Wednesday, September 17, 2014

New IOM Report: Dying in America - Improving Quality and Honoring Individual Preferences Near the End of Life

Today, the Institute of Medicine released a new report called "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." I had the pleasure of serving on the committee for the past 18 months*, which makes me so excited to finally share this report publicly. I hope you will all join the wider health care community in dissecting, analyzing, and disseminating this report.  Without your involvement from this point forward, this will merely be an impotent academic exercise.

Nothing in this report should be shockingly new to anyone in hospice and palliative care (HPC), but you now have this a tool to construct an exciting future where more people get excellent whole person care. All the organizations we work with (especially those outside of HPC and outside of health care) need to understand the recommendations and work to try an implement them locally and systematically. We are a large voice, but we are barely speaking as one.  NHPCO via Hospice Action Network and AAHPM have some great resources on how to work with your local and federal legislators. Let them know you read this and it is important to you!  Share what you find important about this report with your friends and family.

The key areas covered include:

  • Delivery of person-centered, family-oriented care
  • Clinician-patient communication and advance care planning
  • Professional education and development
  • Policies and payment systems
  • Public education and engagement
Two of the most interesting issues to me in this report, are 1) the call to payers and policy makers to integrate medical and social services and the 2) the emphasis on teaching primary palliative skills to all disciplines and specialties.  We can't get to major change with out reforming how the money flows through the system and incentives action over communication, and we as specialists can't satisfy all the palliative care needs in the system, so we need to ensure a basic palliative skill set for all health care providers.

The last major reports were in 1998 (Approaching Death: Improving Care at the End of Life) and 2002 (When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families) and they helped spur a great growth in palliative care as a specialty for physicians.  We have a tent pole now it is time to raise the roof.

Major articles featuring the IOM report (will be updated- check back):
New York Times - End-of-life Care needs Sweeping Overhaul, Panel Says
Kaiser Health News - Dying in America is Harder Than It Has To be, IOM Advises
Science 2.0 - US Health System Doesn't Think About End of Life Care - Yet
Business Insider - US Needs Better End-of-Life Care, Which Might Cut Costs: Study
Washington Post (blog) - It's Time to bury the 'death panel' myth for good. Is this the way to do it?
the kb Group (blog) - The New IOM Report on Dying in America
Geripal (blog) - New IOM Report on Dying in America
Forbes (blog) - Reimagining End of Life Care

*In case you have not been a long time reader, you may not know that I highlighted some potential gaps in the IOM committee when it was first announced in January 2013. While it was not meant as a means to get on the IOM committee (I applied the normal way and was initially not selected), some people put in my name to the IOM, and they added me as a member in February 2013.  It was really a fantastic experience and I learned so much from the many smart people on the committee. I would have loved to write about it while I went through it and share it with all of you, but the IOM review process stresses impartiality and confidentiality as you build the report. But now the report is out in the wild and I hope you will join me in spreading this important information.

Wednesday, September 17, 2014 by Christian Sinclair ·

Tuesday, September 16, 2014

The Role of Neurosurgical Interventions in Palliative Care

(In preparation for the 9/17/14 #hpm Tweetchat, guest host Dr. William Rosenberg summarizes a few of the neurosurgical interventions which may be useful in palliative care. - Ed.)

There are three major ways that neurosurgery can alleviate pain:

1. Targeted Drug Delivery in which medication is delivered directly to the brain or spinal cord by way of a very small catheter placed in the spinal fluid. The catheter could be connected to a pump placed under the skin for longer term use. Alternatively, a procedure not much bigger than a spinal tap can be used to place the catheter and bring it out through the skin to an external pump. When patients require doses of opioids and other medications which give them unacceptable side-effects, like clouding of consciousness, lethargy, loss of appetite, severe constipation, targeted drug delivery can often allow caregivers to reduce or even eliminate such medications, resulting in an improved quality of life and often better pain control.

2. Neurostimulation is the use of electrical stimulation, through small electrodes placed via needle or small incision, to reduce pain. It is especially effective with neuropathic pain (the pain caused by an injured or damaged nerve that sends erroneous signals to the brain causing the perception of burning, itching ,swelling or other kinds of pain). One can stimulate a peripheral nerve, the spinal cord or even the brain (“deep brain stimulation”) to achieve pain control, depending on the circumstances.

Often neurostimulation is not considered in the context of palliative care. But, in such a setting, neuropathic pain can be difficult to address. It is possible to place a neurostimulation lead under the skin and bring it out to an external control (pulse generator). In this way, hard-to-control pain (e.g., after radiation, chemotherapy or the surgical injury of a nerve) can often be addressed without the additional incision and expense of an implanted pulse generator (as is used in non-palliative care settings).

3. Neuroablation is the interruption of certain pain pathways in the brain or spinal cord to achieve pain control. These can be very effective and often will allow the patient to drastically decrease or even eliminate the pain medication s/he is taking. There are a number of such procedures available, depending on the details of the pain. Percutaneous cordotomy, myelotomy and nucleotractotomy are outpatient, CT-guided procedures, done under local anesthesia through a needle, that interrupt the pain pathways for different locations.

