Hospital-Based Palliative Medicine E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Hospital Medicine - Current Concepts
- Sprache: Englisch
The first comprehensive, clinically focused guide to help hospitalists and other hospital-based clinicians provide quality palliative care in the inpatient setting.
Written for practicing clinicians by a team of experts in the field of palliative care and hospital care, Hospital-Based Palliative Medicine: A Practical, Evidence-Based Approach offers:
- Comprehensive content over three domains of inpatient palliative care: symptom management, communication and decision making, and practical skills,
- Detailed information on assessment and management of symptoms commonly experienced by seriously ill patients,
- Advise on the use of specific communication techniques to address sensitive topics such as prognosis, goals of care, code status, advance care planning, and family meetings in a patient- and family-centered manner,
- Targeted content for specific scenarios, including palliative care emergencies, care at the end of life, and an overview of post-hospital palliative care options,
- Self-care strategies for resilience and clinician wellness which can be used to help maintain an empathic, engaged, workforce and high quality patient care,
- A consistent chapter format with highlighted clinical pearls and pitfalls, ensuring the material is easily accessible to the busy hospitalist and associated hospital staff.
This title will be of use to all hospital clinicians who care for seriously ill patients and their families. Specialist-trained palliative care clinicians will also find this title useful by outlining a framework for the delivery of palliative care by the patient’s front-line hospital providers.
Also available in the in the Hospital-Based Medicine: Current Concepts series:
Inpatient Anticoagulation
Margaret C. Fang, Editor, 2011
Hospital Images: A Clinical Atlas
Paul B. Aronowitz, Editor, 2012
Becoming a Consummate Clinician: What Every Student, House Officer, and Hospital Practitioner Needs to Know
Ary L. Goldberger and Zachary D. Goldberger, Editors, 2012
Perioperative Medicine: Medical Consultation and Co-Management
Amir K. Jaffer and Paul J. Grant, Editors, 2012
Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine
James C. Pile, Thomas E. Baudendistel, and Brian J. Harte, Editors, 2013
Inpatient Cardiovascular Medicine
Brahmajee K. Nallamothu and Timir S. Baman, Editors 2013
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 576
Veröffentlichungsjahr: 2014
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CONTENTS
Cover
Hospital Medicine: Current Concepts
Title page
Copyright page
Contributors
Chapter 1: Hospital Care for Seriously Ill Patients and Their Families
