•A 66y/o man with COPD come the ER with worsening of his ...



April 20 (Fri.)

ICM – 9am

Dr. Buscemi

Asna

I042010.doc

Scribed by J. Morgan

End of Life Care

Note: For the first 15 minutes or so, Dr. Buscemi (related to Steve?) went over the Block II ?’s that seemed to a problem. It basically came down to the thought that 2nd years don’t know that much (haha). Really, the questions were above the 2nd year level of understanding. She agreed and stated that they will work harder to have more applicable questions. End of Life (EOL) Care is a subject that we all need for the simple fact that every one of our patients will die (as will we). Most will be old, many with cancer, but there is obviously no specific specialty that will not deal with this.

Background

3 How Americans died in the past . . .

1. In the early 1900s, the average life expectancy was about 50 years (if you were lucky, you made it into your 60’s) and childhood mortality was high.

2. Prior to antibiotics, people died quickly from infectious disease and accidents. Therefore, EOL care was really not that important. Medicine focused more on caring and comfort because there were very few Tx’s, and the pt was usually cared for at home.

4 Medicine’s shift in focus occurred because of:

3. Potential of medical therapies

a. “fight aggressively” against illness, death

4. Improved sanitation, public health, antibiotics, other new therapies

a. increasing life expectancy: 1995 avg 76 y (F: 79 y; M: 73 y)

A. Phases of Illness

1. predictable steady decline with a relatively short “terminal” phase (like cancer)

2. slow decline punctuated by periodic crises (like CHF, emphysema, Alzheimer’s-type dementia)

B. Care giving

1. 90% of Americans believe it is a family responsibility

2. Frequently falls to a small number of people who are often women (spouse or daughter) and ill equipped to provide care

Medical Issues Pertaining to End of Life:

Pain Management (the main discussion of this lecture)

Terminal Dyspnea (EOL shortness of breath, uncomfortable breathing)

Terminal Delirium (EOL confusion)

Nausea (from pain meds or disease itself)

Constipation (from pain meds)

Pain Management Learning Objectives

Understand that pain at the end-of-life can be effectively treated

Understand that drug and non-drug treatments must be individualized for every patient

Know that chronic opioid therapy is not synonymous with drug addiction

Describe the differences and give examples of acute, chronic non-malignant and chronic malignant pain

Describe five medical barriers to pain management

Describe the WHO three-step ladder for cancer pain relief

Identify two patient and two drug-specific risk factors for opioid induced respiratory depression

Define and distinguish between opioid tolerance, physical dependence and psychological dependence

Case Study:

A 50 year old patient with metastatic breast cancer is admitted to the hospital at 1 a.m. because of severe neck pain. She is unable to move her head due to pain which had gradually worsened over two weeks. She has been taking an increasing amount of Percocet with little effect, most recently two Percocet q 4 hours. She is seen by the on-call physician and the following orders are written. Morphine 10-15mg po q 4-6 hours prn severe pain, Tylenol #3 1-2 po q 6 hours prn mild-moderate pain.

The next morning she is still in severe pain. You check the chart and find there have been several one-time verbal orders for IV morphine 2mg. The physician on call was reluctant to increase medicine out of fear of respiratory depression.

General Principles of dealing with pain in End of Life care include:

- Assessment, Management (both pharmacological and nonpharmacological), Education and Expectations (of patient, family, caregivers), Ongoing Assessment, and Interdisciplinary Care (nurses, PT, pharmacist) / Consultative Expertise (pain specialist).

For the Test:

-don’t worry about specific doses or specific drugs. Just know classes (i.e. Benzos, opiates) and be able to “accelerate” a dose (explained later).

Pain Assessment

-pain is now considered the 5th vital sign

-this is good to remember for any pain you will ever assess

A. General Description

1. Location, duration, temporal pattern (come/go or steady), modifiers (better/worse)

2. Quality

a. Somatic: dull/aching, well localized: fracture, bone METS

b. Visceral: dull/sharp/colicky, well localized or referred: gastritis, gallstones, appendicitis

c. Neuropathic: burning, lancinating, numb: Herpes Zoster, spinal disc rupture

3. Intensity - 0-10 scale (0 = no pain ( 10 = worst possible pain)

4. Treatments - What has the pt. used -- drug and non-drug, response to treatment

5. ADLs (Activities of Daily Living) - impact of pain on sleep, eating, movement, mood (pain can cause depression)

6. Review patient understanding of pain causality and patient goals for pain relief (numerical, functional)

a. communication is extremely important; Do they want just comfort care or do they want aggressive care?

b. Need realistic goals. Probably will not get complete relief, but the pt will usually be OK with the best possible.

9 Pain pathophysiology

7. Acute pain

a. identified event, resolves in days to weeks and is usually nociceptive (ex. broken leg)

8. Chronic pain

a. cause often not easily identified, multifactorial

b. indeterminate duration

c. nociceptive and / or neuropathic

B. Nociceptive Pain

1. Direct stimulation of intact nociceptors

2. Transmission along normal nerves

3. Sharp, aching, throbbing

a. Somatic: easy to describe, localize

b. Visceral: difficult to describe, localize

4. Management

1 Opioids are the 1st line Tx for severe pain.

2 Adjuvant (Neuropathic pain meds) / coanalgesics

C. Neuropathic Pain

1. Disordered peripheral or central nerves

2. Compression, transection, infiltration, ischemia, metabolic injury of the nerve

3. Varied types: peripheral, CNS process, complex regional pain syndromes

4. Pain may exceed observable injury (ex. pt w/herpes zoster may have lesions that go away, but still have extreme pain)

2 Described as burning, tingling, shooting, stabbing, electrical

5. Management

a. Opioids

b. Adjuvant / coanalgesics often required

WHO 3-step Ladder

-don’t worry about specific stuff, just the classes used in the specific steps.

-you want to start the pt at the appropriate level (meaning if the pt has metastatic CA, you don’t start them on ASA and see how it goes….give them morphine)

11 Moderate Pain

|1-Mild |2-Moderate |3-Severe |

|ASA |A/Codeine |Morphine |

|Acetaminophen |A/Hydrocodone |Hydromorphone |

|NSAIDs |A/Oxycodone |Methadone |

|± Adjuvants |A/Dihydrocodeine |Levorphanol |

| |Tramadol |Fentanyl |

| |± Adjuvants |Oxycodone |

| | |± Adjuvants |

6. Potency: oxycodone = hydrocodone > codeine = tramadol > propoxyphene

7. Duration: q3-4 for all except tramadol (q6)

8. Cost: generic codeine or oxycodone ................
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