Cingulotomy is a procedure done under brief general anesthesia in which a computer is used to target two areas of the brain to interrupt pathways related to suffering. It can be very effective in treating the “suffering” component of pain. Recently, it was found to be effective in treating the air hunger associated with a lung tumor in a case report (see reference here).

Radiosurgical hypophesectomy is a non-invasive, single visit, outpatient procedure targeting the pituitary gland (hypophysis). It is based on decades of experience with surgically removing the pituitary gland for diffuse pain from bone metastases (cancer that has traveled to the bone). No one knows how it works, but it can be very effective. And, since it is completely non-invasive, the risks are very low. Even pituitary function is usually preserved and, if it is affected, hormones can easily be replaced.

References and Resources

ResearchBlogging.org
Smith TJ, Staats PS, Deer T, Stearns LJ, Rauck RL, Boortz-Marx RL, Buchser E, Català E, Bryce DA, Coyne PJ, Pool GE; Implantable Drug Delivery Systems Study Group (2002). Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. Journal of Clinical Oncology  20 (19), 4040-9 PMID: 12351602 (OPEN ACCESS PDF)

Stearns L, Boortz-Marx R, Du Pen S, Friehs G, Gordon M, Halyard M, Herbst L, Kiser J (2005). Intrathecal drug delivery for the management of cancer pain: a multidisciplinary consensus of best clinical practices. The Journal of Supportive Oncology, 3 (6), 399-408 PMID: 16350425

Raslan AM, Cetas JS, McCartney S, Burchiel KJ (2011). Destructive procedures for control of cancer pain: the case for cordotomy. Journal of Neurosurgery, 114 (1), 155-70 PMID: 20690810

Hayashi M, Taira T, Chernov M, Fukuoka S, Liscak R, Yu CP, Ho RT, Regis J, Katayama Y, Kawakami Y, Hori T (2002). Gamma knife surgery for cancer pain-pituitary gland-stalk ablation: a multicenter prospective protocol since 2002. Journal of Neurosurgery, 97 (5 Suppl), 433-7 PMID: 12507070

What: #hpm chat on Twitter
When: Wed 9/17/2014 - 9p ET/ 6p PT
Host: Dr. William Rosenberg 
Facebook Event Listing: https://www.facebook.com/events/1443430942595064/
Topics:

T1 What has been your experience, if at all, with neurosurgical procedures for palliative care?
T2 Where do you see such procedures fitting into the overall palliative care of patients?
T3 What aspects of these procedures could be modified or changed to make them more beneficial to suffering patients?

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using nurph.com, for ease of following.

We will be posting the transcript and analytics here after the chat takes place. Chat Transcript and Chat Analytics courtesy of @Symplur

(An earlier version of this post appeared first on Dr. Rosenberg's website Center for the Relief of Pain. - Ed.)

(Edit - 9/17/2014 - added links to transcript and analytics - Ed.)

Tuesday, September 16, 2014 by Christian Sinclair ·

To cure almost always, to relieve often, to comfort if we have the time?
A Challenge to Palliative Care

(Please welcome Cory Ingram, MD, MS, FAAHPM to Pallimed.  Dr. Ingram recently attended the 2014 Palliative Care Congress in Montreal at McGill University, "the birthplace of palliative care." He posted many pearls from the meeting to Twitter, and I asked if he would be so kind to summarize his trip to this great conference. Please enjoy! - Ed.)

When Balfour Mount, father of Palliative Medicine in North America, coined the term Palliative Care more than 40 years ago it may have been difficult to envision 1600 people from more than 60 countries making their pilgrimage to Montreal for the biannual celebration of the specialty at the 20th International Congress on Palliative Care. In speaking with colleagues from around the globe the theme that brings them back is consistent. This conference is for the heart.

The congress content is suited for the interdisciplinary nature of the specialities and attendees from around the world. It kicked off with several day long pre-conference workshops. Dr. Tom Hutchinson, editor of the text Whole Person Care*, created a brilliantly constructed day to deeply examine whole person care for persons with cognitive impairment. The day offered a medical review of cognitive impairment followed by a personal account of caring for a loved one with dementia. The question of the personhood and maintenance of personhood while living with dementia was explored prior to an insight into the repercussions for families caring for a loved one with dementia. Preceding a panel discussion, the role of the community was highlighted. It is interesting to think of how we speak about institutionalized persons with dementia as no longer living in the community.

In McGill tradition, the plenary sessions were opened with moving reflections. One reflection set to beautiful music titled “Fragile” from France, which played while photographic images streamed portraying the fragility of life. Plenary sessions with speakers from around the world identified challenges for us to consider for ourselves and those we care for in palliative care. What are the roles of forgiving and forgetting? How do we foster a balance between holding on and letting go? How do you let go if you have nothing to hold on to? How do we balance being proactive and letting things happen naturally? How do we access the spiritual dimensions that are not readily accessible? How do we transfer a fight to control to a search for the meaning of suffering? Is the heart of medicine ultra performance? Where is the art? Where is the lived experience?

