Transcript Palliative Care Issues in End Stage Renal Disease

Palliative Care Issues in
End Stage Renal Disease
Mike Harlos MD, CCFP, FCFP
Medical Director, WRHA Palliative Care
Medical Director, St. Boniface Hospital Palliative Care
http://palliative.info
http://virtualhospice.ca
PALLIATIVE CARE:
World Health Organization Definition
Palliative care is an approach that improves the
quality of life of patients and their families facing the
problem associated with life-threatening illness,
through the prevention and relief of suffering by means
of early identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
PHYSICAL
SUFFERING
PSYCHOSOCIAL
EMOTIONAL
SPIRITUAL
Specific Issues
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Where does RRT fit in Palliative Care?
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Where does Palliative Care fit in RRT?
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What are some of the unique symptom
control challenges in ESRD
Communication issues
EVOLVING MODEL OF PALLIATIVE CARE
“Active
Treatment”
D
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T
H
Palliative
Care
Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
D
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A
T
H
Pain Control
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Variety of pain etiologies in ESRD
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Neuropathic (diabetic neuropathy)
Ischemic (causes nociceptive, visceral, and
neuropathic pains)
Renal insufficiency has significant implications
for opioid choice – morphine and
hydromorphone have active metabolites
which accumulate
TYPES OF PAIN
NOCICEPTIVE
Somatic
NEUROPATHIC
Visceral
Deafferentation
Sympathetic
Maintained
Peripheral
FEATURES OF NEUROPATHIC PAIN
COMPONENT
Steady,
Dysesthetic
Paroxysmal,
Neuralgic
DESCRIPTORS
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Burning, Tingling
Constant, Aching
Squeezing, Itching
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Stabbing
Shock- like, electric
Shooting
Lancinating
EXAMPLES
• Diabetic neuropathy
• Post-herpetic
neuropathy
Allodynia
Hypersthesia
• trigeminal neuralgia
• may be a component
of any neuropathic
pain
Morphine and Hydromorphone
Active Metabolite Accumulation in Renal Failure
Vicious Cycle of Opioid-Induced
Neurotoxicity
Codeine
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Metabolized to C-6-G, norcodeine, and morphine
Guay et al 1987 – found accumulation of codeine in
hemodialysis patients (t1/2 19 hrs) relative to healthy
volunteers (t1/2 4 hrs)
Dose reduction suggested in renal failure:
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Clcr 10-50 ml/min: Administer 75% of dose
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Clcr <10 ml/min: Administer 50% of dose
Morphine metabolites will also accumulate
Methadone
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NMDA receptor antagonist – unique role in neuropathic
pain, preventing tolerance and neurotoxicity
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Becoming a preferred opioid in renal insufficiency
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Inactive metabolites
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Approx. 20% excreted unchanged in urine, the
remainder of the parent drug and metabolites excreted
through feces
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As renal function deteriorates, there is increased
elimination through feces without increased plasma
concentrations
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Nonetheless, “start low and go slow”
Fentanyl
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Inactive metabolites
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No dosage modification needed when administered
as a bolus, but accumulation occurs with chronic
dosing
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Koehntop DE, Rodman JH. Fentanyl pharmacokinetics in
patients undergoing renal transplantation.
Pharmacotherapy 1997
 Marked decreases in fentanyl clearance, related to
degree of azotemia
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Chronic dosing empirically titrated to effect
Oxycodone
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Kirvela et al, The Pharmacokinetics of Oxycodone in
Uremic Patients Undergoing Renal Transplantation,
J Clin Anesth 1996
 Mean elimination half-life was prolonged in uremic
patients due to increased volume of distribution and
reduced clearance.
 Conclusions: Elimination of oxycodone is impaired in
end-stage renal failure
“start low and go slow” approach, with empirical titration
to effect
Meperidine (Demerol®)
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Neurotoxic metabolite normeperidine,
which accumulates in renal insuff.
