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By Joseph D. Rotella

More and more academic centers are developing interprofessional education (IPE) programs to teach palliative care− and it makes good sense. Seriously ill patients and their families suffer as whole human beings and it takes a village of palliative care providers from different disciplines working together to comfort, support, and heal them. If we train palliative care professionals in silos, how can we expect them to be prepared for effective interdisciplinary teamwork when they emerge?

The feature story in the American Academy of Hospice and Palliative Medicine (AAHPM) Fall Quarterly (2015), Interprofessional Education: The More, the Healthier, highlights some of the programs across the country that are doing groundbreaking work in IPE.

It may be easy to see the promise of interprofessional training in palliative care, but it’s hard to do it well. In an AAHPM blog post accompanying the article, Dr. V.J. Periyakoil describes her personal experience as faculty for the VA Interprofessional Fellowship Program, “A gold standard is when all IPE fellows are taught at a level that is challenging to all of them in every single session.” That sets a high bar and she adds, “This area is really ripe for discovery and new innovation.” Like the pioneer teacher with K through 12 students in one classroom, IPE instructors strive for a curriculum that can engage learners with a wide range of individual competencies. When it works well, the students learn as much from each other as they do from their teachers.

When I think back on my own development as an internist and palliative care physician, I am struck by how much I learned informally from my colleagues in other professions. When I was a green intern on my first Cardiac Care Unit (CCU) rotation, it was an experienced (and extremely patient) CCU nurse who showed me how to run a code. Counselors taught me how to deal with challenging families and support the grieving. From chaplains, I learned to understand people in the context of the meaning of their life stories. Social workers modeled how to empower patients and families and to have healthy boundaries. A pharmacist shared best practices on stopping unnecessary medications. A nurse’s aide showed me how a bed bath can be a sacred ritual. I had some great physician mentors, but I think I learned more about palliative care from the interdisciplinary team than from other doctors.

My first experience with formal IPE was about a decade ago when I was a facilitator for a discussion group of medical, nursing, social work and pastoral care students following a screening of the film Wit. One medical student resented the whole process. He said, “This is absurd; no real doctor would behave as badly as the ones in this film.” The other medical students nodded their agreement. A nursing student rolled her eyes and said, barely audibly, “Actually, that is exactly what they do.” Her peers agreed. This was a fantastic teachable moment. IPE is not just about developing knowledge and skills. It’s also about opening minds and removing cultural barriers to teamwork.

Dr. Joe Rotella, MD MBA HMDC FAAHPM is the Chief Medical Officer, AAHPM and a frequent participant in #hpm (hospice and palliative med/care) chat.

What: #hpm chat on Twitter
When: Wed 10/14/2015 - 9p ET/ 6p PT
Host: AAHPM and Steve Smith, CEO of AAHPM

Some questions to ponder for the chat:
1. Are there opportunities for interprofessional palliative care training in your program? If so, how do they work?
2. What do you find to be the biggest challenges to interprofessional learning and collaboration?
3. What is the greatest lesson you ever learned from someone outside your profession?

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 tweetchat.com, for ease of following.

You can access the transcripts and analytics of #hpm chats through @Symplur. 

Image credit: Valerie Everett from Indianapolis, USA via Wikipedia Creative Commons

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by Lizzy Miles

On a recent road trip, I was distracted. I stopped to get gas and accidentally picked up the diesel nozzle. I tried to put it in my gas tank, but it wouldn’t fit. The opening to the tank and the nozzle were incompatible. This is one example of the Japanese concept of Poka-Yoke (mistake-proofing).  While most Westerners are not familiar with the term, we all have benefitted by the design practice. The automobile industry does what it can to design cars in a way to prevent consumers from making mistakes. You cannot put the car in “Drive” unless you have your foot on the brake. Modern cars now remind you if you forget your keys or if you leave your headlights on.

