal intermediaries do appear to increase audits after the first 7 days
HPM 20 Mrs. Tagliatelli is a 76 year old Italian immigrant and widow who has not missed a day of mass in her adult life until this past month. She comes to see her primary care physician in clinic because she missed mass, asking whether she should get hospice. She has heart failure, mild hypertension, and sleep apnea. She has noted that over the last month, her legs are more swollen and she is having increased difficulty walking to church and the grocery store. She still keeps an impeccable home, managing her housecleaning herself, but now is sitting down for a longer period of time after carrying the vacuum up and downstairs. She is also able to maintain her daily rituals of reading the NYTimes Health and Travel sections, cooking three small meals each day. She no longer wishes to return to hospital, and has not been admitted since her myocardial infarction 5 years ago, which preceded her diagnosis of heart failure. At that time, she had a successful resuscitation and wishes to remain full code. She uses CPAP at night for her sleep apnea, but otherwise does not require oxygen. She also tells you that because she lives alone, she keeps a gun in her home for self-protection. Her home medications include: Furosemide 10 mg BID, Atenolol 50 mg daily, lisinopril 10 mg daily, simvastatin 5 mg daily, aspirin 81 mg daily. She also has nitroglycerine 0. 4 mg sl prn (which she has not used since her MI), and acetaminophen 325 mg which she takes “once in a while for an ache. ”
HPM 20 Why would this patient not be admitted to hospice? a)She is full code. b)She lives alone. c)She has greater than a six-month prognosis. d)She is not homebound. e)She has firearms in the home.
HPM 20 Why would this patient not be admitted to hospice? a)She is full code. b)She lives alone. c)She has greater than a sixmonth prognosis. d)She is not homebound. e)She has firearms in the home.
HPM 20 -Hospice Discussion • • Her current NYHA class is 2, due to increased symptoms with activity. General guidelines for heart failure include hospitalization within the last 6 -months to a year, dyspnea with minimal exertion or at rest. Since she still is independent in all ADLs including thorough house-cleaning, without becoming dyspneic, she is unlikely to qualify for a prognosis of 6 months or less. Code status, homebound status, presence of gun in home should not preclude hospice enrollment. Medicare does not require 24 h caregiver in home in order for patient to receive hospice
HPM 21 A couple of years and hospitalizations later, Mrs. Tagliatelli was admitted to hospice. At the time of admission to hospice, she was breathless with minimal exertion. Neighbors and members of her church visited her often offering her food, company, and rides to church. She required oxygen all the time. Even with this, at the time of admission to hospice, she experienced constant dyspnea. Her cardiac medications were continued, morphine ER and IR were added for her dyspnea. After six months on hospice, she is now well palliated, especially since she has been able to have her medications as prescribed and no longer spaces out her medications in order to make them last. However, she continues to require help from her friends and neighbors, and oxygen with minimal activity. She fell once and required a trip to the emergency department. You go to see her for recertification visit What do you write in your recertification note? a)She meets criteria for recertification because her prognosis remains 6 -months or less. b)She does not meet criteria for recertification because she has not shown decline in her condition. c)She does not meet criteria for recertification because her last hospitalization was unrelated to her hospice diagnosis.
HPM 21 A couple of years and hospitalizations later, Mrs. Tagliatelli was admitted to hospice. At the time of admission to hospice, she was breathless with minimal exertion. Neighbors and members of her church visited her often offering her food, company, and rides to church. She required oxygen all the time. Even with this, at the time of admission to hospice, she experienced constant dyspnea. Her cardiac medications were continued, morphine ER and IR were added for her dyspnea. After six months on hospice, she is now well palliated, especially since she has been able to have her medications as prescribed and no longer spaces out her medications in order to make them last. However, she continues to require help from her friends and neighbors, and oxygen with minimal activity. She fell once and required a trip to the emergency department. You go to see her for recertification visit What do you write in your recertification note? a)She meets criteria for recertification because her prognosis remains 6 -months or less. b)She does not meet criteria for recertification because she has not shown decline in her condition. c)She does not meet criteria for recertification because her last hospitalization was unrelated to her hospice diagnosis.
HPM 21 -Hospice Discussion • • Some intermediaries recommend the demonstration of decline in clinical condition for a patient to be recertified, and while this is helpful is the recertification process, it is not a CMS requirement. According to Medicare guidelines, the only requirement for hospice is that a patient’s prognosis is 6 months or less. Documentation of a hospitalization can also help qualify a patient for hospice. The cause of hospitalization does not need to be related to the hospice diagnosis.
HPM 22 A A young man was recently in a motor vehicle collision where he suffered a massive head injury and multi-trauma. He was resuscitated and survived in the ICU with a ventilator, continuous hemodialysis, and multiple pressors for the past 2 days, but now he is clearly declining rapidly. You receive a palliative care consult to help with the ventilator withdrawal. You head down to the unit and the nurse comes to you and says “I am not sure you should talk with the family – the organ procurement agency has just visited to discuss organ donation after cardiac death, and the family want to donate his organs – his liver and lungs may be transplantable. ” What is the best next step? A) Thank the nurse, and back out of the consult B) Talk with the family about the patient, their grief, and counsel them about comfort care after cessation of life-support. C) Ask the attending physician of record who is going to manage the patient’s comfort care after cessation of life-support. D) Work with the family to help them realize this will only prolong the patient’s suffering.
HPM 22 A A young man was recently in a motor vehicle collision where he suffered a massive head injury and multi-trauma. He was resuscitated and survived in the ICU with a ventilator, continuous hemodialysis, and multiple pressors for the past 2 days, but now he is clearly declining rapidly. You receive a palliative care consult to help with the ventilator withdrawal. You head down to the unit and the nurse comes to you and says “I am not sure you should talk with the family – the organ procurement agency has just visited to discuss organ donation after cardiac death, and the family want to donate his organs – his liver and lungs may be transplantable. ” What is the best next step? A) Thank the nurse, and back out of the consult B) Talk with the family about the patient, their grief, and counsel them about comfort care after cessation of life-support. C) Ask the attending physician of record who is going to manage the patient’s comfort care after cessation of life-support. D) Work with the family to help them realize this will only prolong the patient’s suffering.
HPM 22 -2 A day later, the patient’s HCV test comes back positive and he is no longer a viable DCD candidate. The ICU attending asks you to ‘take care of the treatment withdrawal’. The family is very disappointed, and ndicates their only goal at this point is for a comfortable death, without ‘prolonging this any longer. ’ His only symptom-directed med is intermittent fentanyl bolus (700 mcg the last 24 h). He is unresponsive on the vent, without any spontaneous movement. The best next step is to: a)Recommend rapidly stopping all life support including CRRT, ventilator, and pressors over the next hour or so, and starting a fentanyl and lorazepam infusion to keep the patient sedated. b)Recommend staggering withdrawal of life support over a couple days including stopping CRRT and pressors now in the hopes that the patient dies on the ventilator. c)Discuss with the family different approaches to life-support withdrawal. d)Switch the patient from fentanyl to morphine boluses as you extubate him, as morphine is more effective for air-hunger.
