Download Residency Education in Palliative Care

Residency Education
in Palliative Care
A Longitudinal Community Medicine Project
Sergio Urcuyo, MD
PGY-1
Contra Costa Regional Medical Center
Why Palliative Care?
From the Beginning

What is palliative care? (WHO)




“The active total care of a patient whose
disease is not responsive to curative
treatment”
“The goal of palliative care is the achievement of best
possible quality of life for patients and their families “
“Palliative care affirms life and regards dying as a normal
process, and neither hastens nor postpones death. “
“Many aspects of palliative care are also applicable early in
the course of the disease in conjunction with disease
modifying treatment, such as chemotherapy, radiotherapy,
and surgery. “
Hospice




Hospice is derived from the Latin word hospitum
which means a place where guests are received with
hospitality and lodging
Hospice as we know it dates back to 17th century
France
The first hospice in the USA was started in 1974 in
New Haven, CT
The word Hospice can now be
used to describe a philosophy of
care, an organization, or a
specific site
Hospice and Palliative Care





Similar philosophies
Palliative care can be started as early as is
appropriate
Hospice needs to start with a good faith
estimation of less than 6 months to live
Palliative care is often instituted in any setting
(including acute care)
Hospice is usually instituted in someone’s
residence, a nursing home, or a prison
“Where” matters





70% of deaths occur in hospitals
16% of deaths occur in nursing
homes
17% of deaths occur at home
Home deaths are more common
in malignancies
1999 Medicare study
30% of all deaths among the elderly with
malignancies occurred after transfer to a hospital
 50% of those occurred within 96 hours of transfer.

Nursing Homes and Hospice



Nursing homes are eligible for hospice
reimbursement under Medicare
Then why do 70% of nursing homes not have
hospice patients?
Omnibus budget passed in 1987 encourages
rehab and acute care over
comfort care through
higher reimbursement
Why do we care?




By 2030 20% of the population
of the US will be over age 65
More than 50% of malignancies
occur in this age group
67% of cancer deaths occur in
this age group
This age group as higher rates
of functional loss, caregiver stress,
and institutionalization
AHRQ Study on Preparedness




50% of terminal patients had an advanced
directive
12% of advanced directive patients had received
input from their physician in its creation
65-76% of physicians were not aware of the
existence of patients’ advanced directives
So, advanced directives will solve all of our
issues, right?
AHRQ Study, continued






ADs helped in less than 50% of decisions
ADs became active too late to make a diference
Language in ADs was too non-specific
Surrogates named were often not present or too
emotionally distraught to help
Physicians were only 65% accurate in predicting patient
preferences – they tended toward under treatment
Surrogates were more likely to over-treat even after
discussing it with the patient
Bad Doctor!
How do we be good doctors?





Journal of Family Practice in February 2002
Not a RCT
Looked at where PCPs had success in end-oflife care
Results showed that the relationships and role
playing were more important than their skills
and knowledge
Results identified 3 roles played…
The Consultant





The expert in diseases and the dying process
Will make decisions based on
medical facts when families
can’t
Families to make decisions when
able
Do we let families take all the
responsibility for turning off
the ventilator?
Do we act paternalistically
because we ‘know better’?
The Collaborator



Information hub between
patient, family and medical
team to ensure all parties have
the same understanding
Combines the consultant’s skills
with an understanding for the
family’s experience
Example: Letting a 30 yr old with terminal brain
cancer go fishing
The Guide

Understands
The facts
 The family wishes
 And how to get there


Example: A family who is resistant to hospice
gets listened to by a thoughtful MD who realizes
that they feel that way because the family
understands hospice as “giving up” on the
patient.
The Pink Elephant

I’m already good with patients,
So can I leave now?



Not yet…
The study said it took
doctors 2 decades to
get good at this
And the medicine is still
important
Question 1

A 62 year-old male with metastatic lung cancer presents
with skeletal metastases to the lumbar spine with no
cord compression or nerve impingement. His pain is
not relieved with over-the-counter medications he has
tried at home. He has not been on opioids. Other than
lung cancer, he does have chronic kidney disease; he’s
been told he might soon need dialysis. His serum
creatinine is 6.2. Which of the following opioids is the
most appropriate agent to administer in repeated doses?