On this particular road trip, I was on my way to visit my Uncle Paul who is a retired Union Carbide scientist. I asked him about mistake-proofing and how it works. There are several components to successful mistake-proofing:

1. Examine “what if?” – Wonder what could go wrong
2. Analyze all the steps in a process
3. Never underestimate the users’ ingenuity to bypass safeguards
4. When mistakes do happen, examine why they happen and contemplate how to prevent

I believe there are opportunities for hospice and palliative care organizations to integrate a Poka-Yoke approach.

Poka-Yoke is not new to healthcare, but is more prevalent in hospital environments. A friend who worked as a career med-flight nurse practitioner told me about several examples used in the hospital:

• Patients are asked multiple times for information confirming their identity
• Morbidity and Mortality Conference to review process and/or clinical errors
• Critical Incident Stress Debriefing (CISD) process after particularly rough cases

The difficulty with integrating a Poka-Yoke approach in hospice and palliative care would be that it requires an organization or industry to admit that it makes mistakes. In order to improve, we would have to admit that we are not as good as we could be. The challenge with that reflection is that our industry is having a hard enough time as it is right now. We do not always get positive press for what we do. A few years ago it was Sarah Palin and Death Panels. Now it’s inaccurate newspaper articles about hospices admitting non-dying patients just for profit.

I did an informal content analysis of the complaints about hospice in the comments section of one of the less favorable newspaper articles. There were caregivers who felt their loved one received too much medication and others who said there wasn’t enough attention to symptoms. Some commenters felt there wasn’t enough emotional support, and others felt it was “forced” on them. Coupled with what’s going on in the media with the “right to die” advocates, and the groups who are afraid they’re being pushed into hospice, there is clearly a theme here.

People want control of their own life and death. Right now, they don’t feel in control.

Yes, we have to acknowledge there is room for improvement. It is easy for us to point upstream and say that it is the hospitalists or the oncologists that are not making referrals, and that’s are number one problem with hospice, at least.  But is it? I challenge the #hpm community to brainstorm.

What is our responsibility as end of life professionals for the referral process?

How do we give patients and families a feeling of control?

What could hospice and palliative care professionals be doing better?

I have one suggestion for the answers: Community. This is what we are trying to do with Pallimed is to bring together the hospice and palliative care community to share ideas so that we can become better. But also, I believe (at least in my hometown) the hospices and palliative care organizations are not out in the community enough.  We need to step out of the shadows. We don’t have to talk about death all the time. Community engagement builds trust. Look at the events at St. Christopher’s in England. They have plays and art and curry night. They are integrated into the community so that when people need hospice, they are not afraid.

“Oh, hospice, I went to a potluck there last month.”

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by Dr. Denise Marshall - Pallium Canada

Today, every area of healthcare has a public health agenda. That is, every area of healthcare except palliative care. Palliative care would benefit from a public health approach by developing a wider community context in which palliative care services can make their contributions. A public health approach takes the responsibility of palliative care from a few highly trained specialists to a community that considers it “everybody’s business.”

Public Health Palliative Care is also known as Health Promoting Palliative Care (HPPC) and was developed as a social movement. The underlying philosophy behind HPPC is the Ottawa Charter for Health Promotion that was established in 1986, including 5 core principles:

• Building public policies that support health
• Creating supportive environments
• Strengthening community action
• Developing personal skills
• Reorienting health services

HPPC places emphasis on community development and partnerships across all sectors to empower communities, instead of emphasizing the responsibilities of health services as the primary advocate of change. This framework supports those with life limiting illnesses and their families by encouraging, sustaining and resourcing community capacity. The framework also provides opportunities to enhance access to palliative services, which is particularly relevant in Canada where only 16 to 30% of Canadians have access to good quality palliative care.