HPM 22 b
HPM 22 B A day later, the patient’s HCV test comes back positive and he is no longer a viable DCD candidate. The ICU attending asks you to ‘take care of the treatment withdrawal’. The family is very disappointed, and ndicates their only goal at this point is for a comfortable death, without ‘prolonging this any longer. ’ His only symptom-directed med is intermittent fentanyl bolus (700 mcg the last 24 h). He is unresponsive on the vent, without any spontaneous movement. The best next step is to: a)Recommend rapidly stopping all life support including CRRT, ventilator, and pressors over the next hour or so, and starting a fentanyl and lorazepam infusion to keep the patient sedated. b)Recommend staggering withdrawal of life support over a couple days including stopping CRRT and pressors now in the hopes that the patient dies on the ventilator. c)Discuss with the family different approaches to life-support withdrawal. d)Switch the patient from fentanyl to morphine boluses as you extubate him, as morphine is more effective for air-hunger.
HPM 22 • Donation by Cardiac Death = a public good = very compatible with palliative consultation – grief, symptom advice, active management of comfort care • • Donation=important generative act for family, not ‘prolonging suffering’ Hospitals must have DCD policies in place about who directs patients care after extubation, while awaiting hopefully rapid death and organ procurement = may be palliative team = never can be transplant surgeon or OPO people Staggered vs All-at-once withdrawal – family should be involved with the discussion. Limited evidence shows family’s have greater satisfaction with staggered withdrawal IF their loved one had a prolonged ICU stay. Satisfaction greater with all-at-once if ICU stay <3 days. No real reason to switch from fentanyl to morphine; no compelling reason not to. Fentanyl: costlier, not renally excreted, we have a baseline on this patient. Morphine: cheaper, may accumulate but less of a worry if time to death is short (1 -2 d), and not any better for labored resps than other opioids Board Pearl: If answer includes examining patient or talking more – that’s probably the best answer
HPM 23 A 47 year old woman with a severe, idiopathic, dilated cardiomyopathy is receiving hospice care at home. She is ineligible for cardiac transplantation or a ventricular assist device. She has mild resting dyspnea but becomes severely dyspneic after just a few steps of ambulation. Her nurse measures her resting and ambulatory oxygen saturation while breathing ambient air: it is 96 and 92%, respectively. The patient is taking digoxin, bumetamide, hydralazine, isosorbide dinitrate, albuterol MDI, warfarin, senna, and clonzepam. The patient requests home oxygen therapy to help alleviate her breathlessness. The best response is: a)Order home oxygen therapy for the patient b)Initiate lorazepam prn for dyspnea c)Recommend use of a hand-held fan and prn morphine for her dyspnea d)Request that the patient see her cardiologist for further optimization of her heart failure meds
HPM 23 A 47 year old woman with a severe, idiopathic, dilated cardiomyopathy is receiving hospice care at home. She is ineligible for cardiac transplantation or a ventricular assist device. She has mild resting dyspnea but becomes severely dyspneic after just a few steps of ambulation. Her nurse measures her resting and ambulatory oxygen saturation while breathing ambient air: it is 96 and 92%, respectively. The patient is taking digoxin, bumetamide, hydralazine, isosorbide dinitrate, albuterol MDI, warfarin, senna, and clonzepam. The patient requests home oxygen therapy to help alleviate her breathlessness. The best response is: a)Order home oxygen therapy for the patient b)Initiate lorazepam prn for dyspnea c)Recommend use of a hand-held fan and prn morphine for her dyspnea d)Request that the patient see her cardiologist for further optimization of her heart failure meds
HPM 23 -Dyspnea Discussion • • Home oxygen therapy is not recommended as first-line treatment for dyspnea in non-hypoxic patients. It has been shown to be equivalent to ‘sham’ delivery of ambient air via nasal cannula. While there is a role for it even in normoxic patients (it ‘works’, just no better than ambient air), it is not first-line. Hand-held fans have been shown to improve dyspnea, and there is professional consensus that opioids are first-line agents for the symptomatic relief of refractory dyspnea that is not responding to treatment of the underlying cause. Benzodiazepines are 2 nd line and she is already on one Cardiac optimization has a role, but she is already on appropriate meds and less likely to help than air, opioids
HPM 24 Mr. L is a 52 -year-old homeless man. One week ago, he was admitted to the ICU with respiratory distress and was intubated. A chest CT scan revealed a large necrotic mass filling the right hemithorax, obliterating the right and narrowing the left mainstem bronchi. Sputum cytology confirmed a diagnosis of non-small cell lung cancer. Oncology states that there is no role for chemotherapy or radiation unless he could be weaned off the ventilator, which was considered doubtful in the setting of his airway obstruction. Mr. L is unable to participate in medical decision-making. The patient’s mother, who is the authorized decision maker, meets with the palliative care team to discuss prognosis and treatment options, including withdrawal of life-sustaining treatments. The mother is adamant that all life-sustaining measures be continued despite a previous discussion that Mr. L’s disease severity will prevent him from ever leaving the ICU, let alone the hospital. Mr. L’s mother expresses hope that, despite the physician’s prediction, a miracle will occur that will allow her son to leave the hospital.
