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by Julie Childers, MD

(Patient information is fictionalized to illustrate this case.)

Case:
Mr. K is a 88-year-old man with advanced dementia who was brought to the emergency room for agitation and hitting another resident in the dementia unit of his nursing home. This behavior was not new for him. Mr. K, a veteran, spent his time pacing the halls; though he was not oriented, he spoke clearly (frequently about events during the war), ate well, walked easily, and was physically strong. Most of the time Mr. K was calm and could be redirected. However, he occasionally would become agitated and even violent. He would sometimes take his prescribed medications and sometimes refused; when he refused, it was difficult to persuade him and impossible to force him. Multiple medications had been prescribed for his agitation, including lorazepam, risperidone, and olanzapine; none were successful. When he came to the emergency room, he was discovered to have significant urinary retention. Two liters of urine were removed from the bladder, and he became calmer.

Discussion:
More history from the patient’s daughter and the nursing home staff revealed that many of Mr. K’s episodes of agitation coincided with urinary tract infections (UTIs). Among the medications which Mr. K regularly refused was terazosin, prescribed for benign prostatic hypertrophy (BPH). Urinary retention caused by his untreated BPH made him more susceptible to UTIs and also caused pain which he was unable to explain verbally. An indwelling Foley catheter had been previously attempted; however, the presence of the catheter also seemed to cause him distress. How could Mr. K’s symptoms from BPH be treated in a way that would not worsen his agitation?

Background:
The incidence of BPH increases with age, from 20% of 40-year-old men to more than 80% of men over the age 80. Common symptoms are urinary frequency, nocturia, urgency, hesitancy, weak or intermittent urine stream, straining to void, and sensation of incomplete voiding.

There are two main types of medical treatment for BPH: alpha blockers and 5-alpha-reductase inhibitors. Alpha blockers work by reducing prostatic smooth muscle tone and have an immediate effect on urinary flow.

Nonselective alpha blockers (doxazosin, prazosin, and terazosin) can also have systemic side effects, including dizziness, orthostatic hypotension and fatigue. Tamusolin is a highly selective alpha-1A-adrenergic antagonist which avoids these side effects but is more expensive. Studies of alpha antagonists have found an average 25-30% improvement in urinary symptoms.

Five-alpha-reductase inhibitors (finasteride, dutasteride) act by preventing the conversion of testosterone to dihydrotestosterone in the prostate gland, thereby shrinking the gland. Men generally need treatment for 6 to 12 months before the size of the prostate is reduced enough to improve symptoms.


For men with acute urinary retention due to BPH, many urologists recommend a trial of catheterization with use of alpha blockers, followed by attempts at spontaneous voiding. If this fails, transurethral resection of the prostate (TURP) is often performed. This procedure involves the insertion of a scope into the bladder, while the bladder is irrigated; the urologist is able to directly visualize the prostate tissue and resect it piece by piece. The procedure takes 60 to 90 minutes and can be performed under general anesthesia, with a spinal or epidural nerve block or a regional nerve block.

For men who are not candidates for TURP and who have ongoing urinary obstruction, catheterization is an option. A foley catheter can be placed in an office setting, but carries an increased risk of urinary tract infection. Intermittent catheterization can also be used for long term management of urinary obstruction. The final option is a suprapubic catheter, which is placed surgically through the abdominal wall and into the bladder. This reduces trauma to the urethra and the incidence of bladder infection.

Back to the Discussion:
Mr. K’s daughter met with palliative care, psychiatry, internal medicine and urology to discuss the options. Medical treatment for BPH was unlikely to be successful in reducing further episodes. Intermittent catheterization was discussed with urology; however, due to the size of his prostate, catheterization was extremely difficult.

Even if Mr. K would allow it, it couldn’t be done by nursing home staff. TURP might be the most effective treatment for him, but the urologists did not recommend that or any other surgical procedure due to his overall health and his lack of ability to adhere to post-operative care. It was decided to attempt an indwelling Foley again; however, even with the administration of haloperidol prior to the procedure, Mr. C became so distressed and agitated that his daughter asked the urologists to stop.