Compassionate Communities (CC) and Conceptual Clarity 

Download the Report

The Compassionate Cities/Communities model is a theory of practice for HPPC. In fact, HPPC projects are typically described as “Compassionate Communities” projects. The CC model attempts to bridge the gaps between the realities of widespread “experience” of distressing death and “practice.” Previously, these gaps have neglected the social needs of dying or simply ignored it. These gaps include:

• Inadequate and inequitable access to integrated, high quality palliative care
• Inadequate support for caregivers
• Limited and inequitable service capacity across all care settings
• Lack of clear accountability for the delivery of palliative care
• Lack of system integration

To address these gaps, the CC model emphasizes reforms to the way palliative care is conceptualized, organized and delivered. It treats palliative and end-of-life care as a community responsibility and creates partnerships between the community and services.

Compassionate Communities Projects in Action 

Where do we turn for support of the CC model? What are the next steps to make the CC model a reality in our community? Illuminating and learning about existing international and “made in Canada” CC projects is a great start. Notable CC projects include:

• Hospice Friendly Hospitals, Ireland
• Frailty index – A global clinical measure of fitness and frailty in elderly people
• Compassionate watch – i.e. Neighbourhood watch
• Death education elementary schools/hospice partnerships
• Spiritual companions
• Integration of formal and informal care networks
• LTC pubs/beer coasters
• Caregiver Day
• Airport posters
• Die-alogues: Conversations on Life and Death, Thunder Bay

Pallium Canada and Mobilizing your Compassionate Community

Pallium Canada’s professional development opportunities, clinical decision-support tools and e-Learning Essential Approaches to Palliative and End-of-Life care (LEAP) courseware and LEAP Facilitator Training sessions. The LEAP courseware is designed for a generalist-level interprofessional audience - primarily physicians, nurses, pharmacists and social workers. Pallium Canada’s Guiding Principles are to promote interprofessional care, translate and diffuse knowledge, promote active learning, and connect community to local palliative care resources. LEAP is increasing service capacity across care settings through tailor-made, setting-based curriculum, including: LEAP Core, LEAP Mini, LEAP Mini Oncology, LEAP Paramedic, LEAP Long-Term Care, and Taking Ownership.

Learning Resources

Learning resources are intended to bridge existing gaps, increase capacity and enhance access to palliative care. Pallium Canada is increasing capacity and enhancing access to palliative care through the Pallium Canada’s professional development opportunities, clinical decision-support tools and e-Learning resources are intended to bridge existing gaps, increase capacity and enhance access to palliative care. Pallium Canada is increasing capacity and enhancing access to palliative care through the Learning Essential Approaches to Palliative and End-of-Life care (LEAP) courseware and LEAP Facilitator Training sessions. The LEAP courseware is designed for a generalist-level interprofessional audience - primarily physicians, nurses, pharmacists and social workers. Pallium Canada’s Guiding Principles are to promote interprofessional care, translate and diffuse knowledge, promote active learning, and connect community to local palliative care resources. LEAP is increasing service capacity across care settings through tailor-made, setting-based curriculum, including: LEAP Core, LEAP Mini, LEAP Mini Oncology, LEAP Paramedic, LEAP Long-Term Care, and Taking Ownership.












  


On October 28^th, 2015 Pallium Canada is taking our palliative care initiatives one step further with our Symposium entitled “Mobilizing YOUR Compassionate Community!” Hosted at the Westin Ottawa Hotel, the Symposium will engage participants to adapt, apply, and mobilize the international Compassionate Communities model to Canadian realities. We will learn about the movement, illuminate “made in Canada” CC projects, network with like-minded visionaries, and begin to develop a blueprint to build and support the CC movement in Canada. 


What: #hpm chat on Twitter
When: Wed 9/23/2015 - 9p ET/ 6p PT
Host: Dr. Denise Marshall - Pallium Canada

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 tweetchat.com, for ease of following.

You can access the transcripts and analytics of #hpm chats through @Symplur. 

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by Christian Sinclair

Our field of palliative care lost one of our great educators when Dr. Andrew Billings died this week. Thankfully, he was a great mentor and teacher to so many, that he will truly live on in the caring hands of so many clinicians impacted by his long years of work. His leadership with his wife, Dr. Susan Block, in creating the Harvard Palliative Care Education and Practice (PCEP) program has extended his teaching influence beyond the Boston streets where he practiced for so many years.