May cause seizures, death
Should not be used in chronic dosing,
regardless of renal function
Delirium at End of Life
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Common: 80 – 90% in last few weeks
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Almost always multifactorial; illness, medications
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May rapidly worsen, with paranoia and agitation
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Very distressing for all involved
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Not likely to be reversible in last few days of life,
such as after D/C dialysis
Main intervention is effective sedation
Common Medications for Sedation
in Terminal Delirium
Nozinan (methotrimeprazine)
• Phenothiazine neuroleptic
• Dopamine antagonist, with histamine and muscarinic
receptor antagonism as well (effective general
antinauseant)
• Oral, sublingual, subcutaneous routes
Versed (midazolam)
• benzodiazepine
• Subcutaneous route; about 1/3 as potent as IV route
• Can mix with methotrimeprazine in same syringe
Communication Issues in Sedation for Delirium
at End of Life (e.g. Dialysis Withdrawal)
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Delirium not reversible; ongoing physiologic decline
Once effectively sedated, will not likely awaken again
Medications not hastening process, but ensuring
comfort
Encourage ongoing communication by family,
including private time alone with patient
Be cautious in presenting “non-choices” as choices…
there no other realistic options but aggressive
sedation in trying to settle a restless, agitated,
delirious person who is imminently dying
Dyspnea
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In prospective studies approaches 80% in final days
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Effectively controlled in < 50% in studies
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Multifactorial
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Pneumonia is a common final event
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Treatment requires urgency:
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often rapid progression
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severe distress
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often only hours before dying
Dyspnea Management
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Non-Pharmacological
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Calm reassurance
Fan
Open window
Sitting upright
Pharmacological
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Oxygen
Opioids – may need aggressive titration with IV
boluses q10 min with escalating dose
Sedatives – Neuroleptics (methotrimeprazine) or
Benzodiazepines
Antisecretory agents – scopolamine, glycopyrrolate
Pruritus
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Common in ESRD; prevalence 50 – 90 %
Various etiologies suggested - e.g.:
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inadequate dialysis
secondary hyperparathyroidism
dry skin
divalent ion accumulation and precipitation in skin
mast cell dysregulation
abnormal cutaneous innervation
aluminum toxicity
elevated serum histamine
elevated serum serotonin
substance P
altered immune function
others
Potential Treatments For Uremic Pruritus
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optimizing dialysate concentrations of magnesium and
other divalent ions
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emollients and moisturizers
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ultraviolet B light
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Naltrexone (opioid antagonist) – conflicting results in
randomized crossover trials; don’t use if needs opioids
Thalidomide – effective in > 50% of patients; Note: fetal
malformations… use appropriate caution in women
Capsaicin cream may help in localized itch
Mirtazapine – antidepressant – H1 , 5HT2 , and 5HT3
receptor blocker
Potential Treatments For Uremic Pruritus ctd
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H1 antihistamines ineffective
Ondansetron – recently found to be no more
effective than placebo in randomized doubleblind trial
Withdrawal of Dialysis
Catalano C et al,
Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993.
Nephrol Dial Transplant. 1996 Jan;11(1):133-9.
60
n = 88
# Patients
50
40
Median survival = 8 days
30
20
10
0
<3
3 - 10
> 10
Survival Time Following Discontinuation of Dialysis (Days)
Withdrawal of Dialysis –
Palliative Issues in Ensuring Comfort
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Communication
Anticipating symptoms, aggressive response
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Pain (generally only if a pre-existing problem)
Nausea
Restlessness, confusion
Dyspnea – fluid balance, pneumonia
Pruritus
Myoclonus, twitching
Communication
Anticipating need for non-oral medication routes
Communication
Common Communication Issues
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Treatment decisions - “Would you prefer the rock, or
the hard place?”
Food and fluids
Withdrawing or withholding treatment seen as
euthanasia
Sedation is seen as euthanasia
“You wouldn’t let an animal die this way”
Everyone would be better off if I’d just die
How long have I got?
How will I die? (rarely asked, always worried about)