In conclusion, the paradigm of the future of medicine is one where palliative care is central to the core of care for all persons. To this end, the Montreal Declaration was created as a formal request for inclusion of palliative care in the United Nations 15 year health targets. You can add your voice to the growing support for the Montreal Declaration by signing on.

Take home messages:

1. Provide whole person palliative care.
2. Understand that palliative care is at a cross road of the humanities and sciences.
3. Avoid limiting our scope to symptomotologists.
4. Maintain “radical presence” to the humanity of another.
5. The art of palliative care is to find the core of each and every person.
6. Dr. Chochinov and Canadian Virtual Hospice launch a new film on Dignity Conserving Care.
7. The elephant in the room is Euthanasia this year in Canada.
8. Euthanasia is not about end of life care….rather it is about life ending procedures.
9. Euthanasia has no place in palliative care.
10. Stay true to the founding principles of palliative care with attention to total pain of the whole person and their family.

Cory Ingram, MD, MS, FAAHPM is a Senior Associate Consultant in Palliative Medicine, Senior Associate Consultant Palliative Medicine, Assistant Professor of Palliative and Family Medicine, Director of Palliative Medicine Mayo Clinic Health System, Director of Palliative Medicine Office of Population Health Management all at the Mayo Clinic in Rochester, MN. The views expressed in this article are my own and do not reflect the views of my employer.

*Link is an Amazon Affiliate link with proceeds going to Pallimed

by Cory Ingram ·

Friday, September 12, 2014

Draw the Lines: The Art of Setting Boundaries

One cannot work in end of life care without being challenged by boundary issues. Hospice and palliative care professionals are present during the most intimate time of a person’s life – their death. I certainly am not an expert on boundaries, but I do think about them often. Consider this article a set of contemplations regarding boundary challenges we face.

Challenge: The Appearance of Compassion versus Professional Neutrality

My first internship was at a mental health counseling center. My training emphasized having a neutral facial expression at all times. The purpose, I suppose, is so the client feels comfortable with being open with the counselor. If the client revealed an unpopular thought, the counselor would not want to have a reaction that would lead the client to feel self-conscious about their disclosure. It makes sense, in theory, but there are times when facial expressions are not only warranted, but helpful.

I was leading a bereavement group and a client told a story about feeling responsible for a relative’s death in a car accident. She told her story in great detail and by the end, most of the other attendees were crying. I managed to hold back my tears, but my eyes did water. After the group, the woman who told the story came up to me and thanked me. She said she had attended individual counseling and felt like the counselor didn’t even care. She said she could tell by my face that I cared.

A couple of years later, I went to a training by Bob Neimeyer, a well-renowned expert on complicated grief. He shared a video of a counseling session and he cried with the client who had experienced a tragic death. I felt validated; if he could share emotion, then it must be okay.

Where to draw the line: The key to compassionate expression, I believe, is to not grieve more than the client. If your reaction is so strong, the client ends up comforting you, then you may need to examine your own triggers.

Challenge: Intimacy versus Professional Distance

When we come into a patient’s life during a hospice admission, we are there during the most vulnerable time. We begin as strangers and we have to build rapport through openness and being approachable. If we are “too” professional, we can come across as cold or uncaring. It becomes a balancing act. We want them to see us as likeable AND trustworthy AND professional.

As we see patients decline, we are there for them, listening to the most intimate problems they face. They may tell us about embarrassing symptoms or about interpersonal conflicts within their family. We are their confidants. If we do our jobs well, they are comfortable with us and comforted by us.

Most people who work in hospice and palliative care are in the profession because it is our calling. I’m sure every professional has heard the phrase, “it takes a special person.” We are special and we do this job because we care.

Where we get into trouble: It is possible to care too much. One of my mentors taught me the acronym NATO - Not Attached To Outcome. We should not become so involved in a patient’s care that we think we know what’s best for them beyond what they want. We also have to be careful our relationship with the patient does not preclude them from relying on their own social supports. This most often happens when there is negative family dynamics. We especially do not want to get in the middle of the family dynamics. It is not our family. We should be neutral.

Challenge: Teamwork versus Personal Time

Hospice and palliative care is a round-the-clock profession. In an ideal world, the organization would be a well-oiled machine and every team would be appropriately staffed to cover all scenarios. The reality of the hospice business is there are sometimes staffing issues, call-offs, and of course, vacations. My absolute favorite part about working in hospice and palliative care is the team. I love the IDG meetings and the feeling of camaraderie among coworkers with a shared passion. We care about each other. We communicate and we collaborate often. We don’t ever want to let our co-workers down. If one nurse is in the weeds, the others will pitch in to help out. I have never experienced teamwork at this level in any of my other professional roles.

Where do we draw the line? Sometimes our willingness to help out our fellow staff comes at a price. We cancel our personal plans and we say, “I’ll do it.” I'm sure you can remember a time you have done this yourself. Maybe you were asked on your day off to attend a a death. Without a blink of the eye you said, "Yes, of course, happy to help." Your clinical manager never knew about the watercolor class, daughter's softball game or other event you missed.