In 2004, while I was finishing up my hospice and palliative medicine fellowship in North Carolina, I was lucky enough to attend the Harvard PCEP program.  Excited to just be near some of the field's luminaries like Billings, Block, Bruera, Christakis, Truog VonGunten, Weissman and others was a big thrill. To then find out that I was assigned to the small group with Andy Billings as the facilitator floored me.

He was extremely approachable as a teacher, which immediately helped set us all on a level playing field. As we discussed communication skills, he would share small insights that would help unlock a different way of hearing the conversation. In the more introspective sessions, he provided safe-space for the small group to discuss our own understanding of spirituality, religion, and our philosophies on life, so we could better care for patients and families.

After PCEP, we kept in touch occasionally by email, and running into each other at AAHPM meetings. I was sometimes concerned I might be a bother to such a busy, accomplished man, yet he always genial and welcoming. He always made me feel welcome.

Thanks Andy, for everything.


Read more about Andrew Billings in his own words in his 2007 reflection on his career in palliative care and hospice or a piece in the New York Times featuring him.

Christian Sinclair is a palliative medicine physician at the University of Kansas Medical Center, where he provides inpatient consultation, and outpatient clinic services. He hopes to be always genial and welcoming, like Andy.

Photo credits: Christian Sinclair, personal collection

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by Arif Kamal MD, MHS

Palliative care is at a crossroads. We have for several decades leveraged our tenacity, charisma, and evidence base to transition ourselves from a novel consultative service to the accepted, standard-of-care approach of caring for persons with serious illness and their caregivers. Despite the remarkable integration of our services and care philosophy, we are not immune to the shifting winds of change across all of healthcare. From the upper echelons of healthcare on down, clinicians, administrators, payers, and patients are all evolving they ways they deliver, receive, and evaluate healthcare. Among all the changes and evolutions taking place, one thesis statement summarizes the transformation between the old and new ways: Quality. Now. Matters. And it is how we react to the increasing calls for measuring, reporting, and proving quality of healthcare delivery in specialty palliative care that will dictate the future sustainability and growth of the discipline.

Modern approaches to total quality management depend on a diligent focus by organizations in four key areas: regular implementation of structured quality improvement cycles, transformation to a culture of continuous awareness of service defects, engagement for change by employees across all levels of an organization, and a patient-centric definition of quality that welcomes consumer feedback. Admittedly, these are difficult concepts to master, and harder still to implement. Further, in palliative care, the clinical services we provide are diverse, complex, and demanding. The answers are not always easy, and not often found by leaders outside of our field. Improving the quality of care we deliver is fundamentally the professional responsibility of those who know the discipline from the inside. Although we possess expertise at providing clinical care, developing consultative programs, and growing our field, the fundamental infrastructure to learn, collaborate, and improve our care through an advanced understanding of healthcare quality improvement is missing, and sorely needed.

As a grassroots effort to change this, we at the Global Palliative Care Quality Alliance are hosting the inaugural “Quality Matters Conference” on October 15, 2015. This webinar-based, half-day virtual conference will use short didactic sessions (limit 20 minutes) and open Q and A sessions to address several of these impending changes for our field, and across healthcare. We will discuss topics such as: the national landscape of quality measurement, the Measuring What Matters initiative from AAHPM, evolving reimbursement policies and their links to quality measurement, leadership for change and motivating clinicians, and billing and coding tips for busy clinicians. All the topics center around our theme for the conference, “Innovation through Collaboration,” which highlights the need to band together within the discipline to guide innovations in high-quality palliative care delivery. To emphasize the importance of such education, we will provide complimentary registration and Continuing Medical Education (CME) and Continuing Nursing Education (CNE) through Duke University (register at www.gpcqa.org/qmc). We hope to provide an informative, collaborative, and engaging environment for palliative care team members of all backgrounds to learn more about palliative care quality.