1.1 EPIDEMIOLOGY OF HOSPITAL CARE FOR THE SERIOUSLY ILL
1.2 PALLIATIVE CARE
1.3 THE ROLE OF THE HOSPITAL-BASED CLINICIAN IN PALLIATIVE CARE
1.4 THE STRUCTURE OF THIS BOOK
1.5 REWARDING PRACTICE
1.6 CARING FOR MRS MORTON
REFERENCES
Section 1: Symptom Management
Chapter 2: Pain Management: A Practical Approach for Hospital Clinicians
2.1 ETIOLOGY AND TYPES OF PAIN
2.2 A PRACTICAL GENERAL APPROACH TO PAIN
2.3 OPIOID ANALGESICS
2.4 NONOPIOID CLASSES OF MEDICATIONS
2.5 NONPHARMACOLOGICAL INTERVENTIONS
2.6 TRANSITION TO OUTPATIENT
2.7 OPIOID RISK EVALUATION AND MITIGATION STRATEGIES
2.8 ADDICTION AND DIVERSION
REFERENCES
Chapter 3: Dyspnea: Management in Seriously Ill Hospitalized Patients
3.1 DEFINITIONS, PREVALENCE, AND TRAJECTORIES
3.2 ASSESSMENT
3.3 DIFFERENTIAL DIAGNOSIS
3.4 DIAGNOSTIC PROCEDURES
3.5 TREATMENT
REFERENCES
Chapter 4: Nausea and Vomiting: Evaluation and Management in Hospitalized Patients
4.1 PATHOPHYSIOLOGY
4.2 MANAGEMENT
4.3 APPROACH TO COMMON CAUSES
4.4 INTRACTABLE NAUSEA AND VOMITING
4.5 CONCLUSION
REFERENCES
ADDITIONAL RESOURCES
Chapter 5: Delirium: Identification and Management in Seriously Ill Hospitalized Patients
5.1 CLINICAL FEATURES OF DELIRIUM
5.2 DIFFERENTIAL DIAGNOSIS OF DELIRIUM
5.3 CAUSES FOR DELIRIUM
5.4 DELIRIUM ASSESSMENT
5.5 PHARMACOLOGIC TREATMENT OF DELIRIUM
5.6 NONPHARMACOLOGIC TREATMENT OF DELIRIUM
REFERENCES
ONLINE RESOURCES
Chapter 6: Depression and Anxiety: Assessment and Management in Hospitalized Patients with Serious Illness
6.1 INTRODUCTION
6.2 RECOGNIZING SYMPTOMS OF DEPRESSION AND ANXIETY IN SERIOUSLY ILL PATIENTS
6.3 DIFFERENTIATING AMONG CONDITIONS MARKED BY SYMPTOMS OF DEPRESSION AND ANXIETY
6.4 MANAGEMENT OF DEPRESSION AND ANXIETY IN PALLIATIVE CARE
6.5 CONSULTATION WITH OTHER SPECIALISTS
6.6 CONCLUSION
REFERENCES
ADDITIONAL RESOURCES
Section 2: Communication and Decision Making
Chapter 7: Effective Communication with Seriously Ill Patients in the Hospital: General Principles and Core Skills
7.1 INTRODUCTION
7.2 KEY STEPS WHEN OPENING THE ENCOUNTER
7.3 KEY SKILLS TO USE THROUGHOUT THE ENCOUNTER
7.4 CLOSING THE ENCOUNTER
7.5 SPECIAL SITUATIONS
REFERENCES
Chapter 8: Family Meetings and Caring for Family Members
8.1 WHY CARE FOR FAMILIES OF PALLIATIVE CARE PATIENTS?
8.2 EFFECTIVE COMMUNICATION WITH FAMILY MEMBERS
8.3 ADDITIONAL INTERPROFESSIONAL SUPPORT FOR FAMILIES
REFERENCES
Chapter 9: Assessing Goals of Care: A Case-Based Discussion
9.1 ROAD MAP FOR DISCUSSING GOALS OF CARE
9.2 USE OF INTERPRETERS
9.3 CONCLUSION
REFERENCES
Chapter 10: Documenting Goals of Care and Treatment Preferences in the Hospital: A Case-Based Discussion
10.1 PRACTICAL IN-HOSPITAL DOCUMENTATION
10.2 TROUBLESHOOTING
10.3 SUGGESTED RESOURCES
REFERENCES
Chapter 11: Prognostication: Estimating and Communicating Prognosis for Hospitalized Patients