Over time, though, one needs to be careful about self-sacrifice to the detriment of our own personal lives. If we give too much, we will leave nothing for ourselves. Each person’s capacity for where their line is may be different, but we must draw a line at some point.

Have I solved the great boundary conundrum? I wish. The boundary challenges come with the job. The key to maintaining boundaries is to be aware of our interactions. The ideal boundary “line” is balanced between what is best for the patient and what is best for us. If our boundaries are too restrictive, we risk the patient not feeling that we care. If we do too much for the patient, we risk compassion fatigue.

Lizzy Miles, MA, MSW is a hospice social worker in Columbus, Ohio best known for bringing the Death Cafe concept to the United States. You can follow her on Twitter here.

Friday, September 12, 2014 by Lizzy Miles ·

Friday, September 5, 2014

Stand Up To Cancer Can Have a Palliative Care Focus - How You Can Help

If you have not been on any social media channels, watching TV, listening to the radio, or picking up a newspaper or magazine in the past week, you may have missed that tonight Friday September 5th is the Stand Up to Cancer (SU2C) concert/fundraiser. (Which channel is it on? Doesn't matter it will be simulcast on 31 channels.) What is this and why will I later be asking you to watch it and take notes? Well, keep reading if you want to make a difference in palliative care.

SU2C draws all sorts of celebrities to talk about their personal experiences with cancer whether it be with their family, friends or even themselves. When I first heard of this organization in the late 2000s (the oughts? the oughties? anyway...), I wasn't really sure of their mission, their likely longevity, and I was honestly a bit skeptical if their funds would actually go to cancer research or care. Maybe, I thought, this is just a feel good vehicle for stars to feel like they were making a difference. I admit I may have been a tad bit too cynical about the whole fundraising enterprise back then.

In the intervening years, I became more familiar with the background, work, responsibilities and excitement which comes along with development work. Working on the AAHPM's first major fundraising campaign, Shaping the Future, enforced the importance of motivating people to drive resources to a strong mission. Seeing the impact of the ALS Ice Bucket grassroots campaign was a fantastic learning experience for all of us in hospice and palliative care. I've done my homework on SU2C and frankly they are a pretty stand-up organization when it comes to administering donations. Rated 4 stars on Charity Navigator, they earn high marks for Accountability, Transparency and Financial Impact. They are backed by the Entertainment Industry Foundation, which is an umbrella organization for many causes.

With the help of the American Association for Cancer Research, SU2C has supported 750 researchers and 140 clinical trials organized into Dream Teams focused on translational research (bench to bedside) for rapid impacts in patient care. But when you look at the details of their research teams it is pretty clear the focus is on genetics, and biomedical therapies. The mission statements of SU2C and AACR never explicitly mention anything resembling palliative care or the more benign and accepted supportive care. But this year the theme is 'Survivorship,' and as any palliative advocate knows quality of life (QoL) is a big piece of survivorship. So seeing this big concert extravaganza has my brain thinking a bit more creatively about how HPM can learn from SU2C, and maybe how HPM can influence SU2C in the future.

So here is what we all need to do - watch and engage with the SU2C concert/media storm in the next 24-48 hours. In particular, listen to celebrities experiences with cancer. Sure, some of them will talk about 'ending cancer', 'fighting cancer' (don't get us started on battle language), 'curing cancer' and other lofty long term goals. Yet what we must listen for are the moments where we can say "THAT'S PALLIATIVE CARE!"

I'm talking about the discussions of quality of life while someone is receiving treatment, taking time to be with family, rediscovering spirituality, complicated grief, uncontrolled symptoms which went untreated, health care communication successes and failure. You will hear many situations which are truly about the impact of palliative care (whether it was available or not), and that, my friend, is where we come together and make a list of all the times when palliative care themes, philosophies or approaches were used or could have been used to help people Stand Up To Cancer.

Here is where the magic happens. Once we have a collection of true experiences shared publicly we can reach out to Stand Up To Cancer and start a dialogue about making next year's theme about palliative care. Yes, it is a long shot, but we could sit by or instead we could stand up ourselves to advocate for some of this great support to improve the quality of life of all people with cancer, whether they survive or not. And if that big piñata of a goal doesn't work, we now know a group of celebrities who have shared very real experiences about palliative care and maybe we might be able to reach some of them to champion this great cause.

So will you stand up?

Friday, September 5, 2014 by Christian Sinclair ·

Thursday, September 4, 2014

Hospice and Palliative Medicine Boards 2014 - Free Board Questions!

October 2nd is fast approaching and many eager doctors will be brushing up on their Medicare Hospice regulations, ethical dilemmas, and opioid conversions as they prepare for the 2014 Hospice and Palliative Medicine Board Certification. So first off those of us at Pallimed want to wish you all good luck, and we hope your teams, mentors, and faculty are all behind you giving you the support, information, advice and most importantly time you need to pass the boards and be a part of the hospice and palliative medicine workforce for a long, long time.