The collaborative spirit of palliative care is truly one of its greatest strengths. We regularly come together to teach, learn, and grow from each other. We are the model that other disciplines strive to emulate. We look forward to seeing many wonderful colleagues at the upcoming Quality Matters Conference to learn how we can all play a vital role in improving the experience of those with serious illness and their caregivers, one quality improvement initiative at a time.

We will also be talking about quality initiatives in palliative care during the September 16th #hpm chat. We hope you can join us then. Details are below.

Dr Arif Kamal (@arifkamalmd) is an Assistant Professor of Medicine at Duke University. His research is focused on palliative care outcomes, quality, and professional burnout.

What: #hpm chat on Twitter
When: Wed September 16, 2015 - 9p ET/ 6p PT
Host: Dr. Arif Kamal (@arifkamalmd)

Follow @hpmchat on Twitter for all the latest on #hpm chats.

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 a chat client like Tchat.io or Tweetdeck for ease of following.

You can access the transcripts and analytics of #hpm chats through @Symplur. 

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by Michael D. Fratkin

The ground is shifting under our feet as our society seems finally to be looking at the nature of human mortality and the way we care for each other…or don’t…as we complete our lives. Zubin Damania, MD aka ZDoggMD is now part of that conversation since the release of “Ain’t the Way to Die” his first not-so-funny medical parody music video focused on how we so many of us die in the hospital in a not-so-funny way. A hospitalist refugee from burn-out at a big academic center, ZDogg continually reinvents himself as an “off-white rap star” with a passion for saying what needs to be said with growing impact.

 

 That doesn’t surprise any of us that have been practicing professionals in palliative care and hospice over the last 35 years. We have done our best to share our perspective and to inform our society. And our society has only just now seem to be paying attention. I sat down with ZDogg for an interview to address a question raised by Atul Gawande in an interview before his plenary at the AAHPM Assembly, “…why the hell aren’t people listening to you?”

 

Michael D. Fratkin, MD is a palliative care physician and founder of Resolution Care, a unique palliative care practice in Northern California. Resolution Care was featured on Pallimed in Dec 2014.

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by John M. Saroyan

Vermont is the sixth smallest in area and the 2nd least populous of the fifty United States. Medicare data from 2013 show that Vermont had among the lowest hospice penetrance rates in the country along with New York, Wyoming, South and North Dakota, and Alaska. While enrollment in hospice has been associated with improved survival for CHF, colon, lung and pancreatic cancer, improved quality of care for persons dying of dementia, and improved mortality outcomes in surviving widowed spouses, I find knowledge of these research findings to be low. And while a sense of comfort and relief for millions of Americans is provided by hospice every year, it is frequently felt to be a service for the imminently dying.

Since beginning my role as Hospice Medical Director for BAYADA Home Healthcare in Vermont and New Hampshire in 2013, I have spoken with health care providers of many disciplines in the region about why hospice utilization may be so low. Hospice practice in rural and remote areas is captured in population based data that can be broken into counties but is poorly represented in hospice and palliative care literature. Its day to day challenges and successes are learned from actual and shared experience.

This #hpm chat encompasses an international group of participants who bring a diversity of experience to the topic of building high quality and lasting hospice programs in rural areas. My aim is to pose questions that will lead us to common ground for building these programs in order to meet the end-of-life needs of our patients, families as well as hospice clinical and administrative staff.

Questions that will be posed during #hpm chat:

• How is access to hospice care a barrier for patients and families where you live?
• How is the availability of experienced staff a barrier?
• Have prescription monitoring programs or pharmacy dispensing practices interfered with your ability to dispense opioids?

Dr Saroyan (@jmsaroyan) is the full-time Hospice Medical Director for BAYADA Home Health Care. He also holds faculty appointments at Geisel School of Medicine, UVM Medical Center, and Columbia University.

What: #hpm chat on Twitter
When: Wed August 26, 2015 - 9p ET/ 6p PT
Host: Dr. John M. Saroyan (@jmsaroyan)

Follow @hpmchat on Twitter for all the latest on #hpm chats.

