Transcript if their terminal illness follows its natural course.

EOL and Palliative Care
AMY SHAHEEN
CRISTIN COLFORD
GARY WINZELBERG
Case 1: Question 1
Ms. Jones is an 88 year old female recently diagnosed with
metastatic pancreatic cancer. She has elected for palliative
care only. She is considering hospice care as well.
Which of the following is NOT a requirement for entry into
hospice care under current Medicare guidelines?
A. A physician of record is identified
B. Agreement by the patient to not return to hospital for acute
care
C. DNR (no code) status
D. Expected prognosis of 6 months or less if patient's terminal
illness follows its normal, expected course
E. The approach is limited to a palliative, symptomoriented approach
ANSWER IS C
Explanation
 Patients must have a physician to certify their
appropriateness to receive hospice care, and to
approve their admission orders and changes to
orders during their course of receiving hospice
care.
 Patients may discontinue hospice services at any
time and resume their previous insurance benefit.
This could include a decision to return to the
hospital in the event of acute illness, or with a
decision to resume disease-directed care.
Explanation (cont.)
 Patients do not have to be DNR at the time of hospice
enrollment, though some hospices may question whether a
patient and family understand the goals of hospice services
if the patient chooses to be Full Code. For these patients
communication about the patient’s prognosis and care
goals continues after hospice enrollment.
 On admission to hospice, physicians certify that a patient’s
prognosis is 6 months or less if their terminal illness
follows its natural course. However, this does not
mean that a patient must or will die within 6 months.
There are periodic re-certifications that a physician must
complete and a patient must receive hospice for more than
6 months if they continue to meet prognostic criteria and
have needs served by hospice. If a patient’s condition
improve they may also “graduate” from hospice.
What are the factors that make you consider a
change in goals of care with a patient to palliation or
hospice care?
 Changes in a patient’s care goals should be based on
an understanding of their values and preferences in
the context of their medical condition and prognosis.
Case 1: Question 2
Ms. Jones has elected hospice care and has been having
severe nausea and vomiting. She has noticed some
abdominal distention and has also lost a large amount of
weight. Her husband is worried that she is dehydrated.
Which of the following would you recommend?
Select one best answer
A. Lorazepam (Ativan) orally
B. Ondansetron (Zofran) sublingually with an orally dissolving
tablet
C. Intravenous fluids
D. Rectal suppositories of prochlorperphenazine (Compazine)
E. Nasogastric tube suctioning
Question 2: Answer
D
Case 1: Question 2 Explanation
This patient may have small bowel obstruction. If in
hospital, pt may receive short term IVF. A G-tube could
be used at home for periodic decompression. For
patients at home, the use of rectally administered
medications may be most effective.
In patients with severe nausea and vomiting receiving
hospice at home, oral medications should be avoided as
they may not be absorbed and may exacerbate nausea.
Ondansetran is less likely than prochlorperazine to be
effective at treating nausea related to bowel obstruction.
Case 1: Question 3
Ms. Jones is getting increasingly somnolent and
having subjective dyspnea. You recommend liquid
morphine 2.5 mg sublingually for the dyspnea. How
often should you dose it?
A. Every 4-6hours
B. Every 1-2 hours
C. Once daily
D. Never because with her somnolence you may cause
her to quit breathing resulting in her death
E. Every 12 hours
Case 1: Question 3 ANSWER
A
Explanation
 In an older adult with cancer whom has not been treated with
opioids previously, a starting dose of 2.5-5 mg is appropriate.
However, for this patient’s respiratory distress it may necessary
to give doses every hour until her shortness of breath improve,
and to consider increasing her dose if her dyspnea does not
improve. It may be possible depending on her response to
transition her to a dose schedule of every 4-6 hours once her
breathing has improved. Once or twice daily dosing of a short
acting opioid in a patient with cancer and respiratory distress
would not be adequat. Also, with appropriate dosing of opioids
cessation of breathing should not be a significant concern. The
primary concern is with the patient’s respiratory distress.