Some of you taking the boards this time around may not realize that we have a free set of board review questions we designed in collaboration with GeriPal for the 2012 edition. We called it Blogs to Boards and it was the initial idea of Pallimed contributor and all around fantastic doctor, Suzana Makowski from UMASS. Eric Widera, Paul Tatum, Drew Rosielle and myself contributed to the questions, answers and discussions as well. But since that was a long time ago in internet years, we wanted to remind you of this great free asset.

Now we have not updated the questions since then, and it never went through the rigors of a professional product you might get from somebody like AAHPM, but hey it is free and we think you will learn something that will help you for boards.

PLUS, as an added bonus these 41 questions make great IDG discussion points! So it really doesn't matter if you are taking the test, these will really help you and your fellow clinicians. So please download, share and give us feedback. If we do reuse them, we have licensed them under a Creative Commons license linked below, so please make sure to give attribution, don't use for commercializing purposes, and share alike.

And if you would like to see more great free study materials like this, we are happy to have you volunteer and give us that spark of energy we need to make some more Blogs to Boards questions.

PS - Go check out and add to the great discussion at GeriPal about the importance or distraction of requiring your primary board certification to ensure that your HPM certification is fully legit. The AAHPM sends two representatives to the meeting where they discuss all this important stuff so your comments on that blog post actually matter!

Download Questions Only - PDF
Download Questions, Answers and Discussions - PDF
Also available on Slideshare - Questions Only - Questions and Answers

Creative Commons License

Thursday, September 4, 2014 by Christian Sinclair ·

Wednesday, September 3, 2014

A True Health Care Innovation: "Hello, My Name Is..."

One of the most refreshing things about hospice and palliative care (HPC) is the person-centered focus of care. Many clinicians who discover palliative care are really drawn to this, because it gets back to the roots of caring for another human being. Add in a healthy dose of communication training and HPC clinicians are ready to jump into a patient/family meeting wherever they are needed. But what about the simple stuff?

Dr. Kate Granger is a physician in her last year of training in the UK ( in Elderly Medicine with a Palliative Medicine sub-specialty), who realized as a patient herself, the simple act of a kind and earnest introduction could make a great impact. She was diagnosed with a terminal cancer during her medical training in 2012. During a re-hospitalization with sepsis in August 2013, she made a acute observation that anyone who has ever been a patient will likely recognize: not every person caring for her bothered to introduce who they were. Even more important, she also recognized the following:
“But when somebody did introduce themselves, it made such a difference to how I was feeling about myself. It made me feel more human again.”
Yet Kate did not yield to the frustration of her initial observation as many of us might. She did not field an anonymous complaint to the suggestion box. She sought to change the behavior of health care professionals, (really all people) who may interact with a patient, be they doctor, nurse, therapist, intake person, volunteer, trainee. And what she did was extraordinarily brilliant yet simple and effective, she reflected on her own actions as a physician, wrote about her experience, and asked other health care professionals to join her in making a simple introduction the beginning of every patient interaction. “Hello, my name is…”
Now this started in the UK back in September 2013, and in 2014 the momentum has grown in the UK, and spread worldwide most notably in Canada, and Australia, but from my social media research it surprisingly has not been a big deal here in the United States*. But all of us...we can change that.

We can help share Kate’s passion. We can start “Hello, my name is…” campaigns in our hospitals, nursing facilities, hospices here in the states. Make a commitment yourself on social media and encourage your health care friends to do the same. The hashtag #HelloMyNameIs very popular on Twitter with millions of impressions but mostly in the UK. Great ideas like this live to be shared and we have the ability to bring compassion back to the foundation of health care in the US.


If your organization gets on board, please make sure to share it with @GrangerKate on Twitter or on her blog. If you let us know too, we will make sure to highlight some of the early adopters here in the United States. (If I missed that your organization in the US, did this a long time ago, let me know, I’ll re-edit the post!). If you are a health care social media influencer I challenge you to write about this and help make a difference in your own digital and IRL communities.

When was the last time you were excited about something in health care?
Like, change the world type of excited?

Additional Links:
Make the pledge on Twitter: 

Change your avatar on social media to "Hello, my name is..."
Hello My Name Is...Website
Download Templates and Logos  
Kate and Chris' story on YouTube
Updates and Archives from Dr. Kate Granger on her website: http://drkategranger.wordpress.com/
Donate to Yorkshire Cancer Centre (Kate's chosen charity) via JustGiving
Download her books (Pallimed Amazon Affiliate Links)



*I did find a well written post by Dr. Peter Pronovost at Johns Hopkins, but despite the post it doesn't appear from other searches Johns Hopkins took him up on the great shared idea.

Wednesday, September 3, 2014 by Christian Sinclair ·

Wednesday, August 27, 2014

Palliative Care and Mental Illness

Robin Williams’ death prompted a small flurry of tweets and articles looking for more awareness of and attention to mental health. Earl Quijada (@equijada) and I had a short exchange that really got me thinking about how we view mental illness in the medical world. Our palliative care team cares for a fair number of patients with serious medical illness (cancer, heart failure, etc) who also have serious mental illness (SMI) such as profound depression, bipolar disorder, schizophrenia, etc. In my experience, there are unique challenges to providing the best care to these patients for both their health-care providers and their loved ones. Additionally, it seems likely that these patients experience the medical system in a way that is different and perhaps more challenging to them personally than patients without SMI, creating the potential for suffering.