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 tweetchat.com, for ease of following.

You can access the transcripts and analytics of #hpm chats through @Symplur. 

Image credit: Vermont Hogback Mountain via Wikimedia (CC license)

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by Lizzy Miles

Hospice and palliative care professionals value honesty. We may be the only people in a patient’s life who speak openly about death and dying. There is no time left for us to speak metaphorically. We do our best to be compassionate when we are direct with our communication. In order to provide the best care possible for our patients, we have to build an open and trusting relationship with them. One might assume that since we are authentic with our patients, they are open and honest with us. We know, though, that this is not always the case. Recently, I wrote about the secrets of hospice patients. This article is a continuation of that thought with a discussion of the lies that hospice patients might tell us.

Before we go on, let's be clear that there is no moral high ground in the suggestion that hospice patients may lie. A lie, according to Webster's Dictionary, is simply "an intentionally false statement." It is my assertion that there are times where patients do make false statements to us, and they have their reasons for not being truthful.

If you are new to hospice and palliative care, you might be surprised to learn that patients might lie. If you have worked in hospice and palliative care for a few years, chances are you are nodding your head as you are reading this, with a recollection of your own patient encounters. I have been thinking about this phenomenon for a few years. As always, my articles are inspired by experiences and lessons I have learned as a hospice social worker.

Why do hospice and palliative care patients lie to us?

Perhaps the best way to answer the “why” is to reframe the question. When might hospice and palliative care patients lie? Patients might lie when they do not feel comfortable with telling us the truth. We have not built up trust so that the patient feels we are on their side. Patients may outright lie or they may lie by omission or understate the truth.

Here are some examples of areas of deception:

Current “bad” habits

There are several reasons why a patient may not be honest to a hospice caregiver about their smoking, drinking or drug habit.
1. Patients expect that their medical provider will tell them to stop what they are doing.
2. There is a fear of judgement/labeling by the medical provider.
3. Patients may not think their habit is the provider’s business.
4. A patient is ashamed or embarrassed by the habit.
5. There may be a perception that a truthful answer will result in an unwanted response from the provider.

Patients are not going to naturally understand why we ask questions about smoking, alcohol and drugs. We ask these questions because these habits can affect their plan of care. All three habits can affect how a patient responds to or metabolizes medication. If a patient is a smoker, we want to ensure that they are safe with their habit, especially if they are on oxygen. Before we ask questions about these habits, it would be helpful for the patient to know why we are asking. If we tell them why we need to know about their habits, we have a better chance of getting an honest answer.

Assessment/visit fatigue

In hospice and palliative care, we are constantly assessing. Every staff member that interacts with the patient is asking the patient questions. At times, the patient gets the same question from different staff members. A barrage of questions can be overwhelming for patients. We need to be mindful of the timing of our visits so that patients have a break in between providers as much as possible.

I had one initial assessment with a patient (Mr. J) which directly followed personal care by the aide and the hospice nurse visit. (Hospice social workers are tasked with conducting an initial assessment within five days, and so our timing can be unfortunate at times.) The patient I was assessing was irritated with his shower because movement hurt and he was in a bad mood when I started talking with him. I could not get a straight, honest answer on any question. He told me he had ten children, when in fact he had none. He refused to tell me what he did for a living. Every other word he said was a swear word. He was not in the mood to talk, and eventually, I gave up trying to win him over and gave him the space that he apparently wanted.

What they really think of us and/or our care

Sometimes our experiences when we are patients ourselves can inform our work. It took me three months to get in to see an opthamologist, and then the day of my visit, there were extensive wait times with no updates or apologies. The whole appointment took 4 hours, although my physician time was only 20 minutes. I was seething inside, yet I never complained. I felt helpless because I really needed to see this specialist. You would think I would be better at self-advocacy since I'm a social worker. Though I never said anything to the doctor, you can bet I told a number of people how awful my experience was. It was then that I realized there might be some of our hospice patients who don’t like us or something we have done, but don’t tell us.