The next day we met again, and in accordance with Mr. K’s daughter’s goals for her father decided not to attempt further catheterization or to force medications. She thought Mr. K would not want his life extended at all in his current impaired state. We would attempt to reduce Mr. K’s BPH with measures that were not intrusive to him by continuing to offer him alpha blocking medication and a five-alpha-reductase inhibitor, and by discontinuing any medications that could increase urinary symptoms such as diuretics, anticholinergic agents, and tricyclic antidepressants. When he did have agitation we would assume that it was due to obstructive symptoms and would treat the discomfort with sublingual morphine. Eventually we expected that his bladder would become infected leading to sepsis, or urinary obstruction would damage his kidneys and he would go into renal failure. Rather than treating with antibiotics or readmitting to the hospital, we would keep him comfortable in his current setting.

Conclusion:
In this case, a simple condition that is easily treatable in most men became one that we expected to lead to Mr. K’s death. However, the diagnosis that led it to become life-limiting was Mr. K’s dementia, and the heavy burden which BPH treatments would have placed on him.

Mr. K’s daughter based her decision on Mr. K’s values, saying that if the father she was raised by was able to see himself in his current condition, he would have wanted both to stay in place and to be allowed to die with dignity. Forced catheterization and antipsychotic treatment might have prolonged his life by years but would have caused terrible suffering to himself and his family. With the decision to allow his BPH to progress with minimal intervention, we were able to discharge Mr. K to enroll in hospice at his nursing home and completed a POLST form indicating “comfort measures only”.

References:
1.) American Urological Association Guideline: Management of Benign Prostatatic Hyperplasia (BPH) 2010. http://www.auanet.org/education/guidelines/benign-prostatic-hyperplasia.cfm Accessed August 24, 2014.

2.) Burnett AL, Wein AJ. Benign prostatic hyperplasia in primary care: what you need to know. J Urol 2006; 175:S19.

3.) Dull PD, Reagan RW, Bahnson RR. Managing benign prostatic hyperplasia. Am Fam Physician. 2002 Jul 1;66(1):77-85. Open Access


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 may 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.

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Dusting off the Blogger account and checking in......

JCO published a population-based snapshot that looks at the characteristics of patients with cancer who visited emergency departments in North Carolina during 2008. Lung cancer was the most common cancer identified in visits by a significant margin while breast, prostate, and colorectal cancer were each identifed in a smaller number of visits. Patients with lung cancer were more likely to be admitted to the hospital with a total of 63% of all ED visits for patients with cancer resulting in an admission. The top three complaints included pain, dyspnea, and gastrointestinal complaints. More ED visits occurred during night and weekend hours than regular office hours.

Few brief thoughts/questions to ponder:

• What percentage of the ED visits were preventable? What systems could be introduced to prevent the visits? (Urgent clinic availability, telemedicine, enhanced home health, etc)
• Would these system changes result in a more timely manner and would that result in reduced need for hospital admissions?
• As a palliative care clinician, it's not a surprise to see lung cancer disproportionately represented. One of the results of the Temel et al study regarding palliative care involvement from the time of metastatic NSCLC diagnosis was reduced hospital admissions/ED visits. It's not clear what the "mechanism of action" is, but improved access to a team that can help with the top symptoms certainly is one plausible hypothesis.
• What is the "right number" of appropriate ED visits/hospital admissions? Hard to say, but palliative care as a field should actively work to help our oncology colleagues to push the numbers as low as possible. As much as I like my ED colleagues, the ED is not a fun place to be.

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A few items about palliative care in the ED, prognosis of delirium, and whether antibiotics improve symptoms in pneumonia.  See below the fold.  I'm traveling next week, so probably won't blog again myself until later on in August.  Summer, ugh, is rapidly fading....