With those thoughts in mind, here are the topics for discussion for this week’s #hpm Tweetchat:
  1. How does the medical establishment care now for patients with serious mental illness(SMI)?
  2. What role does palliative care have in improving the care of patients with SMI?
  3. What challenges do we perceive for providing palliative care in patients with SMI? What opportunities exist?
  4. Should palliative care consultation be part of the routine care for patients with SMI?
If you are new to Tweetchats, please see this overview. You can follow along on platforms like nurph.com, Tweetdeck or Hootsuite.

What: #hpm Tweetchat
When: Wed 8/27/2014 - 9p ET/ 6p PT
Host: Dr. Meredith MacMartin
Facebook Event Page: https://www.facebook.com/events/276720409189081

After the chat, we will post the transcript and analytics here.

For more on #hpm Tweetchats see our archive of transcripts and analytics, and other Twitter-related posts here on Pallimed.
For more posts on psychiatry on Pallimed, click here.

Wednesday, August 27, 2014 by Meredith MacMartin ·

Monday, August 25, 2014

Cases: Second-Line Anti-emetic Therapies for Refractory Chemotherapy-Induced Nausea and Vomiting (CINV)

Case:
Ms. Turner* is a 29-year-old woman with recently diagnosed ovarian cancer discovered after presenting to the ED with worsening abdominal pain. CT imaging showed a 4.8cm cystic mass extending from her right ovary, and the surgical pathology revealed ovarian adenocarcinoma. Two weeks post-operatively, she was hospitalized for initiation of chemotherapy, and the palliative care service was consulted for symptom management. Despite having received treatment with ondansetron (Zofran®), aprepitant (Emend®), dexamethasone (Decadron®), lorazepam (Ativan®), and haloperidol (Haldol®), she developed significant nausea and vomiting on the first day of chemotherapy infusion with symptoms worsening on her second day of chemotherapy. She described feeling utterly miserable and fearful about her next chemotherapy infusion, and she was continuing to experience nausea and repeated episodes of emesis overnight with minimal oral intake. Ms. Turner also described an underlying history of anxiety disorder predating her cancer diagnosis. At home she typically smoked marijuana on a daily basis to help manage her anxiety symptoms, which she reported did not interfere with her successful function at work and school. On review of systems, she noted abdominal discomfort for which she was taking low dose oxycodone and that she had not moved her bowels for several days.
Discussion:
Nausea and vomiting (NV) are commonly reported side effects with chemotherapy.1 The primary pathway for NV involves the chemotherapy drugs directly stimulating the chemoreceptor trigger zone (CTZ), in the area postrema at the base of the fourth ventricle. Activated receptors in the CTZ transmit signals to the vomiting center in the brainstem to produce NV. Receptors in the CTZ include serotonergic receptor 5-hydroxytryptamine type 3 (5-HT3), dopaminergic (D2) and neurokinin type 1 (NK-1) receptors. In addition, chemotherapy can damage GI mucosa causing local release of 5-HT3 neurotransmitters by gut enterochromaffin cells, activating peripheral pathways along the vagus and splanchnic nerves and directly triggering the vomiting center. Finally, chemotherapy-associated anxiety may also stimulate the vomiting center through central cortical pathways. Whether transmitted via signals from the CTZ, the cortex, or peripheral inputs, the vomiting center has several different receptors involved in initiating the vomiting reflex: muscarinic acetylcholine (Achm), histamine type 1 (H1), and 5-hydroxytrypamine type 2 (5-HT2).1

Given the pathways for chemotherapy-induced nausea and vomiting described above, 5-HT3 and NK-1 receptor antagonists such as ondansetron and aprepitant, in combination with dopamine antagonists such as haloperidol, are typically effective for treatment of NV. In some cases, however, patients may develop breakthrough nausea and vomiting despite adequate standard therapy requiring additional or alternative anti-emetic medications. According to guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network, there are several categories of second-line agents that may be useful in refractory cases.2,3

The cannabinoids dronabinol (Marinol®) and nabilone (Cesamet®) are both FDA approved for refractory chemotherapy-induced nausea and vomiting.4 Unlike other anti-emetic medications which block receptor activity for their therapeutic effect, cannabinoid effect is exerted by agonist activity on the cannabinoid receptor in the brain CB1.5 Dronabinol is a Schedule 3 synthetic THC (delta-9 tetrahydrocannabinoid). Starting dose is typically 5mg 2 hours prior to chemotherapy and every 4 hours as needed, with a maximum dose of 15mg. Nabilone is a Schedule 2 drug with longer onset and duration of action, and is dosed 1-2 mg twice or three times daily as needed. Studies demonstrate that dronabinol and nabilone are effective for treatment of nausea and vomiting; however, their use is limited by their side effect profile including vertigo, xerostomia, hypotension, dysphoria, and hallucinations.4,5