HPM 24 The next best step is to: a)Schedule another family meeting to reiterate the prognosis of his current condition and the likelihood of recovery b)Involve an ethics committee as the mother’s belief in a miracle is far from a societal norm c)Tell the mother that hope for a miracle is unreasonable, but that she could still hope that her son is comfortable d)Ask the mother about her spiritual beliefs and how it influences her decision
HPM 24 The next best step is to: a)Schedule another family meeting to reiterate the prognosis of his current condition and the likelihood of recovery b)Involve an ethics committee as the mother’s belief in a miracle is far from a societal norm c)Tell the mother that hope for a miracle is unreasonable, but that she could still hope that her son is comfortable d)Ask the mother about her spiritual beliefs and how it influences her decision
HPM 24 -Spiritualty Discussion Test Taking Pearl: any answer which involves exploring something deeper with the patient, or examining them, is probably the correct one • While scheduling another meeting may be appropriate, the ‘problem’ in this scenario is not lack of DATA. Few surrogates base their views of prognosis solely on the physician’s prognostic estimate. Most use a combination of sources including knowledge of the patient’s intrinsic qualities and will to live; their observations and beliefs in the power of their support and presence, and optimism, intuition, and faith Majority of Americans believe in miracles with little difference based on the respondent’s age. Significant differences in belief in miracles have been noted between health care professionals and the general public. Be careful of reframing of hope as it may be perceived as condescending without good understanding of spiritual convictions and beliefs Most individuals would like physicians to ask about their spiritual/religious beliefs. Patients who feel their spiritual needs are supported by the medical team are more likely to receive hospice care than those who report their spiritual needs are unsupported. • •
HPM 25 Omar Johnson is a 64 year old man with cryptogenic cirrhosis in multiorgan system failure in your hospital’s ICU. He is ventilated, unresponsive, and on vasopressors. You and the ICU team agree his chances for surviving this hospitalization are minimal. He has no advance directive. You participate in an ICU family care conference with his wife (his legal decision making based on state law), 2 sisters, and 3 adult sons. They are told he is dying with minimal chance of survival. His sons say they do not think the patient would want to die ‘like this – on machines, ’ and describe several conversations with the patient to support that preference. His wife seems to reluctantly agree with that, but also says, “I can’t give up on him. I can’t have that on my shoulders – I’ll always wonder if I did the right thing. ” The best, next response would be: a)Request ethics consultation b)Along with the ICU physician, suggest to the family that you make the decision on behalf of the patient yourselves, to transition the patient to comfort-care. c)Ask the family to focus on what the patient himself would prefer in these circumstances. d)Express to the family acknowledgment of the emotional difficulty of this, and recommend another meeting the next day.
HPM 25 Omar Johnson is a 64 year old man with cryptogenic cirrhosis in multiorgan system failure in your hospital’s ICU. He is ventilated, unresponsive, and on vasopressors. You and the ICU team agree his chances for surviving this hospitalization are minimal. He has no advance directive. You participate in an ICU family care conference with his wife (his legal decision making based on state law), 2 sisters, and 3 adult sons. They are told he is dying with minimal chance of survival. His sons say they do not think the patient would want to die ‘like this – on machines, ’ and describe several conversations with the patient to support that preference. His wife seems to reluctantly agree with that, but also says, “I can’t give up on him. I can’t have that on my shoulders – I’ll always wonder if I did the right thing. ” The best, next response would be: a)Request ethics consultation b)Along with the ICU physician, suggest to the family that you make the decision on behalf of the patient yourselves, to transition the patient to comfort-care. c)Ask the family to focus on what the patient himself would prefer in these circumstances. d)Express to the family acknowledgment of the emotional difficulty of this, and recommend another meeting the next day.
HPM 25 -Surrogacy Trauma Discussion a) Be wary of it as a board question answer. Ethics consultations have been shown to help with conflict although it wouldn’t be the “best, next response” in this situation. b) Making recommendations for what you believe to be the best plan of care is critically important in these situations. Surrogate decision making is uniquely traumatizing to family members (beyond routine bereavement); when a patient’s preferences are clear, physicians should clearly articulate an appropriate plan of care and not force family members into feeling they are responsible for a patient’s death. c) Generally a good idea – but they already have acknowledged those ‘facts’; the issue here is more comfort with decision-making roles and guilt. d) A 2 nd best option to 2
HPM 26 Mrs. Hassad is a 83 year old retired professor from Iran who is being evaluated for a hospice admission. Her 4 sons live in adjacent homes with their families. She has metastatic breast cancer with bone, liver, and brain. Because of her underlying renal failure and moderate heart failure, she will not be receiving chemotherapy and her physician had arranged home hospice services now that she has completed palliative radiation. She is alert, oriented. The hospice intake nurse calls you because the family and patient state that she does not want to know anything about his diagnosis or severity of illness. Mrs. Hassad’s son tells the nurse not to speak with the patient about her prognosis, her illness, or about code status. You are at the home with the nurse because she does not know how to get her to sign the paperwork to enroll in hospice.
HPM 26 What do you do after confirming with Mrs. Hassad that she does not want to be involved in signing papers or knowing details of his medical condition? a)Explain to the son that you must gain consent from Mrs. Hassad in order to enroll her in hospice in respect of the principle of autonomy. b)Invoke the health care proxy and have Mrs. Hassad’s son sign the paperwork to enroll in hospice. c)Have the son sign the paperwork for hospice since Mrs. Hassad made the autonomous decision to defer decisions to her son. d)Refuse hospice enrollment for the patient since she is unwilling to accept to address her diagnosis and prognosis. e)Clarify to the patient that it is her responsibility to make the decision, based on autonomy, and to avoid trauma of surrogacy in her son. f)Teach the nurse that she should not have questioned the son’s request because that was disrespectful to their culture.
HPM 26 What do you do after confirming with Mrs. Hassad that she does not want to be involved in signing papers or knowing details of his medical condition? a)Explain to the son that you must gain consent from Mrs. Hassad in order to enroll her in hospice in respect of the principle of autonomy. b)Invoke the health care proxy and have Mrs. Hassad’s son sign the paperwork to enroll in hospice. c)Have the son sign the paperwork for hospice since Mrs. Hassad made the autonomous decision to defer decisions to her son. d)Refuse hospice enrollment for the patient since she is unwilling to accept to address her diagnosis and prognosis. e)Clarify to the patient that it is her responsibility to make the decision, based on autonomy, and to avoid trauma of surrogacy in her son. f)Teach the nurse that she should not have questioned the son’s request because that was disrespectful to their culture.
HPM 26 • • Patients can make the autonomous decision to know or not to know information. As outlined in the SPIKES protocol for giving bad news, the Invitation is to ask how much a patient wishes to know. Should patients choose not to be informed they should know that then consents to procedures and medical care must also be deferred to the person they request disclosure to. Healthcare proxy is invoked only when patients lack the capacity to make medical decisions. Here Mrs. Hassad has capacity but chooses to have her son make decisions on her behalf. Hospice enrollment does not require a patient’s acceptance of his or her disease and prognosis. Research shows that most people, regardless of culture or country of origin, wish to have medical information disclosed to them. However, as age and illness advance, patients are more inclined to request less disclosure. One should not assume desire or lack of desire to be involved in medical decision-making and disclosure of information based on culture, religion or country of origin.