Though her death may be hastened by opioid use, the primary
rationale for using roxanol (liquid morphine) is symptom relief.
This is the ethical principle of double effect.
Equi-analgesic dosing of narcotics
Case 2: Question 1
Mr. Smith has just been admitted to the palliative care and
hospice service in his home for a diagnosis of metastatic
lung cancer. He is on a fentanyl patch 50mcg every 72
hours and oxycodone 5-10mg for breakthrough pain and
dyspnea. He is on oxygen at 4 L/minute. He is
complaining of severe abdominal pain. He is conversant.
He hasn’t had a bowel movement since he was discharged 5
days ago. He has passed gas. He has mild nausea but no
vomiting. He last ate about 2 hours ago.
Pex: afebrile, RR 16 HR 100 Blood pressure 118/56
Abd: distended and diffusely tender with normal bowel
sounds. There is hard stool in the rectum.
Question 1:
Choose one answer
What is the best for acute relief of his current
symptoms?
A. Oxycodone 10mg orally
B. Increase his fentanyl patch dose
C. Dulcolox (bisacodyl) suppository
D. Begin Senna daily
E. Milk of magnesia daily
The answer is C
Explanation
• This patient’s main symptom is constipation and use of
suppository is appropriate given the presence of stool in
his rectum.
• All patients started on opioids should be started on a
bowel regimen at the same time which may be increased.
• Senna is a laxative and a standard part of a bowel
regimen but would not provide this patient immediate
relief. Milk of Magnesia is not usually part of a standard
bowel regimen.
• Other options could include an enema and use of
methylnaltrexone (used for opioid associated
constipation).
Case 2: Question 2
A few weeks later when you visits Mr. Smith with his nurse, he
complains about pain in his back. He says it is worse in the night
and has been interfering with sleep. He has increased his
oxycodone as he and the nurse discussed the week prior but it
has had minimal effect. His physical exam is remarkable for
pain at T12, T8, and on his right sacrum. What is the likely
reason for poor pain control?
A.
B.
C.
D.
E.
Metastatic lesions
Narcotic tolerance
Arthritis that was previously undiagnosed
Poor absorption of narcotics
A bad mattress for a cancer patient, recommend a hospital
bed
The Answer is A
Explanation
 In patients with cancer it is important to consider
possibility of bony metastatic disease for new complaints
of back and other musculoskeletal pain.
 Pain from metastatic disease tends to be “somatic” pain –
dull, steady pain.
 Use of radiation for these lesions can be effective as well
medications (such as denosumab or pamidronate) to
reduce the risk of fracture.
 In addition, these patients (including patients receiving
hospice care) should be evaluated for possible cord
compression given indication for urgent XRT to preserve
neurologic function. Xrays are the diagnostic test for
lytic lesions elsewhere in the body (like hip or ribs)
Case 2: Question 3
A few weeks later the patient’s wife calls because Mr. Smith is
increasingly confused and sleepy. His constipation is more difficult
to control with the standard medications. He had been urinating
frequently and drinking a lot of fluid. He has no fever, no cough,
head trauma, or headache.
Meds: Oxycodone 10mg every 6hours
Ativan 0.5mg every 8 hours as needed
Fentanyl 50mcg patch every 3 days
Hydrochlorothiazide 25mg daily
Pex: Vital signs: BP 100/60 weight is down 8 pounds to 137 HR
100 Temp 36.2
Cachectic male, arousable but sleepy, poor concentration but
answers questions appropriately.
Heent: MM very dry
The rest of the exam is non-focal except for depressed reflexes
diffusely
The best explanation for his symptoms is:
A. SIADH due to lung involvement
B. Overdose of pain medications
C. Interaction of lorazepam and fentanyl
D. Brain metastases
E. Osteoclastic stimulation by tumor
The Answer is E
Explanation
 Delirium is highly prevalent among dying patients, with
contributing factors including electrolyte disturbances,
infection, uremia, under-treated pain, medication side
effects and brain metastases. Given this patient’s
significant bony disease burden, hypercalcemia of
malignancy is most likely though hyponatremia should
also be considered especially given his thiazide diuretic
use.