a. Dolophine
b. Morphine
c. Meperidine
d. Fentanyl
Answer


A or D
Dolophine (Methadone) and Fentanyl are
thought to be the safest opiods in renal failure
because they are not renally cleared. This
patient will likely need long-term and aroundthe-clock pain control, so while methadone is
not fast acting it is an option for the overall pain
strategy
Question 2

A patient with metastatic colon cancer is
discharged with oral immediate release
morphine. How often can the patient take the
immediate release oral opioid if pain is severe
and unrelenting?
a. 30 minutes
 b. 60 minutes
 c. 2 hours
 d. 4 hours

Answer



B – Every 60 minutes
The peak effect for oral morphine is 60 minutes,
so administration of another dose
before then is premature
Interestingly, the peak effect of
IV morphine in 6 minutes.
A quick note on pain



66% of dying patients experience pain
33% of people experience pain in last 24 hrs of life.
Consequences of persistent pain include






Depression
Social isolation
Sleep disturbance
Impaired ambulation
Increased health care use and costs
Pain is not the most common symptom but is the most
distressing and feared symptom by patients and families
Question 3

A 66 year old woman with end-stage renal failure presents with
generalized weakness. She has refused dialysis and plans to
enroll in a hospice program. She was unable to get out of bed,
so her family had her brought to the hospital by ambulance. She
can be awakened easily by voice and desires alertness “till her last
moments”. Which of the following medications represents the
best choice for secretion management (“death rattle”) in this
patient if and when it occurs?




a. Scopolamine
b. Glycopyrrolate
c. Atropine 1% eye drops SL
d. Atropine IV
Answer



B – Glycopyrolate
Because glycopyrolate does not cross the bloodbrain barrier, it can be used to treat secretions
(and the “death rattle”) with minimal effect on
mental status.
Atropine and scopolamine are more likely to
cause delirium even though they are all
anticholinergics
The Medicine – Symptom Mgmt









Nausea and Vomiting
Fatigue
Cachexia-Anorexia
Dehydration
Depression
Suicidal Ideation
Derlirum
Dyspnea
Insomnia
Don’t we do this already?



Ury Et. Al in Journal of General Internal
Medicine: Can a Pain Management and Palliative
Care Curriculum Improve the Opioid
Prescribing Practices of Medical Residents?
Study based on data showing how opiods are
incorrectly prescribed
Prospective chard review showed a sustained
improvement in how residents prescribed
opiods
How did they begin



Ury Et. Al. performed a needs assessment at St.
Vincent’s Hospital (800 bed tertiary center with
a 100 resident IM program)
Interviewed families, patients, attendings,
residents
Results showed
Little medical school education on palliation
 Discomfort amongst residents over important issues
on palliation
 Enthusiasm amongst residents about improving
their knowledge

Do we just focus on the
medicine?

After several intravenous administrations of morphine and
lorazepam for severe dyspnea, a patient with advanced
pulmonary fibrosis becomes drowsy, his oxygen saturations drop,
his respirations become shallow, he becomes bradycardic, and
goes into cardiac arrest. The patient has elected an advance care
plan that includes no life sustaining measures. You should:




A. be sure the nurse is counseled for administering the medication too
rapidly
B. initiate CPR and ACLS, so as not to be charged with assisted suicide
C. report the incident to risk management and write it up as an adverse
event
D. consider the principle of double-effect
The “answer”


D – Consider the “double effect”
The principles





Close to death, you will have to relieve symptoms of
suffering
If the intent of the clinician was the “good effect”
The potential bad effects of the meds where considered
The dose and administration were “reasonable”
The double-effect would be cited as evidence that the clinical
team is not practicing euthanasia or assisted suicide and is not
at fault in the patient’s death
Who came up with that
nonsense?




The defense lawyers?
The double effect is attributed to Thomas
Aquinas, the 13th Century Roman Catholic
philosopher.
Is everyone ok with that?
New York Times Article from
Dec 26, 2009
So, how do we improve?




A. Consult palliative care
B. Consult Palliative Care and sign off
C. Consult Palliative Care, sign off
on the patient, and take a vacation
D. Learn more about it
My project

Stage I




Stage II



Assessment
Survey the residents and the incoming interns
Tool will be a modified version of the EPEC-EM
Implementation
Work with Julie Freedman et. al. to develop a curriculum that
will include lunchtime conferences, PBLs, etc.
Stage III


Evaluation (did I waste my time?)
Re-assess everyone and see how (or if) we improved
Thanks for listening