HPM 27 Dr. L is a 44 year old palliative care fellow about to complete two months of a busy inpatient consult rotation. You notice that over the last week she has become detached and disengaged when talking with patients and their family members. The fellow acknowledges feeling tired and drained most of the time, as well as having difficulty falling asleep. She also confides in you a personal sense of failure and selfdoubt. The most appropriate interventions at this time is a) Recommend she see her primary doctor to discuss SSRI therapy b) Recommend she try bright light therapy c) Refer for a transient mirrectomy d) Recommend an educational program in mindful communication
HPM 27 Dr. L is a 44 year old palliative care fellow who is about to complete two months of a busy inpatient consult rotation. You notice that over the last week she has become detached and disengaged when talking with patients and their family members. The fellow acknowledges feeling tired and drained most of the time, as well as having difficulty falling asleep. She also confides in you a personal sense of failure and self-doubt. The most appropriate interventions at this time is a) Recommend she see her primary doctor to discuss SSRI therapy b) Recommend she try bright light therapy c) Refer for a transient mirrectomy d) Recommend an educational program in mindful communication
HPM 27 -Burnout Discussion a) The fellow does not meet DSM-IV criteria for depression. • Further exploration would be a correct answer, but starting an SSRI would not. No evidence that bright light therapy is helpful for symptoms of burnout. Some evidence of a small benefit for depressive symptoms though. Transient mirrectomy is a fictional treatment described by Brad Stuart in an April fools day Geri. Pal post. It reportedly is a non-invasive method of numbing brain centers that may induce clinicians to identify with pain and suffering to a disabling degree. Burnout encompasses 3 domains: Feelings of emotional exhaustion, cynicism or depersonalization, and a low sense of personal accomplishment. The criterion standard for measuring burnout is the Maslach Burnout Inventory (MBI). Participation in a mindful communication program has been associated with improvements in well-being, including burnout. b) • c) • d) • • •
HPM 28 Your hospice team is taking care of Nancy Bush a 46 year old with advanced breast cancer with 8 and 12 year old children. She wants to talk to the kids about her illness and let them know what to expect, but her mother thinks that telling them now will be too hard on them You advise: a. It is best to wait until Nancy’s disease is obvious to the kids so their interactions with their mother will not change b. Telling the children now will make them too anxious c. She should tell the older child, but the younger child is not at an appropriate development age d. Telling the children of the disease may make them less anxious
HPM 28 Your hospice team is taking care of Nancy Bush a 46 year old with advanced breast cancer with 8 and 12 year old children. She wants to talk to the kids about her illness and let them know what to expect, but her mother thinks that telling them now will be too hard on them You advise: a. It is best to wait until Nancy’s disease is obvious to the kids so their interactions with their mother will not change b. Telling the children now will make them too anxious c. She should tell the older child, but the younger child is not at an appropriate development age d. Telling the children of the disease may make them less anxious
HPM 28 -Pedi. Pal Discussion For the purposes of the boards – your default position should be one of truthful disclosure to children of all ages. The highest quality longitudinal study of bereaved children showed: a) The early loss of a parent was associated with poverty, - factors may include the loss of income, as well as the burden of medical expenses b) the increase in separation anxiety symptoms begins prior to death: this speaks to the need for preventive interventions when a family death is impending c) Several studies have shown a higher incidence of substance abuse in bereaved children, up to at least 21 months after the death d) Bereavement pattern associated with early loss of a parent was associated with poverty, substance abuse problems, and greater functional impairments.
HPM 29 You receive a call from the hospice nurse about a new hospice patient, Mrs. Gardner, who had a large ischemic MCA stroke 4 months ago. She has not been able to eat, is unable to turn herself, and has developed a large stage IV decubiti on her low back. The wound measures 10 cm x 8 cm and 1. 2 cm deep. It has some limited undermining and no tunneling. At the wound bed, the spine is visible. The bed of the wound reveals malodorous, necrotic purplish muscle and tissue with extensive serosanguinous drainage. The surrounding skin is intact. Mr Gardner covers her wound with a cream but notes ‘It just keeps getting deeper. ” The patient is turned q 2 hours. The goal of care is to keep her comfortable and at home – a promise he made to her. The hospice nurse asks you for orders to help manage the wound. She will order an air-mattress. .
HPM 29 After washing the bed of the wound with normal saline, applying a thin layer of metronidazole gel to the base of the wound, what do you recommend for a wound care dressing? a)Pack wound with wet-to-dry dressing and cover with ABD pad every 3 days. b)Pack wound with calcium alginate wafer and rope, cover with ABD pad every 3 days. c)Pack wound with hydrocolloid dressing and cover with ABD pad every 3 days.
HPM 29 After washing the bed of the wound with normal saline, applying a thin layer of metronidazole gel to the base of the wound, what do you recommend for a wound care dressing? a)Pack wound with wet-to-dry dressing and cover with ABD pad every 3 days. b)Pack wound with calcium alginate wafer and rope, cover with ABD pad every 3 days. c)Pack wound with hydrocolloid dressing and cover with ABD pad every 3 days.
HPM 29 Foam Dressing ++++ Alginate dressing +++ • May macerate surrounding skin • Can be used in infected wounds Hydrogel ++ Hydrocolloid + • occlusive, should not use with venous/vascular compromise Transparent film Gauze (wet to dry) Nonadherent dressings • Can cause debridement of healing tissue + = level of absorption of dressing Adapted from Frank Ferris
HPM 30 A 45 year old man with HIV-AIDS comes to your clinic for follow-up for HIV-related neuropathy pain. He has long declined any antiretroviral therapy, and has consistently stated he wants supportive-only care focused on maintaining his quality of life. He has a CD 4 count of 90 cells/mm 3. 1 year ago it was 100. He reports worsening pain control which he relates to inability to swallow his morphine ER tabs (100 mg tid) much of the time. He reports mid-throat pain, and frequently chokes on the pills, ‘gags’ them back up. Examination reveals a thin man. Mouth demonstrates scattered white plaques on the palate which reveal a red base when scraped away. Best next step is to: a) b) c) d) Prescribe Nystatin ‘swish & swallow’; change morphine to 30 mg elixir q 4 h scheduled. Prescribe fluconazole; change Morphine. ER pills to to Morphine. ER ‘granules’ in pudding (such as ‘Kadian’ or ‘Avinza’ morphine formulations). Prescribe fluconazole, change his morphine to methadone elixir, and recommend hospice care given his goals of care and prognosis. Prescribe Nystatin ‘swish & swallow’; change his morphine. ER to a fentanyl patch.
HPM 30 A 45 year old man with HIV-AIDS comes to your clinic for follow-up for HIV-related neuropathy pain. He has long declined any antiretroviral therapy, and has consistently stated he wants supportive-only care focused on maintaining his quality of life. He has a CD 4 count of 90 cells/mm 3. 1 year ago it was 100. He reports worsening pain control which he relates to inability to swallow his morphine ER tabs (100 mg tid) much of the time. He reports mid-throat pain, and frequently chokes on the pills, ‘gags’ them back up. Examination reveals a thin man. Mouth demonstrates scattered white plaques on the palate which reveal a red base when scraped away. Best next step is to: a) Prescribe Nystatin ‘swish & swallow’; change morphine to 30 mg elixir q 4 h scheduled. b) Prescribe fluconazole; change Morphine. ER pills to to Morphine. ER ‘granules’ in pudding (such as ‘Kadian’ or ‘Avinza’ morphine formulations). c) Prescribe fluconazole, change his morphine to methadone elixir, and recommend hospice care given his goals of care and prognosis. d) Prescribe Nystatin ‘swish & swallow’; change his morphine. ER to a fentanyl patch.