 This patient’s polyuria is consistent with hypercalcemia.
 With any increase in opioid medication doses there is a
risk of short-term increase in sedation; however, this
patient’s opioid dose has not been changed and he is
experiencing a severe change in mental status would be
less consistent with opioid side effects.
Explanation (cont.)
 While lorazepam and fentanyl can interact to
produce increased sedation, other etiologies should
be considered first. The patient’s presentation is less
consistent with drug side effects unless he is not
taking his medications as prescribed.
 Brain metastases should also be considered – his
neurologic exam is nonfocal which is possible though
less likely.
 Treatment of patient’s hypercalcemia will depend on
his goals of care and can include IVF hydration,
bisphosphonates and calcitonin.
Case 3: Question 1
 Ms. Black is a 74 year old female receiving palliative care
through a home health service due to failure to thrive. She is
living with her daughter and has been on hemodialysis for the
last six years. Her daughter drives her to hemodialysis but
increasingly, Ms. Black has been protesting that she doesn’t
want to go any longer. This upsets her daughter but Ms. Black
has frequently alluded to the fact that she isn’t afraid to die
and isn’t happy with her current quality of life. Ms. Black tells
you that she is only going to dialysis for her daughter and that
she would like to stop. She is demonstrates decision-making
capacity and so you begin discussions with the daughter and
patient that include the possibility of stopping dialysis.
 Which of the following are true statements regarding her
mother’s expected course?
Which of the following are true statements of her mother’s expected course?
Choose all that apply
 A: Her mother would likely live 1-2 weeks without
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hemodialysis
B: The death due to electrolyte abnormalities is typically
very painful
C: Shortness of breath or volume overload may become a
problem early on and can be treated with morphine and
oxygen
D: Only God can determine how long someone has to live
and sometimes people with renal failure live a few
months
E: Cessation of dialysis is euthanasia and you would not
recommend it.
The answers are A and C
Explanation
 The prognosis of patients who stop hemodialysis
depends on factors including whether they have an
instrinsic renal failure and comorbidities such as
CHF that may affect their clinical course.
 For a patient who has been receiving HD chronically,
discontinuation of dialysis would likely cause death
within a few days to a few weeks. Symptoms may
include shortness of breath from volume overload
which can be managed with opioids, anxiolytics and
oxygen, and uremia with decreasing alertness, PO
intake and increasing nausea.
Explanation
Patients who demonstrate decision-making capacity
1. Understand their condition;
2. Weigh risks and benefits of decision; and
3. Express a decision-making preference
May decide to not receive or to discontinue
life-prolonging treatments – this does not
represent euthanasia or physician-assisted
suicide.
Case 3: Question 2
Ms. Black and her daughter decide to stop hemodialysis and have her
stay at home with the assistance of hospice services. You, as the
medical student, are called to her home with the hospice nurse to see
her. When you arrive she has agonal breathing. She is not responsive.
Her daughter asks you to pray with them. The nurse holds her hand
as the daughter begins to pray. You should:
A.
B.
C.
D.
E.
F.
Refuse to pray with them and tell the nurse you are opposed to
praying with people of another religion
Leave the room
Stand quietly with them
Confirm that Jesus is their Savior before joining in their pray
Hold hands with the nurse and join them if you feel comfortable
Let them know she is peeping over the clouds and seeing Jesus as
you sing the Alleluia hymn
Answer C and E
Explanation
 For many patients their faith is an important part of their
identify and serves to help them cope with serious illness.
This faith may or may not be part of an organized
religion. Physicians should seek to support patients and
their families through identifying those who identify faith
as important and ensuring they receive support. In this
situation the physician should seek to support the patient
and daughter by respecting their desire to pray without
violating his or her own beliefs. By standing quietly this
demonstrates respect and concern. Holding the hand of
the nurse, patient or daughter would also be appropriate
if the student felt comfortable.