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[Editor's Note (C.S.) - I would like to introduce Suzana Makowski, MD, MMM, FACP as the newest blogger to the Pallimed team. Suzana and I go back a few years when we first met at the AAHPM Annual Assembly in New Orleans. She has tremendous enthusiasm for hospice and palliative medicine and her insights reach beyond the traditional evidence-based medicine approach. She is the newly elected co-chair for the Humanities and Spirituality SIG for AAHPM and the founder of the Lois Green palliative faculty development initiative. You can also find her on Twitter if you are so inclined (@suzanakm). She will be blogging on the main blog and occasionally on the Arts and Humanities blog also. Please help me in welcoming Suzana!]

Thank you Christian! And of course to Palladius and to Patrick for welcoming me to Pallimed with a rich choice of articles to share. Somehow it seems fitting that my first post refer to an article from Canada – now that Vancouver has been warmed up by the Winter Olympics just a year before that city-of-my-dreams will be swarmed by thousands at the AAHPM assembly next year. Well, in full disclosure, the study was not conducted in Vancouver, but rather in Ontario.

During this time, when the House and Senate continue to debate healthcare reform, when policy-discussions surrounding palliative care are challenged by the tension between the quality and quantity of care, an article emerges from CAMJ (with free online full pdf access) that challenges us to rethink how to focus our resources for patients with serious, end-stage cancer. Taking the IOM’s definition of quality care as “the right care at the right time in the right place,” this article explores how and why patients with serious cancers and their caregivers seek help through the emergency rooms and boldly asks the question whether this is the best care the patient could be receiving.

The point of transition from home to hospital is usually the emergency room. It is a place, as a patient of mine admitted for severe breathlessness, in hospital with a chest tube explained, is never a place you want to spend much time, especially if you aren’t feeling well. “I try anything to avoid waiting hours first in the waiting room, and then on a thin mattress in the hallway or room whose walls are build by wisps of curtain, sometimes waiting for hours in close proximity with strangers.”

We know already that most people want to be at home with family at the end-of-life, we also know that most end up in hospital or institution. We have hypothesized that increasing access and enrollment to hospices might help people meet this goal. This article seeks to understand how frequently and why patients with end-stage cancer choose to go to the ER.

So this begs the question… what percentage of patients with cancer visit the emergency room during the last 6 months and 2 weeks of life?
Of the 91,561 patients who died of cancer between 2002 and 2005, 84% of patients visited the ER in the 6 months prior to death and 34% of patients visited in the last two weeks before death.  They outline the principle reasons for emergency room visits: primary cancer (mostly lung cancer), uncontrolled symptoms (pain, dyspnea and other non-pain symptoms), caregiver fatigue, and infection.
Top reasons for ER visits among patients with cancer:

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In hearing about all the tragedy and occasional stories of hope and amazement with the recent earthquake in Haiti, I have been wondering about the role for a hospice/palliative care philosophy in the treatment of those injured and killed during and after the earthquake. Locally, I have not heard of any hospice or palliative care staff taking leave of work to embark to Haiti. (And if anyone does know of someone with a palliative background who has recently gone to Haiti I would love to interview him/her for Pallimed.)

I have also considered how my skill set might be best applied if I myself had decided to go to Haiti with the relief efforts. Would I fall back to my Internal Medicine training or would the specialized palliative care training be helpful? NPR's health blog 'Shots' recently covered some of the triage dilemmas being dealt with by health care staff on the ground. An excerpt:

A pediatric surgeon raised a tough question about when people should be taken off equipment to help them breathe. "Today the issue was ventilators. We ran out," he said. "What do you do then? We need a reality check. Some people might have to get off the ventilator before you would take them off elsewhere. That ventilator could save the life of someone who is much more salvageable."

But other doctors appeared incensed at the idea of stopping short of using every tool available on even the chance to save a life.