11.1 WHAT IS PROGNOSTICATION?
11.2 WHY IS PROGNOSTICATION IMPORTANT?
11.3 OVERVIEW OF METHODS TO ESTIMATE PROGNOSIS
11.4 TOOLS FOR ESTIMATING NON-DISEASE-SPECIFIC PROGNOSIS
11.5 TOOLS FOR ESTIMATING DISEASE-SPECIFIC PROGNOSIS
11.6 HOW TO COMMUNICATE PROGNOSIS TO PATIENT OR SURROGATE?
11.7 CHALLENGES IN COMMUNICATING PROGNOSIS
11.8 WAYS TO COMMUNICATE PROGNOSIS
11.9 TIPS FOR DELIVERING PROGNOSTIC ESTIMATES
11.10 CONCLUSION
REFERENCES
Chapter 12: Managing Conflict over Treatment Decisions
12.1 USING A NONJUDGMENTAL STARTING POINT TO FIND COMMON VALUES AND GOALS
12.2 MANAGING CONFLICT
12.3 TWO CLINICAL EXAMPLES OF CONFLICT
12.4 UNDERSTANDING REQUESTS TO “DO EVERYTHING”
12.5 UNDERSTANDING BELIEFS IN MIRACLES
12.6 SUMMARY
REFERENCES
Section 3: Practice
Chapter 13: Palliative Care Emergencies in Hospitalized Patients
13.1 WHAT CONSTITUTES AN EMERGENCY IN PALLIATIVE CARE?
13.2 TRADITIONAL ONCOLOGIC EMERGENCIES IN PALLIATIVE CARE PATIENTS
13.3 OTHER EMERGENCIES IN THE HOSPITALIZED PALLIATIVE CARE PATIENT
13.4 SUMMARY AND CONCLUSION
REFERENCES
Chapter 14: Withdrawing Life-Sustaining Interventions
14.1 ETHICAL CONSIDERATIONS
14.2 MEDICAL–LEGAL CONSIDERATIONS
14.3 COMMUNICATION AND THE CRITICAL ROLE OF THE FAMILY
14.4 VENTILATOR WITHDRAWAL
14.5 MEDICATION PROTOCOLS
14.6 ICU POLICIES TO SUPPORT FAMILIES
14.7 WITHDRAWAL OF OTHER LIFE-SUSTAINING INTERVENTIONS
REFERENCES
ADDITIONAL RESOURCES
Chapter 15: Artificial Nutrition and Hydration in Patients with Serious Illness
15.1 INTRODUCTION
15.2 EN
15.3 PN
15.4 ARTIFICIAL HYDRATION ONLY?
15.5 DECISION-MAKING AROUND ANH
15.6 DISCUSSING ANH AT EOL
15.7 LAW AND ETHICS
15.8 PRINCIPLES AND TOOLS FOR THE ANH CONVERSATION
REFERENCES
ONLINE RESOURCES
Chapter 16: Last Days of Life: Care for the Patient and Family
16.1 INTRODUCTION: CARE DURING THE LAST DAYS OF LIFE
16.2 LAST DAYS: EMPATHIC COMMUNICATION AND INTERDISCIPLINARY CARE
16.3 LAST DAYS: SIGNPOSTING AND SYMPTOM MANAGEMENT
16.4 LAST DAYS: AN APPROACH TO PRONOUNCING DEATH
16.5 LAST DAYS: DOCUMENTING AND DISCLOSING DEATH
FURTHER READING
WEB RESOURCES
Chapter 17: Palliative Care after Discharge: Services for the Seriously Ill in the Home and Community
17.1 INTRODUCTION
17.2 HOSPICE
17.3 PALLIATIVE CARE
17.4 CONCLUSION
REFERENCES
Chapter 18: Interdisciplinary Team Care of Seriously Ill Hospitalized Patients
18.1 DEFINITION OF A TEAM
18.2 CORE VALUES
18.3 KEY TEAM MEMBERS FOR PALLIATIVE CARE
18.4 ADDITIONAL AD HOC TEAM MEMBERS
18.5 BECOMING A HIGH-FUNCTIONING TEAM
18.6 CONFLICT RESOLUTION
18.7 CONCLUSION
REFERENCES
WEB RESOURCES
Chapter 19: Self-Care and Resilience for Hospital Clinicians
19.1 INTRODUCTION
19.2 DEFINING THE CHALLENGES
19.3 REWARDS OF CARING FOR THE SERIOUSLY ILL AND DYING
19.4 CULTIVATING PHYSICIAN WELL-BEING AND RESILIENCE
19.5 CONCLUSIONS
REFERENCES
WEB-BASED RESOURCES
Index
End User License Agreement
List of Tables
Chapter 01
Table 1.1 Types of Patients Appropriate for Palliative Care
Chapter 02
Table 2.1 Web Resources
Table 2.2 Commonly Used Opioid Analgesics
Table 2.3 Advantages and Disadvantages of Transdermal Fentanyl Compared to Oral or IV/SC Opioids
Table 2.4 Morphine to Methadone Conversion
Table 2.5 Side Effects of Opioids
Table 2.6 Easy-to-Use Equal Analgesic Conversions between Opioids
Table 2.7 Incomplete Cross-Tolerance Adjustment When Converting between Opioids
Table 2.8 FDA-Approved Manufacturer’s Conversion from Oral Morphine to Fentanyl Patch [7]
Table 2.9 Indications and Contraindications for PCA Use
Table 2.10 Recommended Opioid Starting Doses for Intravenous Patient-Controlled Analgesia [8]
Table 2.11 Commonly Used Coanalgesic Medications
Table 2.12 Morphine Dosing Pharmacokinetics
Table 2.13 Products Subject to Risk Evaluation and Mitigation Strategies (REMS)
Table 2.14 Risk Evaluation and Mitigation Strategies (REMS) Resources
Chapter 03
Table 3.1 Respiratory Distress Observation Scale
Table 3.2 Chest Auscultation and Percussion Summary