Why am I bringing this up? Because we need to remember that a patient is not always going to tell us directly when they are unhappy about something. Occasionally, one staff member will hear from a patient about their dissatisfaction with another staff member, but I suspect there is more dissatisfaction than we realize. A complaint-free patient does not mean we have a content patient. We need to check in with the patient frequently, and give them the opportunity to direct their care. We do not want to have a situation where a patient is very unhappy and we did not know because they didn’t tell us and we didn’t see it. We need to read body language and we need to read between the lines with what patients say and what they don’t say.

How to build a trusting relationship

How does one build a trusting relationship with a hospice and palliative care patient so they feel comfortable telling the truth? This would be a great question for the #hpm tweetchat, as I am sure that there are lots of ideas. I do not claim to have all the answers, though I have often been told by patients that I am “authentic.”

Here is what I try to do:
• Ask permission for everything. Are you open to chatting? Do you mind if I take notes?
• Acknowledge the personal nature of questions. The reason I am asking is because…
• Take “no” for an answer. If a patient does not want a visit, I leave.
• Ask for permission to return.
• Be mindful of my nonverbal and verbal responses when a patient self-discloses.
• Normalize patient behavior and thoughts as much as possible.

Please do share in the comments your own best practices for building a trusting relationship for patients.

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

Image credit: No lies, truth - via iStock
Image credit: Building Trust in Health Care - composite by Christian Sinclair for Pallimed

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by Jordan Keen

Case:
SM is a 25-year-old female with progressively worsening rhabdomyosarcoma despite multiple rounds of chemotherapy and surgery. She presented to the emergency department with worsening of her chronic tumor-related abdominal pain and new, diffuse pain of the muscles and joints. Family reported she had been experiencing episodes of confusion and hallucinations over the past week. Her home pain regimen of long-acting morphine and as needed oxycodone had been titrated aggressively over the past month in an attempt to control her pain (600mg total daily oral morphine equivalents).

When first evaluated by the palliative care consult service, she was in severe distress. She described severe, 10/10, diffuse pain. On exam there was generalized tenderness of the abdomen, as well as her shoulders, upper legs, and lower back. She was exhibiting myoclonic jerks of her upper extremities every 3-4 seconds. Although she was alert and oriented, she was easily distracted during the exam and required frequent redirection.

Our palliative care team was concerned about opioid-induced hyperalgesia (OIH). Suspicion was high given the paradoxical worsening of her pain despite high doses of opioids and the neuroexcitatory signs and symptoms (myoclonus, confusion, and hallucinations) she was exhibiting. Therefore, it was decided to lower the overall dosage and switch her opioid regimen in an attempt to reverse OIH. Her long-acting morphine was discontinued and replaced with methadone 5mg three times per day. Her as-needed oxycodone dose was reduced from 30mg to 5mg every 4 hours. To control the myoclonus, low dose lorazepam was administered three times per day.

View more cases on Pallimed

Discussion:
Opioid-induced hyperalgesia (OIH) is a rare syndrome of increasing pain, often accompanied by neuroexcitatory effects, in the setting of increasing opioid therapy. Clinicians should consider OIH in patients on high dose opioids or during a period of rapid opioid escalation. While case reports show a wide range of dosages can provoke this syndrome, the majority of patients are on very high doses, often greater than 1000mg oral morphine equivalents per day and typically via parenteral routes (IV and intrathecal). Morphine is by far the most common opiate implicated in OIH. Hydromorphone and oxycodone, members of the same class of opiate as morphine (phenanthrenes), can also cause OIH, but oxymorphone has not yet been reported to cause it. Methadone, a synthetic opioid in the class of diphenylheptanes, and fentanyl, a synthetic opioid in the class of phenylpiperidine, are considered less likely to precipitate OIH.