Palliative care staff help families and other medical staff sort through these tough decisions all the time in hospitals across the country, so maybe we as a field should make a concerted effort to be included in the 'essential' staff that might be needed in the next major disaster. Imagine an administrator making a list of the 'expertise' she would like to have in the field. As I think/write more, it does not appear to be such a stretch to consider having medical staff with a hospice or palliative care background on the ground in a major trauma/disaster zone.

• Pain and symptom control
• Skillful communication to traumatized/grieving families and patients
• Whole patient/family approach to care, support to other staff
• Prognostication awareness/skill
• Grief and bereavement counseling (like Alive Hospice and Hope Hospice (Florida) are already doing)
• Ability to engage with one's spiritual support
• Willingness to think outside the box and work in conditions that are not considered ideal medically (i.e. like hospice staff do daily in patient's homes).

Sounds like a good skill set in a disaster zone to me.


In the NPR story, they even mentioned palliative care but it was quickly shot down. (Guess which specialty shot it down?)

Referring to the patients likely to die, one medical planner offered a solution, "What about having palliative care facilities at the intake sites on shore?" A surgeon responded, "And have five hundred tents of dying people in a field right next to a medevac site? We can't do that."

But surely something is better than nothing. "Even if we just give them some painkillers and a comfortable bed, it'll be better than them dying in the street under the sun like a dog," a nurse offered.

But a surgeon argued that easing the death of a doomed person would take a bed that could be used for someone with a real chance of being saved.

Shouldn't we make a more concerted effort to be included in the list of specialists available to help in a disaster? Would we be welcomed or instead shunned given our comfort in discussing issues around death and dying when everyone else is in rescue mode? And what about the patients who were already on hospice. They still need specialized care as well.

(Pictures via Boston.com Big Picture)

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Annals of Emergency Medicine has a couple of related articles about palliative care in the ED.

First is a general discussion about PC in the ED, it's kind of a 'palliative care 101' for ED clinicians and talks about how pc skills are important in the ED setting. It also discusses HPM board certification for emergency medicine physicians.

The other article is a qualitative research study about the experiences and attitudes of emergency department clinicians about providing palliative care and EOL care in the ED. The study involved focus groups of clinicians (docs, nurses, social workers, and techs; n=26; 54% docs including residents) from 2 academic EDs in Boston, and used open ended questions about experiences with, understanding of, and attitudes towards EOL and palliative care in the ED setting.

The results are revealing, and describe deep concerns and frustrations and feelings of clinical inadequacy in these situations: lack of training in symptom management, prognostication, and communication; uncertainty about how to address conflict/unclear goals in an emergency setting; major frustration with outpatient providers about not addressing EOL care/goals/issues/treatment limitations prior to a patient's presentation as well as with systems issues to do with documentation of treatment preferences/DNR orders etc. (sort of stuff that the POLST paradigm in particular is designed to address; still requires however someone to do that prior to a patient showing up in extremis in an ED).

That last issue in particular is one that I've heard from a lot of EM physicians. Clearly the ED is the worst imaginable place to have these conversations/make these decisions. By necessity, however, it is sometimes the right place to have those discussions, but the general sense is that the providers feel not only resentment about having to do it but inadequacy. One doc noted that they find themselves second guessing what they're doing because it is so inconceivable to them that no one else had had these conversations before: “Having these conversations in the ED causes a lot of consternation. I wonder, ‘Am I doing the right thing by this person? Why hasn't somebody else talked to this person about it? Why does it come to me to end up talking to this person?'” The context presented by the first paper (discussing palliative competencies necessary for ED providers, etc.) is obviously some part of the solution but it won't change the larger/deeper issues of these conversations generally happening too late.

One last intriguing discussion in the paper is about the ED providers' reaction to hearing a definition of 'palliative care.' The definition they were provided seems to be standard WHO-ish language: 'The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care can be delivered at the same time as life-prolonging care or as the main focus of care. Palliative care is achieved through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and culture(s).' They mention some were surprised about palliative care not necessarily implying EOL care, but also this:

Several providers (2 attending physicians, 3 residents, 2 nurses, and 1 social worker) expressed frustration that the structured definition of palliative care seemed too broad to be clinically useful. One provider noted, “This seems more of a definition of what good emergency care should be at any given stage than specific for palliative care.”