Table 3.3 Summary of Global Dyspnea Interventions
Chapter 04
Table 4.1 Mechanism-Based Approach to Initial Management of Nausea and Vomiting
Table 4.2 Reversible Causes of Nausea and Vomiting
Table 4.3 Common Causes of Nausea/Vomiting in Seriously Ill Patients
Table 4.4 Properties of Antiemetics
Table 4.5 Nonsurgical Management of Small Bowel Obstruction
Chapter 05
Table 5.1 Main Differential Diagnosis of Delirium
Table 5.2 Risk Factors for Delirium in Hospitalized Patients
Table 5.3 Neuroleptics Used to Treat Delirium
Chapter 06
Table 6.1 Distinguishing among Major Depressive Disorder and Its Look-Alikes
Table 6.2 Anxiety Disorders Commonly Encountered in the Palliative Care Setting
Table 6.3 Common Nonpsychiatric Causes of Anxiety in the Palliative Care Setting
Table 6.4 Drug Treatments for Major Depression and Anxiety Disorders in the Palliative Care Setting
Table 6.5 Factors to Consider in Choosing an Antidepressant in the Palliative Care Setting
Chapter 07
Table 7.1 Responding to Informational Cues: “Ask–Tell–Ask” [15]
Table 7.2 Nonverbal Expressions of Empathy: S-O-L-E-R [18]
Table 7.3 Responding Verbally to Emotional Cues [15, 23] Statement from a patient admitted with a severe COPD exacerbation: “I still can’t even get out of bed without struggling to breathe? I’m so sick of this” Empathic Responses
Table 7.4 Discussing Bad News [24] Patient admitted with pneumonia but now with worsening respiratory status. Likely needs transfer to a higher level of care
Table 7.5 Better Words to Say [26]
Table 7.6 Additional Resources
Chapter 08
Table 8.1 General Principles for Family Meetings
Table 8.2 Framework for a Family Meeting
Table 8.3 Best Practice Approach to Assist Surrogate Decision-Makers
Table 8.4 Responding to Difficult Family Statements
Table 8.5 Additional Resources on Family Meetings and Caring for Families
Chapter 09
Table 9.1 Ensuring Accurate Understanding of the Medical Circumstances
Table 9.2 Assessing Goals and Values
Table 9.3 Confirm Goal and Develop Treatment Plan
Table 9.4 Communicating with Interpreters
Table 9.5 Helpful Language When Speaking with Surrogates [12, 13]
Chapter 10
Table 10.1 Advance Care Planning Forms
Chapter 11
Table 11.1 Categories of Population Averages and Prognostic Tools
Table 11.2 Karnofsky Performance Status Scale
Table 11.3 Palliative Performance Scale (PPS) Tool [7] and Survival Statistics [8]
Table 11.4 Summary of Functional Assessment Staging (FAST)
Table 11.5 3-Month Mortality for Patients Awaiting Transplantation Based on MELD Score [14]
Table 11.6 SPIKES Mnemonic for Delivery of Prognosis
Chapter 12
Table 12.1 Responding to Emotions: NURSE Statements
Table 12.2 Communication Strategies on How to Respond to Beliefs in Miracles
Chapter 13
Table 13.1 Emergencies in Palliative Care
Table 13.2 Factors Influencing the Response to an Emergency in a Palliative Care Patient [4]
Chapter 14
Table 14.1 Strategies for Improving End-of-Life Communication in the Intensive Care Unit (ICU)
Chapter 15
Table 15.1 Common Problems with G-Tube Placement and ANH
Table 15.2 When Should PN Be Recommended for Palliative Care Patients?
Table 15.3 Surrogate Decision-Making
Chapter 16
Table 16.1 Signs and Symptoms of Impending Death and Estimated Prognosis
Table 16.2 Elements of a Death Note
Chapter 17
Table 17.1 Medicare Hospice Benefit Rights and Eligibility Requirements [5]
Table 17.2 Hospice Levels of Care [4, 5]
Table 17.3 Hospice Care for Patients with COPD and CHF [11–14]
Table 17.4 Checklist for Hospice Discharge
Table 17.5 Typical Hospice Emergency Kit Medications
Table 17.6 Comparison of Hospice and Palliative Care
Table 17.7 Web Resources and Applications
Chapter 18
Table 18.1 Five Dysfunctions of a Team
Chapter 19
Table 19.1 Primary Symptoms and Associated Behaviors of Burnout
Table 19.2 Measures That Can Increase Resilience
List of Illustrations
Chapter 01
Figure 1.1 Concurrent model of palliative care.
