Transcript Intractable Pain & Palliative Sedation

Ana Leech, MD
Memorial Hermann Hospice IPU
Memorial Hermann Southwest – Supportive Care
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Define Intractable pain
Define sedation
Define palliative sedation
Describe appropriate use of sedation
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Subjective
Individual
Patient graded
Acute
Chronic
Sporadic
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Not relieved by ordinary medical, surgical,
and nursing measures. It is often chronic and
persistent. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier)
Pain that does not respond to appropriate
doses of opioid analgesics. (McGraw-Hill Concise
Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc)
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Pain resistant or refractory to ordinary
analgesic agents. (Farlex Partner Medical Dictionary © Farlex 2012)
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Ensure patient is taking medication as
prescribed
◦ It is really intractable pain?
◦ Is there fear of addiction?
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Route of administration
◦ Is it the pain, or is the patient not absorbing the
medication – think GI failure
◦ Or maybe there is not enough subcutaneous tissue
– think cachexia
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The right opioid
◦ Opioid rotation
 Slight differences in narcotics
 Metabolite build up
 Myoclonus
 Allodynia
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Bowel regimens
◦ It goes without saying, but it bears
repeating…When was the last bowel movement?
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Adjuvant medications
◦ Gabapentin for nerve pain
◦ Anti-depressants if needed
◦ Topical lidocaine
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Determine goals
◦ Is sedation acceptable
◦ What level of pain is acceptable
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Decreased activity
Calming effect
Side effect
◦ Pain
◦ Anxiety
◦ Nausea
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What it is
◦ Purposeful
◦ For existential suffering
◦ Team decision
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What it is not
◦ Side effect
◦ Euthanasia
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Trial
◦ May need rest for a day or two
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Terminal
◦ Retrospective diagnosis
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Intermittent sedation
◦ May be sufficient to use scheduled dosing
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Usual care is midazolam drip
◦ Start at 2mg/hr
◦ Goal RASS 3-4
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67 year old male
Metastatic cancer
Well controlled on scheduled medications
◦ RASS -1
◦ Peaceful
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Family has distress from exhaustion
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Patient’s daughter insists on palliative
sedation
Read online that is their right to “request
palliative sedation”
IDT met
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Does he meet criteria for palliative sedation?
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No
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No
◦ Patient was comfortable
◦ IDT consesous
◦ Concern that daughter was looking for a reason to
stay in IPU
◦ Complains that euthanasia is not legal in Texas
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30 year old male
Metastatic lung cancer
Dyspnea and distress
◦ RASS +3
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Wife and young children distraught
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Patient’s children present
Family begging for us to do something
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Does he meet criteria for palliative sedation?
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No
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No
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Aggressive symptom management
Sedated to RASS -4
Side effect
Died peacefully
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72 year old male
Locally advanced bladder cancer
Pain
Loss of independence
Incontinent
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Patient is awake and alert
Complains of loss of meaning and purpose
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Does he meet criteria for palliative sedation?
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Yes
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Yes
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Trial of sedation given
2 days of midazolam
Did not wake up after sedation discontinued
Died peacefully
Family grateful he was allowed to rest