Or, in fact, what good medical care in general should entail. I couldn't agree more, and this brings up again discussions we've had on the blog before about major problems we have as a professional community about defining what we do, particularly as we define it away from (or at least more broadly than) EOL care. People 'get' the EOL care aspect. When I told my mother what palliative care was years ago her initial reaction was something like Isn't that what all doctors should do? Obviously, hell yes, absolutely, but then I started trying to describe what palliative specialists do and had a hard time. It's tough defining succinctly, without taking up a whole paragraph, what it is that specialist PC clinicians/teams do (outside of hospice-specific settings). I think this is a real problem because clinicians/clinical services which aren't used to specialist PC, don't 'get it' or whatever (see for instance last week's post about CHf), how are they supposed to understand what we do such that they know when/how/why to involve us. Especially because they read that definition and say to themselves Well I do that (or at least I know I should be doing that). And of course you could argue that 'they' often don't do that very well, or don't realize that it could be done much better, but that's not very, umm, collegial. Of course most clinicians don't have a problem consulting other specialists when they feel like they need help, which makes me wonder if the major problem is a lack of appreciation of what meticulous, patient-centered symptom management and communication actually looks like.

Anyway: my challenge for anyone reading this is to share your 1 sentence description of what specialist palliative care means and/or why it is needed? Or at least short description, if not 1 sentence.

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It was only 3 short months ago that Hurricane Ike devastated the Texas Gulf coastline creating havoc in the Galveston and Houston areas. I had a chance to share some emails with Deborah Perryman, LMSW (Executive Director) and Beverly McCormick, RN, BSN, CHPN, (Community Outreach Education Liaison/Admission Nurse) with Hospice Care Team, a not-for profit hospice that serves the areas hit by Hurricane Ike. Here are some of the excerpts from those emails demonstrating some of the adverse conditions during and after the hurricane. For another Pallimed post on natural disasters and hospice check out the post on the Iowa Floods.
(Note: some details regarding patient stories has been changed to protect patient privacy)

How do you deal with your own needs and losses along with our patients?

McCormick: We have offered each other lots of support, designated a special room where anyone could meet with bereavement person or SW or each other. We've cried a lot at different times, we try to help each other as needed. Now further out, our executive director encouraged trying to take time for ourselves and have fun. We even planned some events just for staff.

We are all clear with boundaries, we do not share our losses with our patients, they have enough to deal with. We can support each other, and can make general comments but focus on patients and families at this trying time. ( That is as always ).

Since many patient couldn't return, our census was greatly impacted which affected staffing, and sadly we had to make some layoffs.

Perryman: It was hard dealing with my own needs and loses because there were so many people hurting. I changed the route coming to the office because the National Guard and Disaster Relief groups made me cry. When we found real food, lunch was provided to the staff which consisted of chili, hot dogs and chips. What a feast! The staff cheered when we received mail for the first time after the hurricane. When the office reopened, there was no power but we decided to meet anyway as patients/families were calling with needs. About 15 minutes after our chaplain prayed, the lights came on. Boy did we cheer then. Driving around town everyday brought new challenges and new waves of emotions. That was certainly a life altering experience.

The staff met every morning to share information ( where to get water, ice, food; stores opened; where to get gas, etc), hugs, tears and accounting for patients/families. Staff was encouraged to take time for themselves. I was finally sent home on Thursday after exhaustion took over. The staff at HCT is awesome and handled the Hurricane like the professionals that they are. Kudos to the staff!!!!!

Can you share some challenging events your hospice staff have encountered?