Chapter 02
Figure 2.1 Biopsychosocial model of pain.
Figure 2.2 Sample opioid medication guide for patients and caregivers.
Chapter 05
Figure 5.1 Causes of Delirium
Figure 5.2 Delirium algorithm.
Chapter 10
Figure 10.1 Iterative advance care planning documentation.
Chapter 15
Figure 15.1 What Happens to Stroke Patients with Dysphagia Who Receive G-Tubes? A quarter of stroke patients who receive PEG tubes die within a month and another quarter regain enough swallowing ability to have the tube removed within 2–3 years. In the remaining half of patients, enteral feeding is withdrawn or becomes essentially permanent.
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Hospital Medicine: Current Concepts
Scott A. Flanders and Sanjay Saint, Series Editors
Hospitalist’s Guide to the Care of the Older Patient 1e
Brent C. Williams, Preeti N. Malani, David H. Wesorick, Editors, 2013
Inpatient Anticoagulation
Margaret C. Fang, Editor, 2011
Hospital Images: A Clinical Atlas
Paul B. Aronowitz, Editor, 2012
Becoming a Consummate Clinician: What Every Student, House Officer, and Hospital Practitioner Needs to Know
Ary L. Goldberger and Zachary D. Goldberger, Editors, 2012
Perioperative Medicine: Medical Consultation and Co-Management
Amir K. Jaffer and Paul J. Grant, Editors, 2012
Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine
James C. Pile, Thomas E. Baudendistel, and Brian J. Harte, Editors, 2013
Inpatient Cardiovascular Medicine
Brahmajee K. Nallamothu and Timir S. Baman, Editors 2013
Hospital-Based Palliative Medicine: A Practical, Evidence-Based Approach
Steven Pantilat, Wendy Anderson, Matthew Gonzales and Eric Widera, Editors, 2015
Hospital-Based Palliative Medicine
A Practical, Evidence-Based Approach
Edited by
Steven Pantilat, MD, FAAHPM, MHM
Palliative Care ProgramDivision of Hospital Medicine, Department of MedicineUCSF School of MedicineSan Francisco, CA, USA
Wendy Anderson, MD, MS
Palliative Care ProgramDivision of Hospital Medicine, Department of MedicineUCSF School of MedicineSan Francisco, CA, USA
Matthew Gonzales, MD
Division of Hospital Medicine, Department of MedicineCity of Hope National Medical CenterDuarte, CA, USA
Eric Widera, MD
Division of Geriatrics, Department of MedicineUniversity of California San FranciscoSan Francisco, CA, USA
Series Editors
Scott A. Flanders, MD, MHMSanjay Saint, MD, MPH, FHM
Copyright © 2015 by John Wiley & Sons, Inc. All rights reserved
Published by John Wiley & Sons, Inc., Hoboken, New JerseyPublished simultaneously in Canada
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Library of Congress Cataloging-in-Publication Data:
Hospital-based palliative medicine : a practical, evidence-based approach / edited by Steven Pantilat, Wendy Anderson, Matthew Gonzales, Eric Widera. p. ; cm. – (Hospital medicine, current concepts ; 8) Includes bibliographical references and index.