Case 4: Question 1
Ms. Brown has metastatic breast cancer. She has been
receiving chemotherapy for palliation for the last two
years. She has mets to her bones and liver. She has
recently been found to have mets to her brain. She has had
whole brain XRT recently. For the pain she has been on
oxycontin 20mg two times daily but has developed trouble
swallowing. Her nurse recommends liquid morphine as
needed and a long acting fentanyl patch. What dose of the
fentanyl patch should she use?
A. 25mcg every 3 days
B. 75mcg every 3 days
C. 100mcg every 2 days
D. 150mcg every 2 days
The answer is A
Explanation
Common conversions for narcotics:
•1 mg IV morphine = 3 mg oral morphine
•5 mg IV morphine = 1 mg IV hydromorphone
•30 mg oral morphine = 7.5 mg oral hydromorphone
•1.5 mg oral morphine = 1 mg oral oxycodone
Note: Conversion factors are only a rough guide to approximate the
correct dose
Equianalgesia Example:
 2 tablets of oxycodone/acetaminophen (5mg/325
mg) every 4 hours is equal to what daily dose of long
acting morphine (MS Contin)?
 Each tablet contains 5 mg oxycodone;

12 tablets = 60 mg oxycodone/24 hours
 60 mg oxycodone = 90 mg oral morphine
 60 mg morphine divided into two dosing intervals =
45 mg long acting morphine (MS Contin) every 12
hours
After applying the fentanyl patch, how many more
doses of the oxycontin should she take?
A. One
B. Two
C. Three
D. Four
E. Five
The Answer is A
How often can she dose the oral liquid morphine?
A. 15-30 minutes
B. 1-2 hours
C. 3-4 hours
D. 5-6 hours
The answer is B
Explanation Case 4: question 1 through 3
 Opioids have different half-lives and take different times
to reach therapeutic levels.
 Use of a fentanyl patch is appropriate for patients who
have difficulty swallowing and relatively stable pain
medication dose needs as the patch is only changed every
three days (occasionally patients will be active
metabolizers and have patch changed every 2 days).
 After a fentanyl patch is placed the medication effects
does not start for approximately 12 hours so this patient
should receive an additional dose of oxycontin.
Explanation Cont…
 In hospice, nurses and physicians collaborate regarding
symptom management.
 Nurses in hospice care may serve in role of primary
health care professional with the physician in a
consultant role.
 For breakthrough medications the dose should be
approximately 10% of the patient’s scheduled doses over
a 24 hour period (eg, if the 24 hours is 100 mg of PO
morphine, then the breakthrough dose would be 10 mg).
 This may be given as often as 1-2 hours though the
interval may be decreased based on the patient’s
response and whether there are any factors that affect
absorption including renal and liver function.
Case 4: Question 4
Ms. Brown dies a few weeks later. The nurse discusses
hospice grief services with her children and husband.
About three months later you see her husband in the office
for his regular exam with your attending. His children are
worried about him. He says that he sometimes imagines
he hears his wife’s voice. He has gained a few pounds
because he is eating out with friends. He is sleeping well.
He still cries occasionally when he thinks about his wife
A.
B.
C.
D.
Major depression
Normal grief reaction
Post-traumatic stress disorder
Psychotic disorder
The answer is B
Explanation:
 This is normal reaction after someone dies. He is not
experiencing major depression as he is eating and
getting out with family and friends. Imagining
voices from someone with whom he lived for years is
not uncommon as long as there is no other evidence
of psychosis. He is not describing other aspects of
post traumatic stress disorder.
Case 5: Question 1
Ms White is a 59 year old who is being seen in the
office. She has a litany of illnesses including diabetes,
renal insufficiency, hypertension and hemiparesis
from a stroke. She has well controlled depression. She
lives with her husband and in the last couple of years
has had a variety of complications including a partial
foot amputation and decubiti ulcers on her sacrum.