Perryman: One of the biggest challenges was the cell phones. FEMA and others took over the cell towers prior to the storm on Friday and it was difficult to impossible to get cell phone coverage. My home land line remained intact throughout ALL of the storm and after the storm. One of the hospices in our alliance provided an emergency number just hours before Ike hit. It was a blessing as the patients, families, and staff could stay in touch. Between my home line and cell phone, we were able to remain in communication with everyone.

Another big challenge was that people wanted to return home right now!! There were curfews, gas shortages, no food in stores, many (like me) still had no power. Some employees slept in the office as there was power and air conditioning!! One nurse had to go out during the curfew
to make a visit as the patient was transported home at the family's request to get him settled and order meds.

McCormick: I talked with a patient from a trailer in the woods to try and get access to oxygen refills and refill medications just so he could return home. Nursing facilities were totally stretched going to places with halls for rooms and their sack of personal belongs, traveling with staff who had to leave their families etc. A church sent volunteers to help with care. One nursing home was so damaged, it is closing, the other doesn't want to reopen without UTMB hospital to send patients. So many people are so uprooted.

Were your emergency /disaster plans helpful?

Perryman: Yes. HCT practiced the emergency plan for Rita and it was okay. Since then there had been some drills and were able to work out a few hitches. The biggest challenge with the emergency/disaster plan was that every time we began a phase of the plan, the path of Hurricane Ike came closer and closer to Galveston County. It was a challenge staying one step ahead of the storm! Thankfully, all of our patients were accounted for and provisions made to meeting their needs.

McCormick: We do have a good emergency plan in place and it worked. We triage our patients on admit and weekly; they have hurricane info in their patient handbook. We send two weeks meds, supplies, obtain oxygen and give names of hospices in locations they evacuate to.

Any particularly difficult clinical situations that you would care to share?

McCormick: I admitted a patient the Thursday after the hurricane and their friends graciously took in three families on evacuation including this dying patient who in fact died only a few days later. I readmitted a patient last week who had been followed at home by Houston hospice, now living in a rented condo in Galveston. Her husband was home trying to save belongings before their house was cut down as most are up to four feet through the sheet rock down to wood. He lost most of his belongings plus knowing he'll lose his wife of 50 years soon as well. Fortunately they are blessed with adult children who help.

I went to admit a patient and it was almost impossible to get into the house. There was a chair at the bottom of the front door to the trailer about 10 feet below, fortunately, there was a way to get in the back door, no AC, caregiver a young mother with an infant. Tough times.

I met with a man at small community hospital who hadn't evacuated in Galveston, but got so sick with no power, water, etc, he had finally gone there (to the hospital). He wants to return to home, but has no caregiver and so we'll see what we can do. He said he had hoped to be washed out to sea with the Hurricane as his doctor told him he was a goner! (I doubt that, but that was his interpretation and why he accepted home hospice when discharged).

Our chaplains and social workers are giving much support; and volunteers, if not affected, have been helping as well, one is giving out food from a church and offering support.

We've all been working hard. Lots of things are hard as very few live in their homes.

Perryman: The most difficult was trying to staff crisis care around curfews. We were very limited in mobility due to no power, NO GAS, damage in neighborhoods. Staff was able to meet everyone's needs by being creative and resourceful during and after the hurricane.

HCT was able to keep a core team (RN, social worker, and chaplain) within miles of our service area.

Three months later, it is amazing where we are. Our Emergency Management, Bruce Clawson, in Texas City was awesome. He provided guidance and assurance prior to the storm. After Hurricane Ike, daily calls provided needed information and updates to meet the devastation
that was left behind. It was hard at times not to panic-- which is the right decision totally pack the office or leave it-- go or stay--and yet all of the choices made worked. We are very blessed and look forward to a break until next Hurricane Season.

Thanks to Ms. Perryman and Ms. McCormick for sharing this helpful insight. If you are making any donations to hospices this year in your local area, you might consider giving to some of the hospices in the areas hit by Hurricane Ike.
(Images via Wikipedia Commons)

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