ISBN 978-1-118-77257-7 (paperback)I. Pantilat, Steven, editor. II. Anderson, Wendy, editor. III. Gonzales, Matthew, editor. IV. Widera, Eric, editor. V. Series: Hospital medicine, current concepts; 8.[DNLM: 1. Palliative Care–methods. 2. Evidence-Based Medicine–methods. 3. Hospitals. WB 310] R726.8 616.02′9–dc23
2014034458
Cover image: istockphoto-senior-17379381 / 08-09-11 © Syldavia;istockphoto-doctor-using-digital-tablet-talking-with-senior-patient-24015116 / 04-24-13 © monkeybusinessimages; andistockphoto.com-close-up-of-a-young-female-caring-doctor-3924891 / 08-03-07 © Yuri
Contributors
Alberta Alickaj, MD, Urgent Care, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Wendy G. Anderson, MD, MS, Division of Hospital Medicine and Palliative Care Program, Department of Medicine, UCSF School of Medicine, San Francisco, CA, USA
Katherine Aragon, MD, Palliative and Supportive Services, Lawrence General Hospital, Lawrence, MA, USA
Robert M. Arnold, MD, Leo H Criep Chair in Patient care, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA, USA
Eduardo Bruera, MD, Palliative Care and Rehabilitation Medicine, F.T. McGraw Chair in the Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Margaret L. Campbell, PhD, RN, FPCN, College of Nursing/Office of Health Research, Wayne State University, Detroit, MI, USA
Brook Calton, MD, MHS, Division of Geriatrics, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
Jamie Capasso, DO, Division of Palliative Medicine, Hospitalist Department, University of California, Irvine, CA, USA
Kristen A. Chasteen, MD, Palliative Medicine, Henry Ford Hospital, Wayne State University School of Medicine, Detroit, MI, USA
Amy M. Corcoran, MD, CMD, FAAHPM, Center of Excellence in Palliative Medicine, Department of Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
Neha J. Darrah, MD, Instructor of Clinical Medicine, Division of General Internal Medicine, Department of Medicine, Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Barbara Egan, MD, SFHM, FACP, Hospital Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Howard Epstein, MD, FHM, CHIE, Executive Vice President & Chief Medical Officer, PreferredOne® Health Plans, University of Minnesota Medical School, Twin Cities, MN, USA
Nathan Fairman, MD, MPH, Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, Sacramento, CA, USA
Lynn A. Flint, MD, Division of Geriatrics, Department of Medicine, UCSF School of Medicine, San Francisco VA Medical Center, San Francisco, CA, USA
Paul Glare, MBBS, FRACP, FACP, Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Matthew J. Gonzales, MD, Division of Supportive Medicine, Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
Yvona Griffo, MD, Palliative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Dawn M. Gross, MD, PhD, Division of Supportive Medicine, Department of Supportive Care Medicine, Sheri & Les Biller Patient and Family Resource Center, City of Hope National Medical Center, Duarte, CA, USA
Jane Hawgood, MSW, Palliative Care Program, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
Jeremy M. Hirst, MD, Department of Psychiatry UC San Diego School of Medicine and Psychiatry & Psychosocial Services, UC San Diego Moores Cancer Center and Palliative Care Psychiatry, UC San Diego Health System, San Diego, CA, USA
Scott A. Irwin, MD, PhD, Psychiatry & Psychosocial Services, UC San Diego Moores Cancer Center; and Palliative Care Psychiatry, UC San Diego Health System; and Psychiatry, UC San Diego School of Medicine, San Diego, CA, USA
Sara K. Johnson, MD, Palliative Medicine, Hematology/Oncology Division, University of Wisconsin, Madison, WI, USA
Amy S. Kelley, MD, MSHS, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA
Joshua R. Lakin, MD, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
Solomon Liao, MD, FAAHPM, Palliative Care Service, Hospitalist Program, Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, USA
Elizabeth Lindenberger, MD, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
B. J. Miller, MD, Department of Medicine, University of California, San Francisco, CA, USA
Jason Morrow, MD, PhD, Division of Geriatrics, Gerontology, and Palliative Medicine, University of Texas Health Science Center at San Antonio and L.I.F.E Care/Palliative Medicine Program, University Health System, San Antonio, TX, USA
Nina R. O’Connor, MD, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
Steven Z. Pantilat, MD, FAAHPM, MHM, Division of Hospital Medicine, Department of Medicine, UCSF School of Medicine, San Francisco, CA, USA
Sarah M. Piper, MD, Department of Palliative Care, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
Rosene D. Pirrello, BPharm, RPh, Department of Pharmacy Services, University of California – UC Irvine Health, Orange, CA, USA
Michael W. Rabow, MD, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
Thomas T. Reid, MD, MA, Department of Medicine, University of California, San Francisco, CA, USA
Eva Reitschuler-Cross, MD, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
James M. Risser, MD, Palliative Care and Hospital Medicine, Regions Hospital, Health Partners, St Paul, MN, USA