HPM 30 -HIV Discussion • • • He has esophageal candidiasis as well as thrush: systemic antifungal therapy is indicates, not just topical All the strategies to manage pain in setting of pill dysphagia are ok; methadone switch is probably least desirable due to complexity of switch and drug-drug interactions with fluconazole Hospice care is not appropriate for the patient based on prognosis. Hospice eligibility guidelines, while not very evidence-based, suggest a CD 4 count <25 cells/mm 3 or a persistent viral load >100, 000 copies/ml, as well as a serious HIV related comorbidity such as CNS lympthoma, MAC bacteremia untreated or unresponsive to treatment, Progressive multifocal leukoencephalopathy, systemic lympthoma, visceral Kaposi’s sarcoma, renal failure, cryptosporidium infection, or toxoplasmosis unresponsive to therapy.
HPM 31 Ms. F is a 64 year old who you see in your palliative care clinic 2 months after the death of her husband in an ICU. She describes sadness over the loss of her husband, as well as waves of yearning, helplessness, and guilt over her decision to proceed with the terminal extubation of her husband. She reports sleep and appetite changes, as well as fatigue. Which of the following in the most likely diagnosis? a) b) c) d) Grief Complicated grief disorder Post-Traumatic Stress Disorder Major depressive disorder
HPM 31 Ms. F is a 64 year old who you see in your palliative care clinic 2 months after the death of her husband in an ICU. She describes sadness over the loss of her husband, as well as waves of yearning, helplessness, and guilt over her decision to proceed with the terminal extubation of her husband. She reports sleep and appetite changes, as well as fatigue. Which of the following in the most likely diagnosis? a) Grief b) c) d) Complicated grief disorder Post-Traumatic Stress Disorder Major depressive disorder
HPM 31 -Grief Discussion a) Grief • A normal response to loss • Often come in waves and may include denial, anger, disbelief, yearning, • anxiety, sadness, helplessness, guilt, sleep and appetite changes, fatigue, and social withdrawal. The frequency of feeling negative symptoms of disbelief, yearning, anger, and depressed mood has been shown to generally peak by 6 months. b) Complicated Grief / Prolonged Grief Disorder • For 10 -20% of bereaved individuals, grief can become complicated and • • • significantly impact their ability to function May lead to psychiatric morbidity, suicidal ideation, functional disability, and low quality of life. Key features include separation distress with intense yearning and longing for the deceased, as well as dysfunctional thoughts, feelings, or behaviors related to the loss. Several psychotherapy treatments have been shown to be beneficial including Cognitive Behavioral therapy and Complicated Grief Treatment (CGT).
HPM 31 -Grief Discussion c) PTSD Family members of patients in the ICU are at risk for PTSD Symptoms of 1) re-experiencing the traumatic event, 2) avoidance of situations associated with the death; and 3) increased arousal. Must also have significant social or occupational impairment. • • d) Depression: • DSM-IV criteria: individuals must have at least two weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression: sleep disturbances guilt and feelings of worthlessness lack of energy loss of concentration and difficulty making decisions anorexia or weight loss psychomotor agitation or retardation suicidal ideation • •
HPM 32 You are awoken at 2 am the day before your interdisciplinary hospice team meeting, by a nurse who just joined your hospice. She is visiting Mr. Gunter Liszt, an 89 year old who is on hospice with end-stage heart disease. He has an ejection fraction of 21%, is oxygen dependent. He was last hospitalized for recurrent pulmonary edema and systolic blood pressure in the 80 s. During his hospitalization, he developed cardiorenal syndrome and has become oliguric, with a daily urine output of 80 -100 mls. He is on Amiodarone 600 mg daily, furosemide 40 mg bid via PICC line, metoprolol 25 mg bid, oxycodone 5 mg prn dyspnea, lorazepam 0. 5 mg SL prn. He had been weaned off of his dobutamine drip a day prior. He was discharged back to his nursing home with hospice services 4 days ago. During that time, he became increasingly somnolent, with peripheral mottling, and over the last 2 days has become anuric. His family was called by the nurse, and was notified that his prognosis was poor: likely hours to maybe days. He is DNR/DNI and you learn that has an implanted pacemaker and defibrillator. The family is at the bedside distraught, watching him, the nurse nervously explains. “He is actively dying, but every few minutes he jumps out of bed –the defibrillator is shocking him again and again. His heart rate is erratic and in the 150 s. He is moaning from time to time. What can I do? ”
HPM 32 What is the next best thing to do? a)Comfort the family while waiting for the defibrillator company to send a representative out to deactivate the defibrillator. b)Restart the dobutamine drip. c)Start a morphine drip at 1 mg/hour. d)Tape a magnet to his chest over the defibrillator. e)Give the patient lorazepam 1 mg IV push now. f)Review with the admissions team the importance of identifying patients with AICDs, and having associated goals of care about deactivation
HPM 32 What is the next best thing to do? a)Comfort the family while waiting for the defibrillator company to send a representative out to deactivate the defibrillator. b)Restart the dobutamine drip. c)Start a morphine drip at 1 mg/hour. d)Tape a magnet to his chest over the defibrillator. e)Give the patient lorazepam 1 mg IV push now. f)Review with the admissions team the importance of identifying patients with AICDs, and having associated goals of care about deactivation
HPM 32 -AICD Discussion a) Calling the AICD company or EP consultant is a secondary step to stopping the ICD and improving the patient’s comfort. b)Restarting the dobutamine drip will not reverse the process and will aggravate the arrhythmia c) Morphine is contraindicated in renal failure, and while giving him analgesics is indicated, stopping the source of his suffering is a more urgent priority d)Taping a magnet to the chest is the best initial step – followed by calling the company to have a representative come to turn off the device. e)Lorazepam will not change the circumstance, and the patient is already mostly unresponsive. f) All hospice agencies should have policies & procedures in place about this, but now is not the time to address them
HPM 33 A 40 year old man is at home receiving hospice care for metastatic bladder cancer to peritoneum, lung, pleura, and spine. His ECOG is 4. His back and chest wall pain had been well controlled on morphine. CR 100 mg bid, dexamethasone 4 mg bid. In the last week he has become progressive more dyspneic, such that he reports severe air hunger at rest, despite medication changes including dexamethasone 8 mg bid, lorazepam 2 mg q 6 h, and transitioning to a morphine PCA which is now at 8 mg/hour with a 8 mg/10 minute PCA dose. He is normoxic on 4 lpm of O 2 by nasal cannula. He declines inpatient admission for evaluation and symptom relief. You think he has less than a week to live. He tells you, “I can’t go on like this – this is not how I wanted to die. Can’t you put me sleep so I don’t have go through this? ” The best term to describe what the patient is asking for is: a)physician assisted suicide b)proportionate palliative sedation c)terminal sedation d)deep, continuous sedation