Olanzapine (Zyprexa®) is an atypical antipsychotic which antagonizes multiple neurotransmitters including dopamine at D1, D2, D3 and D4 brain receptors; acetylcholine at muscarinic receptors; serotonin at 5-HT2, 5-HT3, and 5-HT6 receptors; catecholamines at alpha-1 adrenergic receptors; and histamine at H1 receptors.6 Several studies have demonstrated its utility for treating chemotherapy-induced nausea and vomiting.6 No studies have specifically compared it to haloperidol or other atypical anti-psychotics for treatment of nausea, although several authors have argued that it is the multiplicity of olanzapine’s receptor activity which contributes to its effectiveness. The recommended dosing is 5mg orally daily starting 1-2 days before chemotherapy, then 5-10mg daily for days 1-4 of chemotherapy. Side effects include sedation, dry mouth, increased appetite, hyperglycemia and postural hypotension.2,3

Metoclopramide (Reglan®) has central and peripheral anti-dopaminergic activity, and at high doses also exerts 5-HT3 antagonist effect which is thought to contribute to its anti-emetic effect.1,2 Because of its low therapeutic index, metoclopramide is typically reserved for patients who are intolerant or refractory to first line anti-serotonergic agents. Dosing is 10-40 mg IV 30 minutes prior to chemotherapy, then every 4 to 6 hours as needed.3 An alternate dosing strategy is 1-2 mg/kg 30 minutes before chemotherapy and then repeated 2 hours after chemotherapy for 2 doses, and then every 3 hours for 3 doses. Side effects include dystonia, akathisia, sedation, and esophageal spasm. Pretreatment with diphenhydramine (Benadryl®) will decrease risk of extrapyramidal reactions.2

Benzodiazepines are most useful in cases of anticipatory NV, which is thought to be a conditioned reflex as a result of prior poor control of emesis during chemotherapy treatment.3 The phenomenon involves the development of NV when a sensory stimulus (ie, the sights, sounds, or smells of chemotherapy clinic) becomes paired with the experience of symptomatic chemotherapy treatment. After a conditioning period (ie, repeated chemotherapy infusions in clinic), the sensory stimulus or anxiety from negative anticipation may trigger NV before the patient has even received the chemotherapy infusion.7 The mechanism involves signals along intracerebral projections in the cortex directly stimulating the vomiting center. Older studies had described the phenomenon in up to 25% of patients with poorly controlled symptoms by the fourth treatment cycle; however, the frequency appears to have decreased with the advent of more effective anti-emetic regimens. Patients with refractory NV are at higher risk of developing anticipatory NV. The intermediate-acting benzodiazepine lorazepam is helpful for treatment of anticipatory NV and as an adjunct in cases of refractory NV, with starting doses of 0.5-1mg oral or IV, and up to 2mg, every 6-8 hours as needed for anxiety and nausea.7

Resolution of the Case:
Based on her symptoms and previous history, Ms. Turner was started on dronabinol 5mg three times daily during her chemotherapy treatment while in the hospital, along with the scheduled ondansetron and haloperidol. A bowel regimen of senna (Senekot®) and polyethylene glycol 3350 (Miralax®) was also initiated, as opioid-induced constipation was likely contributing to her symptoms. Within 24 hours, she had resolution of emesis and improvement of her nausea, enabling her to resume oral intake.

Summary:
While standard anti-emetic therapies with 5-HT3 and dopamine antagonists are effective and well-tolerated in most cases of chemotherapy-induced nausea and vomiting, occasionally refractory symptoms necessitate addition of a second-line agent such as a cannabinoid, olanzapine, or metoclopramide. Patient characteristics such as age, previous experience with cannabinoids, and medical comorbidities will impact the choice of second-line agent. Dronabinol or nabilone may be most effective in younger patients and those with previous experience of tolerating cannabinoids. Olanzapine is preferable in elderly patients or populations for whom there may be a concern about the psychoactive properties of cannabinoids. Substitution of high dose IV metoclopramide for other dopaminergic and 5-HT3 medications could also be helpful in certain cases, especially if there are additional concerns about GI dysmotility or intolerance to standard 5-HT3 agents.

References:
1. Wood G, Shega J, Lynch B, Von Roenn J. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207.
2. Basch E, Prestrud AA, Hesketh PJ. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29:4189. Open Access PDF
3. Hesketh PJ. Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2008; 358(23):2482-94.
4. Wilner LS, Arnold R. Cannabinoids in the Treatment of Symptoms in Cancer and AIDS, 2nd edition. Fast Facts and Concepts. December 2007; 93.
5. Todaro B. Cannabinoids in the Treatment of Chemotherapy-Induced Nausea. J Natl Compr Canc Netw 2012; 10:487-492.
6. Nizukami N, Yamauchi M. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting in Patients Receiving Highly or Moderately Emetogenic Chemotherapy: A Randomized, Double-Blind, Placebo-Controlled Study. Journal of Pain and Symptom Management March 2014; 47 (3)542-550.
7. Roscoe J, Morrow G. Anticipatory Nausea and Vomiting. Support Care Cancer Oct 2011; 19 (10): 1533-1538. Open Access PDF

Original Case by Helen Dorra, MD, Edited by Christian Sinclair, MD
University of Pittsburgh Medical Center

Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. It is published as a means to illustrate important teaching points in healthcare. Patient details have been changed by Pallimed editors to help with anonymity. Links and small edits are made for clarity and to abide by Pallimed editorial standards.