Kira Skavinski, DO, Palliative Care Service, Hospitalist Program, Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, USA
Michael A. Stellini, MD, MS, FACP, Hospice and Palliative Medicine, John D. Dingell Veterans Administration Medical Center and Wayne State University School of Medicine, Detroit, MI, USA
Rebecca L. Sudore, MD, Medicine/Geriatrics, University of California, San Francisco, San Francisco, CA, USA
Marieberta Vidal, MD, Department of Palliative Care and Rehabilitation, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
Eric W. Widera, MD, Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
Chapter 1Hospital Care for Seriously Ill Patients and Their Families
Steven Z. Pantilat, Wendy G. Anderson, Matthew J. Gonzales, and Eric W. Widera
Mrs Morton was an 82-year-old woman with ovarian cancer metastatic to the lung, liver, and peritoneum with massive ascites diagnosed 1 year ago. She had undergone many cycles of chemotherapy but stopped chemo several months ago due to progression of disease and increasing fatigue. Mrs Morton was living at home with her daughter, son-in-law, and three grandchildren. A few days earlier, she had stopped eating and drinking. She became sleepier and spent all of her time in bed. On the morning of admission, Mrs Morton’s daughter awoke to find that her mother was not able to speak or even open her eyes and was moaning and breathing fast. Feeling panicked, her daughter called 911. The ambulance arrived within a few minutes. They found Mrs Morton hypotensive, tachypneic, tachycardic, hypoxic, and in respiratory distress. They asked about advance directives, but were told that Mrs Morton had not completed one. They started an IV, gave fluids, administered oxygen, and rushed Mrs Morton to the hospital.
On arrival in the emergency department, the emergency physician and nurse asked the family, “Would you like us to do everything possible?”
Her family responded, “Yes,” as virtually anyone would to this question.
The emergency physician called the hospitalist on call STAT to the emergency department to admit Mrs Morton and notified the intensive care unit that she would soon be on her way up.
1.1 EPIDEMIOLOGY OF HOSPITAL CARE FOR THE SERIOUSLY ILL
For hospitalists, intensivists, emergency physicians, advance practice nurses, nurses, and all clinicians who practice in the hospital, the story of Mrs Morton is all too common. Overall, about one-third of Americans die in hospitals; many more spend some time in a hospital in the last year of life [1]. Among Medicare beneficiaries, nearly 70% are hospitalized in the last 3 months of life, one-third receive ICU care in the last month of life, and over half die in a hospital or nursing home [2].
While it is arguable whether Mrs Morton needed hospital admission to receive quality care at the end of her life, as hospice or palliative care at home would likely have provided the care she needed, the reality is that for many people hospital care provides relief and recovery from exacerbations of chronic illness. People with acute shortness of breath from heart failure or chronic obstructive pulmonary disease (COPD), bowel obstruction from pancreatic cancer, altered mental status from liver failure, and pain from a pathologic fracture often experience rapid and dramatic improvement in symptoms and quality of life from hospital care. Even patients who prefer to avoid hospitalization may find that hospital care provides the quickest and best option for relief of symptoms. For example, Chapter 4 discusses options for treating patients with malignant bowel obstruction. In this clinical setting, hospitalization may offer the best option for relief of nausea, vomiting, and pain. At the same time, for a patient like Mrs Morton, there will likely come a time when hospitalization will not only fail to provide relief but may also impose additional burdens for her and her family. Although it can be difficult to predict which hospitalization will be the last one or whether hospitalization will provide more benefit than harm, each hospitalization for the seriously ill provides an opportunity to clarify goals of care to ensure that care is consistent with patient preferences, promotes benefit, and limits harm.
Studies of patients with serious illness have shown consistently what these patients need and want from the healthcare system: relief from pain and other symptoms; clear communication about their illness, prognosis, and treatment options; and psychosocial, spiritual, and practical support [3, 4]. Addressing these needs is critical for providing high-quality care to patients with serious illness, and as such provides the overarching organizational structure to this book. Further, it requires a team approach as no single clinician has expertise in all these domains. Hospitalists and other hospital-based physicians, nurses, social workers, and chaplains must collaborate to ensure that patient needs are attended to. Such collaboration can happen formally, as with a palliative care consultation team, or more informally through clinicians working together to share insights and develop and implement plans of care.