HPM 33 A 40 year old man is at home receiving hospice care for metastatic bladder cancer to peritoneum, lung, pleura, and spine. His ECOG is 4. His back and chest wall pain had been well controlled on morphine. CR 100 mg bid, dexamethasone 4 mg bid. In the last week he has become progressive more dyspneic, such that he reports severe air hunger at rest, despite medication changes including dexamethasone 8 mg bid, lorazepam 2 mg q 6 h, and transitioning to a morphine PCA which is now at 8 mg/hour with a 8 mg/10 minute PCA dose. He is normoxic on 4 lpm of O 2 by nasal cannula. He declines inpatient admission for evaluation and symptom relief. You think he has less than a week to live. He tells you, “I can’t go on like this – this is not how I wanted to die. Can’t you put me sleep so I don’t have go through this? ” The best term to describe what the patient is asking for is: a)physician assisted suicide b)proportionate palliative sedation c)terminal sedation d)deep, continuous sedation
HPM 34 Regarding the prior patient who is requesting deep, continuous sedation… His medication treatment plan should include which of the following: a)escalation of his morphine continuous rate until he is unarousable b)anticholinergic medication to minimize retained oropharyngeal secretions c)intravenous normal saline to prevent dehydration d)bolus and continuous intravenous midazolam or pentobarbital to maintain a state of unresponsiveness
HPM 34 Regarding the prior patient who is requesting deep, continuous sedation… His medication treatment plan should include which of the following: a)escalation of his morphine continuous rate until he is unarousable b)anticholinergic medication to minimize retained oropharyngeal secretions c)intravenous normal saline to prevent dehydration d)bolus and continuous intravenous midazolam or pentobarbital to maintain a state of unresponsiveness
HPM 34 -Palliative Sedation Discussion Proportionate palliative sedation implies minimal sedation to achieve symptom relief Terminal sedation=continuous deep sedation=palliative sedation to unconsciousness: implies deliberate pharmacologic induction of a coma, usually until death CDS is best done by using bolus (especially to initiate the coma) and then continous infusions of a sedating medication such as a barbiturate, benzodiazepine, or propofol. It should not be done with opioids as they are inadequate as sedatives, and escalating doses can cause myoclonus and seizures. Routine end of life cares should be given including secretion management. IV hydration has no coherent indication in these situations in which life is no longer being prolonged and a patient is comatose.
HPM 35 Mr. Xiao is a 63 -year-old edentulous Chinese immigrant, long-standing smoker who is on hospice for an unresectable fungating squamous cell carcinoma at the base of his tongue with metastasis to lung. He is getting nutrition and medications through a feeding tube. His medications currently include: Methadone 70 mg tid, oxycodone 60 mg q 2 hours prn, dexamethasone 8 mg daily, scopolamine patch 1. 5 mg, topical viscous lidocaine mixed with thrombin powder swish and spit prn. He and his wife come in distraught due to his pain, bleeding, and most of all the malodor. He also often gags on his own blood. He hopes to have his grandchildren visit soon, and does not want them to be put off by smell in his mouth. He tells you of a friend of his from the infusion suite who received a single-fraction of palliative radiation for his painful metastasis to his femur and asks if there is a similar approach for him. Due to the anatomy of the tumor, palliative embolization is not an option. Which of the following treatment options is the most appropriate? a) b) c) Single-fraction radiation Hypo-fractionated Radiation therapy Standard radiation therapy
HPM 35 Mr. Xiao is a 63 -year-old edentulous Chinese immigrant, long-standing smoker who is on hospice for an unresectable fungating squamous cell carcinoma at the base of his tongue with metastasis to lung. He is getting nutrition and medications through a feeding tube. His medications currently include: Methadone 70 mg tid, oxycodone 60 mg q 2 hours prn, dexamethasone 8 mg daily, scopolamine patch 1. 5 mg, topical viscous lidocaine mixed with thrombin powder swish and spit prn. He and his wife come in distraught due to his pain, bleeding, and most of all the malodor. He also often gags on his own blood. He hopes to have his grandchildren visit soon, and does not want them to be put off by smell in his mouth. He tells you of a friend of his from the infusion suite who received a single-fraction of palliative radiation for his painful metastasis to his femur and asks if there is a similar approach for him. Due to the anatomy of the tumor, palliative embolization is not an option. Which of the following treatment options is the most appropriate? a) b) c) Single-fraction radiation Hypo-fractionated Radiation therapy Standard radiation therapy
HPM 35 -Palliative Radiation Discussion • • Single fraction XRT is often an excellent approach for palliation of painful bone metastases. It is not appropriate for oral/throat tumors, even for palliation. Hypofractionated radiation (5 -14 doses, as opposed to the standard ~6 week course) has a role for palliation of oral tumors. • Irradiation of the mouth can lead to severe mucositis, dry mouth, dental disease, and thrush. In patients with teeth, this is particularly concerning. Patients with fillings need to have dental guards to prevent local ulceration. Even patients without teeth need to have close symptom management for acute and subacute symptoms from the radiation therapy. • Using mouthwashes such as Biotene® or a simple combination of baking-soda and salt in water may help the severe xerostomia. Mucositis and thrush need to be treated throughout the course of radiotherapy and for a week to 10 days post-therapy, or as long as symptoms are present.
HPM 36 You are a medical director for a hospice agency. MF, an 83 yo woman with metastatic breast cancer leading to bone marrow infiltration and chronic cytopenias has been receiving hospice care at home with your agency for 2 months. She is ambulatory, and spends half her time in bed or a chair due to weakness and fatigue, but rates her quality of life as very high. She has confirmed with her RN case manager her goals are to have as good a quality of life as possible, but is not interested in further treatments to prolong her life. At a follow-up visit with her oncologist who is her hospice attending physician, MF complains of worsening and distressing fatigue. The oncologist orders a CBC, which showed a hemoglobin of 7. 4 mg/d. L and a hematocrit of 23. 3 months ago they were 9. 5 mg/d. L and 29. She orders a transfusion of 2 U PRBC; the patient indicates interest in receiving it. You call the oncologist to discuss the transfusion and she says tells you it has helped the patient’s fatigue in the past and hopes it will help her now.
