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Be a Hero to a Dying Patient: Symptom Management At BEAHERO TO A DYING PATIENT: SYMPTOM MANAGEMENT AT END- OF LIFE. Robert G. Wahler, Jr., Pharm.D., BCGP, FASCP, CPE Clinical Assistant Professor, UB SPPS Director, Clinical Pharmacy Services, Niagara Hospice 1 2019 Wahler RG LEARNING OBJECTIVES 1. Identify common symptoms experienced by patients with advanced illness. 2. Select or recommend medication options for specific palliative symptoms. 3. Discuss various pharmacologic interventions for common symptoms. 4. Define treatment measures in the last hours of life. 2 INTRODUCTION 2.8 million death/year in US, 1.4 million in hospice. It is important to address and manage each end-of-life symptom to improve the quality of life for the patient. An interdisciplinary team approach is beneficial throughout the care of the patient. This is evident when addressing more psychologically based symptoms, such as delirium. 3 INTRODUCTION The ASHP Guidelines on the Pharmacist's Role in Palliative and Hospice Care - Essential Clinical and Administrative Roles Direct patient care Optimize the outcomes of symptom management and palliative care patients through the expert provision of evidence-based, patient-centered medication therapy as an integral part of an interdisciplinary team Serve as an authoritative resource on the optimal use of medications in symptom management and palliative care Anticipate transitions of care when recommending, initiating, modifying, or discontinuing pharmacotherapy for pain and symptoms Medication order review and reconciliation Manage and improve the medication-use process in patient care settings Education and medication counseling Demonstrate excellence in the provision of medication counseling to patients, caregivers, and families Administrative roles 4 Ensure safe use of medications in the treatment of pain and symptoms Medication supply chain management Herndon CM, Nee D, Atayee RS, Craig DS, Lehn J, Moore PS, Nesbit SA, Ray JB, Scullion BF, Wahler RG, Waldfogel J. Am J Health Syst Pharm 2016;73(17):1351-1367. SELF-ASSESSMENT QUESTION Which common LTC admission diagnosis is the highest ranked reason for hospice admission? A. Cancer B. Heart Failure C. Dementia D. COPD E. Cerebrovascular Disease Conditions qualifying for hospice admission Conditions requiring palliation TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2017 (SIMPLIFIED) RankReported principal diagnosis Count Percentage 1 All Alzheimer's & Dementia 260,085 32.7% 2 All Heart Disease 141,116 17.7% 3 All Cancer 120,746 15.2% 4 All COPD 111,305 14.0% 5 All Cerebrovascular Disease 71,205 8.9% 6 Parkinson’s disease 40,186 5.0% 7 ESRD 21,549 2.7% 8 Kidney disease, not End-Stage 15,632 2.0% 9 Sepsis, unspecified organism 14,012 1.8% CHANGES DURING THE DYING PROCESS Change Manifested by/Signs of: Fatigue, weakness Decreasing function, hygiene Inability to move around bed Inability to lift head off pillow Cutaneous ischemia Erythema over bony prominences Skin breakdown, wounds Decreasing appetite/food Anorexia intake, wasting Poor intake Weight loss, muscle and fat, notable in temples 9 Medscape Internal Medicine The Last Hours of Living: Practical Advice for Clinicians Emanuel, L., Ferris, F. D., von Gunten, C. F., & Von Roenn, J. H. March 24, 2015 (http://www.medscape.com/viewarticle/716463_2 Accessed 4-2-15) CHANGES DURING THE DYING PROCESS Change Manifested by/Signs of: Cardiac dysfunction, Tachycardia renal failure Hypertension followed by hypotension Peripheral cooling Peripheral and central cyanosis (bluish color of extremities) Mottling of the skin (livedo reticularis) Venous pooling along dependent skin surfaces Dark urine 10 Oliguria, anuria CHANGES DURING THE DYING PROCESS Change Manifested by/Signs of: Neurologic dysfunction, including: Decreasing level of Increasing drowsiness consciousness Difficulty awakening Unresponsive to verbal or tactile stimuli Decreasing ability Difficulty finding words to communicate Monosyllabic words, short sentences Delayed or inappropriate responses Verbally unresponsive Terminal delirium Day-night reversal Confusion Agitation, restlessness 11 Purposeless, repetitious movements Moaning, groaning CHANGES DURING THE DYING PROCESS Change Manifested by/Signs of: Respiratory Change in respiratory rate—increasing dysfunction first, then slowing Decreasing tidal volume Abnormal breathing patterns—apnea, Cheyne-Stokes respirations, agonal breaths Loss of ability to Dysphagia swallow Coughing, choking, aspiration (Opportunity for Loss of gag reflex Pharmacists to “shine”) Buildup of oral and tracheal secretions Gurgling (“death rattle”) 12 CHANGES DURING THE DYING PROCESS Change Manifested by/Signs of: Loss of Incontinence of urine or bowels sphincter Maceration of skin control Perineal