She is tired of being in the hospital every couple of
months and each visit complains about it despite doing
what she can to care for herself. You feel that she is a
candidate for palliative care. The benefits of palliative
care include:
The benefits of palliative care include:
Choose all that apply
A. Prioritizing comfort over cure as an option
B. The goal of care is better management of symptoms
C. A do not resuscitate order is placed
D. She would not be allowed to go to the hospital
E. Cure is not a goal
Answer is A and B
Explanation Case 5: Question 1
 Palliative care seeks to ensure that seriously ill patients and their
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families receive the best possible care consistent with their goals of
care.
Components of palliative include symptom assessment and
management, emotional and spiritual support for patients and
families, and assistance with decision-making with goal of patients
receiving care consistent with their treatment values and
preferences.
Use of palliative care does not have to be based on patients’
prognoses and may be initiated at the onset of the diagnosis of a
serious or life-limiting condition.
Most palliative care services are provided to hospitalized patients
though increasingly palliative care is being offered in clinic and
long-term care settings.
Palliative care can co-exist with disease-directed treatment even
with a curative intent.
Explanation (cont.)
 Hospice services are provided to patients with a terminal
condition (prognosis < 6 months if disease follows its
natural course) whom choose comfort as their exclusive
care goal and generally prefer to remain at home.
Hospice is a comprehensive insurance benefit that
assumes responsibility for all care (medications, durable
medical equipment) related to the patient’s terminal
condition. Though hospice provides nursing support it
does not offer 24/7 care at home. There are dedicated
hospice facilities available for continuous care for
patients with significant unmet symptom needs and
limited prognoses.
Case 5: question 2
Today, Ms. White is complaining of burning pain in
her limb that was unaffected by the stroke. She can’t
sleep because of the pain. She feels like there are
needles in the bottom of her foot when she stands.
This type of pain is best described as
A. Visceral
B. Somatic
C. Neuropathic
D. Colicky
The answer is C
Case 5 explanations
 Visceral pain is pain that results from the activation of noci

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
receptors of the thoracic, pelvic, or abdominal viscera.
Visceral pain is the pain we feel when our internal organs are
damaged or injured and is by far the most common form of
pain.
Visceral pain is vague and not well localized and is usually
described as pressure-like, deep squeezing, dull or diffuse.
Visceral pain is caused by problems with internal organs, such
as the stomach, kidney, gallbladder, urinary bladder, and
intestines. These problems include distension, perforation,
inflammation, and impaction or constipation, which can cause
associated symptoms, such as nausea, fever, and malaise, and
pain.
Visceral pain is also caused by problems with abdominal
muscles and the abdominal wall, such as spasm.
Explanation (cont)
 Somatic pain is caused by the activation of pain receptors
in either the body surface or musculoskeletal tissues. It
is usually described as dull or aching
 It is usually described as dull or aching. Generally
speaking, somatic pain is usually aggravated by activity
and relieved by rest.
 Neuropathic pain is caused by injury or malfunction to
the spinal cord and peripheral nerves. Neuropathic pain
is typically a burning, tingling, shooting, stinging, or
"pins and needles" sensation. Some people also complain
of a stabbing, piercing, cutting, and drilling pain.
 Colic pain starts and stops abruptly from sources
including renal calculi and gallstones.
Case 5: question 3
The best treatment at this time for her pain is:
A. Clonidine
B. Dexamethasone
C. Ibuprofen
D. Lorazepam
E. Gabapentin
F. Hydrocodone
The answer is E
Explanation Case 5: Question 3
 Gabapentin is a standard treatment for neuropathic pain.
 Opioids include hydrocodone as well as clonidine can
also be used for neuropathic pain but are not first-line
options.
 Steroids and NSAIDs are treatments for somatic pain,
including bony pain.
 Lorazepam is not a treatment for pain but can be used for
associated anxiety.
 With starting any pain medication both their intended
benefits, potential side effects, drug interactions and
pharmacokinetics should be considered.