HPM 36 The best next step would be to: a)Decline to cover the costs of the transfusion as it is unrelated to the patient’s terminal diagnosis b)Agree that the hospice will cover the costs of the transfusion, and will monitor her for signs of improvement c)Recommend that the patient receive oral iron supplementation and methylphenidate d)Discharge the patient from your agency’s care, as she has chosen to seek life-prolonging treatments for her cancer.
HPM 36 The best next step would be to: a)Decline to cover the costs of the transfusion as it is unrelated to the patient’s terminal diagnosis b)Agree that the hospice will cover the costs of the transfusion, and will monitor her for signs of improvement c)Recommend that the patient receive oral iron supplementation and methylphenidate d)Discharge the patient from your agency’s care, as she has chosen to seek life-prolonging treatments for her cancer.
HPM 36 a) Anemia is clearly related to her cancer diagnosis, and the hospice agency has assumed responsibility for all palliative treatments related to that diagnosis. b) There are no data to guide us about when/who to transfuse for symptomatic anemia in hospice and EOL settings. Anecdote, and common sense, indicate that some people have subjective improvement in energy/fatigue with transfusions; some clearly do not. This has been an effective tx for the patient in the past, and she is ambulatory. In addition, the hospice agency runs the risk of sending a message to the patient and her doctor that patients have to forego expensive treatments, even if palliative, and may undermine the patient’s relationship with her oncologist c) Iron supplementation is unlikely to help with the patient’s anemia given its cause (marrow infiltration). There is no known role for psychostimulants in anemia-associated fatigue. d) Despite the question of benefit of transfusion for fatigue, there is even less reason to think it will actually prolong her life. In this situation, the intent and likely outcome of transfusion is strictly palliative.
HPM 37 JW is a 48 year old female with metastatic osteosarcoma of her L pelvis (mets to lung and spine), undergoing chemotherapy. She is hospitalized for neutropenic fever; her hospital course has been unremarkable. Her albumin is 2. 7 g/dl, calcium is 10. 4 mg/dl, and LDH 700 IU/L. She has a poor appetite and has lost 5 kilos in the last 2 months. She has been getting steadily weaker and now needs assistance with housework, and occasionally needs help getting up from a chair/toilet. She understands her cancer is incurable, and asks you how much time you think she has to live. She tells you her oncologist told her ‘It was in God’s hands. ’ The best initial response is: a) b) c) d) I am God: 63 days. I can’t understand why all these oncologists never tell their patients the truth! Most likely 1 -3 months Most likely 4 -6 months
HPM 37 JW is a 48 year old female with metastatic osteosarcoma of her L pelvis (mets to lung and spine), undergoing chemotherapy. She is hospitalized for neutropenic fever; her hospital course has been unremarkable. Her albumin is 2. 7 g/dl, calcium is 10. 4 mg/dl, and LDH 700 IU/L. She has a poor appetite and has lost 5 kilos in the last 2 months. She has been getting steadily weaker and now needs assistance with housework, and occasionally needs help getting up from a chair/toilet. She understands her cancer is incurable, and asks you how much time you think she has to live. She tells you her oncologist told her ‘It was in God’s hands. ’ The best initial response is: a) b) I am God: 63 days. I can’t understand why all these oncologists never tell their patients the truth! d) Most likely 4 -6 months c) Most likely 1 -3 months
HPM 37 • • • She has an incurable, metastatic tumor, hypoalbuminemia, elevated LDH, weight loss, progressive functional decline, and a PPS/KPS of 60. Performance status=best predictor in general: KPS 40 -60 have median survivals in the 1 -3 mo range. Less than 40 median survival is less than a month. Other factors independently help predict survival as well including presence of dyspnea, hypoalbuminemia, elevated LDH, hypercalcemia (median survival 68 wk), leptomeningeal disease (median survival 21 days) Prognostic disclosures, in patients who want to hear them, are best done by giving accurate estimates with ranges, as well as disclosure of uncertainty. There is ongoing work on whether using graphs or graphic representations, and whether disclosures are best are as survival statistics over time (eg ‘ 80% survival at 6 months, meaning 4 out of every 5 patients with your condition would be alive at 6 months’), vs estimates of survival length, or combinations of these. There is no clear professional standard about which one is best. Using at least one rhetorically negative phrase helps patients retain negative information better (e. g. ‘The results were not good…’). Patients, in research settings, say they want as much info in as many ways as possible. For the boards, probably frank & honest is the best policy.
HPM 38 Ms. L is a 46 year old who is currently receiving treatment for metastatic breast cancer. She has 3 children ages 8 -13. Ms. L comes to your office complaining of fatigue. She states that she wants to participate more with her children’s lives but symptoms of fatigue limit what she can do. She denies difficulty initiating or maintaining sleep. At times she is tearful but there activities, such as watching movies with her children that bring her joy. She denies worthlessness or excessive guilt. Which of the following has the best evidence to improve her symptoms? a) b) c) d) Structured Exercise program Paroxetine Limit energy expenditures Megestrol
HPM 38 Ms. L is a 46 year old who is currently receiving treatment for metastatic breast cancer. She has 3 children ages 8 -13. Ms. L comes to your office complaining of fatigue. She states that she wants to participate more with her children’s lives but symptoms of fatigue limit what she can do. She denies difficulty initiating or maintaining sleep. At times she is tearful but there activities, such as watching movies with her children that bring her joy. She denies worthlessness or excessive guilt. Which of the following has the best evidence to improve her symptoms? a) Structured Exercise program b) Paroxetine c) Limit energy expenditures d) Megestrol
HPM 38 a)Moderate exercise: • Improvements have been shown to include less fatigue, decreased sleep disturbance, improved functional capacity, and better quality of life. b) Antidepressants, including paroxetine: • Not shown to be beneficial for fatigue outside of patients who are depressed. c) Energy conservation and activity management (ECAM) • One study showed modest benefit • Only limiting energy expenditures as answered in C would be insufficient. • Decreasing activity may lead to further muscle wasting, loss of physical strength, and worsening endurance. d) There is no evidence that megestrol improves cancer related fatigue
HPM 39 Mr A is a 67 year-old Spanish-speaking man with metastatic pancreatic cancer diagnosed during this hospital stay. The physician on the palliative care team, Dr. S is organizing a family meeting to discuss prognosis and goals of care. The meeting is to include Mr. A and his son, the oncology team, and the social worker on the palliative care team. Mr A speaks only Spanish. His son speaks both English and Spanish, as does Dr. S. The son says that he has been acting as the interpreter during previous meetings with physicians. The best next step would be: a) Use a professional interpreter, but Dr. S should avoid short phrases in English as they often don’t give enough context to give an accurate interpretation b) Mr. A’s son should act as the interpreter if it is ok with Mr A c) Dr. S should conduct the family meeting in Spanish d) Use a professional interpreter but ensure that the he/she is briefed before the family meeting.