Existing data suggests that OIH is caused by multiple opioid-induced changes to the central nervous system including:

• Activation of N-methyl-D-aspartate (NMDA) receptors
• Inhibition of the glutamate transporter system
• Increased levels of the pro-nociceptive peptides within the dorsal root ganglia
• Activation of descending pain facilitation from the rostral ventromedial medulla
• Neuroexcitatory effects provoked by metabolites of morphine and hydromorphone

OIH can be confused with tolerance as in both cases patients report increased pain on opioids. The two conditions can be differentiated based on the patient’s response to opioids. In tolerance, the patient’s pain will improve with dose escalation. In OIH, pain will worsen with opioid administration. This paradoxical effect is one of the hallmarks of the syndrome. On physical exam, patients are grimacing in pain with moderate-to-severe distress, myoclonus, altered mental status or delirium and often allodynia (pain due to non-painful stimuli, such as light touch).

Typically, if you suspect OIH, you should get a pain or palliative care consultation because it will seem wrong to decrease opiates in a patient in severe pain. Opiate dose reduction and rotation to a synthetic opioid such as fentanyl or methadone is recommended. Methadone has the additional benefit of NMDA antagonism. It is not surprising that methadone has been shown to improve or resolve OIH given the role NMDA activation plays in causing OIH. Adjuvant therapies, such as acetaminophen or neuropathic pain medications, should be considered as they may decrease the need for opioids. Benzodiazepines may be a temporary addition to manage myoclonus as the OIH resolves.

Symptoms of OIH do resolve when patients are treated with the above strategies. However, it can be long and difficult to wean some patients to a low enough level of opioids to stop OIH. Existing literature does not address any long-term consequences of OIH. We hope to see more research on this subject.

Over the next 48 hours in the hospital, her myoclonus improved. Her pain and mental status improved more slowly. It took a week to re-establish control of her pain. At the time of discharge, she rated her pain as 3/10. Her new pain regimen consisted of methadone 10mg three times a day and oxycodone 5mg every 4 hours as needed.

References:
1. Chu, L. Opioid-induced Hyperalgesia in Humans: Molecular Mechanisms and Clinical Considerations. The Clinical Journal of Pain Issue: Volume 24(6), pp 479-496. 2008.

2. Smith, M. Neuroexcitatory Effects Of Morphine And Hydromorphone: Evidence Implicating The 3-GlucuronideMetabolites. Clinical and Experimental Pharmacology and Physiology, 27, pp 524–528. doi: 10.1046/j.1440-1681.2000.03290. 2000.

3. Mao, J. Opioid-induced abnormal pain sensitivity. Current Pain and Headache Reports. Volume 10, Issue 1, pp 67-70. 2006

4. Lee, M et al. A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician 2011; 14:145-161. ISSN 1533- 3159. Open Access PDF

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by Jenni Linebarger

“… in the movie, sadness saved all their lives.”

I heard these words from a 9-year old at the end of an NPR story on Pixar’s new film Inside Out. (Note: that the audio has more than the webpage written content.) I thought to myself: There is a movie explicitly about emotions? About the importance of what so many deem to be “negative” emotions? What?! I need to see this movie. How can this movie be used within palliative care?

Such sentiments were supported further as I read stories from parents who wrote about the impact watching Inside Out had on their families. One writer notes, Inside Out is a movie in which you see the “beauty and bittersweetness of grief… Deep within the theme of this movie is also the impact that tragedy has on our past memories.”

With these reviews in mind, our palliative care team went to see the movie together recently. The movie lived up to the expectations set for me. I can imagine using the “characters” (emotions) to help explain the mixed feelings encountered in the word of palliative care.

I’m also still smiling at the scene in which Sadness sits down and listens to the life review of an imaginary friend named Bing Bong… She doesn't say much at all, but afterwards he is amazed about how much better he feels. Palliative care anyone?


Jenni Linebarger, MD, MPH, FAAP is a pediatric palliative care physician at Children's Mercy Hospital in Kansas City, MO. 

Image credit: Found via Idle Hands