Monday, August 25, 2014 by Christian Sinclair ·

Friday, August 22, 2014

Building a Better Mortality Prediction Rule

You will often hear the lament from people within and outside of the hospice and palliative care fields, that doctors are pretty bad at making effective prognostication. Patients and families frequently search for a predictable road map to understand the course they are likely on, and even when they cede the understandable uncertainty to the physician, the doctors will often reply with an unhelpful retorts like, “I don’t know what may happen. There is only one person who does.”

I doubt all of those physicians are referring to Dr. Mark Cowen, but they may want to take notice of what he and his colleagues at St. Joseph Mercy Hospital in Ann Arbor, Michigan have been doing for the past couple of years. Having already developed and validated a 30-day mortality prediction rule (MPR) (published in 2013), the team now advanced the idea to a prospective, real-time mortality prediction rule study. Published online in the Journal of Hospital Medicine this month, “Implementation of a Mortality Prediction Rule for Real-Time Decision making: Feasibility and Validity” may help clinicians move from pre-contemplation to contemplation when it comes to applicable prognostication.

The MPR in this study was completed on almost 10,000 patients admitted to the hospital (78%) and an outpatient surgery center (22%) at a tertiary community teaching hospital over the Fall 2012 to Winter 2013 (yup, flu season!). Some high mortality risk (dialysis units, transfers from outside hospitals) and low mortality risk admissions (child birth/OB) were not included, most likely because the ability to implement the rule before having a bed assigned was more challenging to accomplish. Since this is not only a validity study, but also a feasibility study, they nicely discuss the diplomacy, champion-finding, and need for paid support staff for this project to work. Interestingly, the authors note the ED staff were open to this prediction rule only if they could accomplish the task “within the time a physician could hold his/her breath.” Be careful what you say in a research administrative meeting, you may see those words published in a journal article some day!

The rule was Web-based and pre-populated data from the EMR without any manual effort. Updates were done to the Web-based rule as often as every minute! Then ED doctors or surgery center nurses reviewed the pre-populated information and made overrides if necessary. Samples of the questions asked include:

History or presence on admission of:
  • Atrial fibrillation
  • Solid-tumor cancer
  • Metastatic cancer
  • Cognitive deficit
  • Leukolymphoma
  • Other neuro deficit
Patient’s current condition/treatments:
  • Respiratory failure
  • Heart failure Injury
  • Sepsis
  • Abnormal vital signs
At first the clinicians did not have access to the score but that changed over the course of the study, which to me is one of the weaker parts of the study. It treats this whole group as one, but really this is equivalent to having a study where you have blinded the clinicians and the patient, and then midway through you started to un-blind some of them as to the treatment/test/intervention. The authors talk about two care processes put in place as these scores became available which may impact the true validity of this MPR de novo. Wouldn't it make more sense to test this MPR without changing any behavior (via knowing the score), and then test how it could impact clinical delivery and patient outcomes? The impact of this MPR was a slight bit muddled because of that contamination of the study population.

They split the population into 5 risk categories by quintiles, with the highest risk population having an approximate 7-35% chance of 30d mortality.

But let’s get to the real meat of what Pallimed readers care about, did this study group look at palliative care consults, or hospice utilization? Sorta, kinda. We're going to need to do a little hypothesizing and I will expand on that in an upcoming post. We will talk about what an accurate MPR could do for palliative care and hospice utilization.

Of note, nurses worked with this tool, so if anyone says that prognostication is not the role of a nurse, you can point them to this article.  Nurses should not be excluded from prognostication based on credentials. I appreciate when nurses give me an honest assessment of prognosis, and I hope other doctors out there do as well.

Some other information that would be really helpful is understanding the outliers in the high risk strata.  Who were the people who lived but were high risk? And for how long? Do they have any significant quality of life issues post-hospitalization?

Other info that would be great to see is how much overlap there was in the different groups. For example, if you had palliative care while in the hospital, what was your likelihood of a 30d readmission.

So overall, this is a really good study, and is very accessible in the way it is written. Since it is published in a non-core HPM journal it should be quite easy to approach your hospitalists and ED colleagues to talk about possibly doing a validation study in your local hospitals.

Credits: Future Road Sign - iStockPhotos; Quote - Illustration by Pallimed; Chart - From article under Fair Use guidelines for for nonprofit educational purposes. Full copyright of that figure is retained by the journal.

ResearchBlogging.orgCowen, M., Czerwinski, J., Posa, P., Van Hoek, E., Mattimore, J., Halasyamani, L., & Strawderman, R. (2014). Implementation of a mortality prediction rule for real-time decision making: Feasibility and validity Journal of Hospital Medicine, Early Publication DOI: 10.1002/jhm.2250

Friday, August 22, 2014 by Christian Sinclair ·

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