HPM 39 Mr A is a 67 year-old Spanish-speaking man with metastatic pancreatic cancer diagnosed during this hospital stay. The physician on the palliative care team, Dr. S is organizing a family meeting to discuss prognosis and goals of care. The meeting is to include Mr. A and his son, the oncology team, and the social worker on the palliative care team. Mr A speaks only Spanish. His son speaks both English and Spanish, as does Dr. S. The son says that he has been acting as the interpreter during previous meetings with physicians. The best next step would be: a) Use a professional interpreter, but Dr. S should avoid short phrases in English as they often don’t give enough context to give an accurate interpretation b) Mr. A’s son should act as the interpreter if it is ok with Mr A c) Dr. S should conduct the family meeting in Spanish d) Use a professional interpreter but ensure that the he/she is briefed before the family meeting.
HPM 39 • Simple language and short phrases are easier to interpret accurately. • The son may not accurately translate what is said by the physician. It is the standard of care, especially for the boards (!), to use professional medical interpreters • • Physicians who can speak a second language should use an interpreter unless they have native fluency in that second language and know medical terminology in that second language. Another reason that Dr S should consider not running the family meeting in Spanish is that other health care providers at the family meeting will still require interpretation services. Medical interpreters have expertise in interpretation as opposed to ad hoc interpreters (i. e. family members, hospital staff). Errors in interpretation occurs less commonly with professional interpreters and patient satisfaction is higher. Professional interpreters should be briefed before a family meeting especially if a difficult conversation will take place including delivering bad news or discuss end-of-life issues.
HPM 40 You are called to see a 13 year old for a palliative care consultation. You call the pediatric oncologist who tells you the boy has had sarcoma for 4 years, and since he has been hospitalized for the latest round of cancer treatment the pain has become much worse. The oncologist shares that recent scans show the latest treatment is not working and there are no further measures he would offer, but he is not sure if he will discuss this with the patient himself. The parents know, and have been asking for increased pain medication, but the attending is concerned they are trying to “you know…move things along. ” The best initial response to his concern is a)“It is a myth that opioids hasten death at the end of life” b)“They probably are trying to protect him from finding out what is going on” c)“Thoughts of hastening a child’s death are not uncommon in these circumstances, but it’s usually because of uncontrolled pain. ” d)“If you tell the patient the truth, the parent’s grief will be diminished. ”
HPM 40 You are called to see a 13 year old for a palliative care consultation. You call the pediatric oncologist who tells you the boy has had sarcoma for 4 years, and since he has been hospitalized for the latest round of cancer treatment the pain has become much worse. The oncologist shares that recent scans show the latest treatment is not working and there are no further measures he would offer, but he is not sure if he will discuss this with the patient himself. The parents know, and have been asking for increased pain medication, but the attending is concerned they are trying to “you know…move things along. ” The best initial response to his concern is a)“It is a myth that opioids hasten death at the end of life” b)“They probably are trying to protect him from finding out what is going on” c)“Thoughts of hastening a child’s death are not uncommon in these circumstances, but it’s usually because of uncontrolled pain. ” d)“If you tell the patient the truth, the parent’s grief will be diminished. ”
HPM 40 a) b) c) d) (morphine myth): while that is generally true, that response is pedantic and off-topic, and bad consultation form. is psychological speculation is true. In one study, 36% (49 of 136, about 1 in every 3) of parents of deceased children, in retrospect, would have considered discussing hastening death under certain circumstances with a breakdown of scenarios given. Uncontrollable pain was the most common circumstance to elicit a hypothetical consideration of HD. 15% would have considered HD for non-physical suffering. Bottom line: thoughts of hastening death are common. This phrase, followed by an offer to explore the situation with the family further, is the best response to the requesting physician. is tricky. Research supports that adolescents want disclosure of information to them, and part of this consultation should involve addressing the question of what the patient himself should be disclosed. For the boards, of course the default posture should be for one of disclosure to children. However this response is premature, and not addressing the reason you are being consulted.
HPM 41 Your hospital ethics committee asks you to weigh in on a challenging case in the emergency room: a 3 month old baby, Marisol, with anencephaly has been brought to your publically-funded hospital from a private hospital. The baby is clearly having difficulty breathing and the mother (who has sole custody) is requesting that her baby be intubated for ventilatory support. "They wouldn't do it at Hospital Private, but told me you had to. After all, only God should determine when a baby dies - not you, nor I. " The pediatrician and neurologist both reinforce that with or without a ventilator, "it is a matter of time" before the baby dies. "Intubation seems to us medically inappropriate, ” they state. “We will do the right thing, morally and legally. We will take your advice. ” What is your hospital's legal obligation in this case? a)Baby Marisol must be intubated, and should move to establish a court-appointed guardian. b)Baby Marisol should not be intubated, instead the focus should be on comfort at end-of-life. c)Baby Marisol should not be intubated, and move to establish a court-appointed guardian.
HPM 41 Your hospital ethics committee asks you to weigh in on a challenging case in the emergency room: a 3 month old baby, Marisol, with anencephaly has been brought to your publically-funded hospital from a private hospital. The baby is clearly having difficulty breathing and the mother (who has sole custody) is requesting that her baby be intubated for ventilatory support. "They wouldn't do it at Hospital Private, but told me you had to. After all, only God should determine when a baby dies - not you, nor I. " The pediatrician and neurologist both reinforce that with or without a ventilator, "it is a matter of time" before the baby dies. "Intubation seems to us medically inappropriate, ” they state. “We will do the right thing, morally and legally. We will take your advice. ” What is your hospital's legal obligation in this case? a)Baby Marisol must be intubated, and should move to establish a courtappointed guardian. b)Baby Marisol should not be intubated, instead the focus should be on comfort at end-of-life. c)Baby Marisol should not be intubated, and move to establish a court-appointed guardian.
HPM 41 • • • Baby Doe Regulations were established in 1985, after the cases of Baby Doe (born in 1982) and Baby Jane Doe (born in 1983) helped solidify the role that parents could take in making decisions to withhold types of medical interventions in cases of serious life-limiting illness. Baby K followed in 1992 – born in Washington DC with anecephaly, her mother insisted on continuing with maximal supportive care including tracheotomy with ventilator support and long ICU stays. The hospital considered intubation unethical and inhumane. Two courts ruled in favor of the mother, concerned about the slippery slope and potential violation of EMTALA. Emergency Medical Treatment and Active Labor Act requires federally funded hospitals to stabilize patients who arrive with an emergency medical condition. The judge in Baby K’s case was concerned that ruling against the mother might permit hospitals to turn away accident victims with terminal illnesses such as cancer or AIDS, “on the grounds that they eventually will die anyway. ”
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