candidiasis Pain Facial grimacing Moaning Tension in forehead, between eyebrows Loss of ability to Eyelids not closed close eyes Whites of eyes showing (with or without pupils visible) Rare, unexpected events: Bursts of energy just before death occurs, the "golden glow"13 Aspiration, asphyxiation TWO ROADS TO DEATH The Difficult Road Confused Tremulous Restless Hallucinations Normal Pain Dyspnea Mumbling delirium Sleepy Anxiety Lethargic Nausea/Vomiting Myoclonic jerks The Usual Road Obtunded “Gurgling” Seizures Semicomatose Comatose 14 Adapted from: The Last Hours of Living: Practical Advice for Clinicians Emanuel, L., Ferris, F. D., von Gunten, C. F., & Von Roenn, J. H. March 24, 2015 Dead (http://www.medscape.com/viewarticle/716463_2 Accessed 4-2-15) PORTMANTEAU –DESIRABLE PROPERTIES 1. Multiple therapeutic effects 2. Minimal drug interactions 3. Multiple routes of administration 4. Wide therapeutic window 5. Cost-effective 6. Convenient dosing schedule 7. Dose response and favorable ceiling effect Dickerson. European Journal of Palliative Care 1999; 6:130-136. PALLIATIVE CARE TOOLKIT “intensol” = concentrated liquid Morphine liquid (Roxanol) 100mg/5ml (aka 20mg/ml) Methadone liquid 10mg/ml Hydromorphone liquid 1mg/ml Oxycodone liquid 20mg/ml Lorazepam liquid 2mg/ml (buccal admin of tabs) Alprazolam liquid 1mg/ml (also ODT) Haloperidol liquid 2mg/ml Atropine 1% ophth. gtts Dexamethasone liquid 1mg/ml Ondansetron ODT Metoclopramide liquid 5mg/5ml and ODT ($$$) 16 De Lima L, Doyle D. The International Association for Hospice and Palliative Care List of Essential Medicines for Palliative Care. Journal of Pain & Palliative Care Pharmacotherapy. 2009;21(3):29-36. Dickerson D. The 20 essential drugs in palliative care. European Journal of Palliative Care. 1999;6:130-136. WHO'S CANCER PAIN LADDER FOR ADULTS • “… consistently failed to provide sufficient relief to 10%–20% of advanced cancer patients with pain, particularly in cases of neuropathic pain and pain associated with bone involvement”* *Nersesyan, H., & Slavin, K. V. (2007). Therapeutics and Clinical Risk Management, 3(3), 381–400. X • Two Step Versus the Standard Three Step Approach of the WHO Analgesic Ladder for Cancer Pain Relief trial World Health Organization • Remove Step 2? http://www.who.int/cancer/pa lliative/painladder/en/ European Palliative Care Research Centre TVT trial https://www.ntnu.edu/prc/tvt-study-information Accessed 4-1-2017 Accessed 4-1-2017 WHERE TO START Base the initial treatment on the severity of pain the patient reports. Mild – Non-opioid analgesic Moderate – Opioid Severe (Pain emergency)– Opioid Provide Rx. PRN analgesic medication “Take the medication if unexpected pain occurs.” “Call for an appointment to evaluate the pain problem.” Begin a bowel regimen. Miaskowski, C. et. al. (2004). Guideline for the Management of Cancer Pain in Adults and Children, APS Clinical Practice Guidelines Series, No. 3. Glenview, IL: American Pain Society. The Dosing Frequency Conundrum Suffering 3 hrs 2.5 hrs Whitten, et al. The Permanente Journal 2005;9(4):9-18. 19 19 THE NEXT STEP “Administer a long-acting opioid on an around-the- clock basis, along with an immediate-release opioid to be used on an as-needed basis, for breakthrough pain once the patient's pain intensity and dose are stabilized.” Miaskowski, C. et. al. (2004). Guideline for the Management of Cancer Pain in Adults and Children, APS Clinical Practice Guidelines Series, No. 3. Glenview, IL: American Pain Society. BREAKTHROUGH PAIN (BTP) MEDICATIONS Which opioid to give? Same as long-acting? How much to give? Start at 10-20%1,2 of total daily dose Example: 60mg ER Morphine 5-10mg PRN BTP “Allow rescue doses of short-acting opioids of 10% to 20% of the 24-hour total of long-acting or regularly scheduled oral opioid dose up to every 1 hour as needed” - NCCN How often to give? Based on pharmacokinetics, but no longer than q3h intervals When to change long-acting meds? Patient dependent 1. Miaskowski, C. et. al. (2004). Guideline for the Management of Cancer Pain in Adults and Children, APS Clinical Practice Guidelines Series, No. 3. Glenview, IL: American Pain Society. 2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Adult Cancer Pain V.1.2017. © 2017 National Comprehensive Cancer Network, Inc. 3. Ashburn M, Lipman A, et. al. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Glenview (IL): American Pain Society (APS); 2003. METASTATIC BONE PAIN NSAIDs & Cox-2-Inh Corticosteroids • Pros • Anti-inflammatory • Start dexamethasone • Useful for mild to moderate pain 2-16mg/day (PO or IV) • Up to ~30mg daily • Adjunctive • Anti-emetic • Cons • Appetite stimulation • Ceiling effect • Antidepressant effects - • Toxicity (esp. elderly) “stimulatory” • Significant
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