Increasingly, it is hospitalists and other hospital-based specialists who care for people with serious illness in the hospital like Mrs Morton [5]. Over time, hospitalists have come to care not only for people with classic medical conditions, such as pneumonia and COPD, but also for people with cancer and cardiac, neurologic, and surgical problems either as admitting physicians or through comanagement. The high frequency of hospitalization among the seriously ill and those approaching the end of life places the clinicians who work in these settings in an ideal position to promote optimal quality of life for these patients.
1.2 PALLIATIVE CARE
Palliative care is the field of medicine focused on providing the best possible quality of life to people with serious illness and those near the end of life. Palliative care is defined as follows:
…specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. [6]
There are several important parts of this definition that bear highlighting. First, palliative care is for people with serious illnesses. While palliative care is also about caring for people near and at the end of life such as Mrs Morton, fundamentally, palliative care is for people with serious illnesses such as heart disease, COPD, cirrhosis, cancer, and dementia and would have been appropriate for Mrs Morton from the time of diagnosis. The term serious illness is also helpful when talking with patients about the need for palliative care or the decision to involve palliative care specialists. Patients can easily relate to and understand that they have a serious illness and that additional care will be helpful to them. In the hospital, palliative care will also be appropriate for patients with fulminant acute illness such as massive intracranial hemorrhage and trauma. The important point for hospitalists to remember is that palliative care is not only for the terminally ill and also for those at the very end of life.
Palliative care is also appropriate at any stage in a serious illness, and patients can receive palliative care while still pursuing curative intent treatment such as chemotherapy, radiation therapy, percutaneous coronary interventions, surgery, and hemodialysis. Many patients and physicians harbor the misconception that receiving palliative care means that patients must forsake curative intent treatment. This misunderstanding is a common barrier that unnecessarily precludes patients from receiving palliative care. Patients admitted with exacerbations of heart failure or COPD, with complications of cancer or its treatment, and those with dementia all may benefit from symptom management, clarification of goals of care, and psychosocial support. One helpful question to ask for determining whether a patient would benefit from palliative care is, “Would I be surprised if this patient died in the next year?” This “surprise” question helps clinicians identify patients appropriate for palliative care [7]. If the question is difficult to apply to every patient, clinicians can also consider the types of patients who would be appropriate for palliative care (Table 1.1).
Table 1.1 Types of Patients Appropriate for Palliative Care
Advanced heart failure, second readmission in a year
Breast cancer and malignant pleural effusion
Brain metastases
Dementia and aspiration pneumonia
New diagnosis of idiopathic pulmonary fibrosis
Cirrhosis, second admission for altered mental status
Awaiting solid organ transplant
“Would I be surprised if this patient died in the next year?”
If the answer is “No,” provide and/or refer for palliative care.
Consistent with what patients say they need from the healthcare system, palliative care seeks to relieve the symptoms, pain, and stress of a serious illness. Relief of symptoms and pain is the first priority as patients can only focus on what is important to them and on having meaningful time when their symptoms are controlled. Control of symptoms allows patients to consider the issue that is at the heart and the ultimate goal of palliative care: improving quality of life. In fact, one helpful way to explain palliative care to patients and families is to state that the goal is to help patients “achieve the best possible quality of life for as long as possible.” This focus on promoting quality of life and understanding that it is defined uniquely by each patient is at the crux of what palliative care is about. It is also helpful to explain to patients that palliative care provides an extra layer of support. Few hospitalized patients would decline extra support, and the more seriously ill the patient, the more attractive and necessary the extra support becomes.
Hospitalized patients fall along a continuum of an illness trajectory, and palliative care plays a significant role in the care of patients throughout this continuum. The needs of these patients with serious illness will vary over the course of illness, and as shown in Figure 1.1, the relative focus on palliative care and curative intent treatment may change. Similarly, the depth and intensity of involvement with palliative care concerns will change over time, but from diagnosis to death, patients with serious illness will encounter situations where they will need and benefit from palliative care.
Figure 1.1 Concurrent model of palliative care.
Source: © Steven Pantilat, MD and Regents of the University of California.
As will be highlighted throughout this book, there is considerable evidence for the efficacy and effectiveness of palliative care. A review of the evidence shows that palliative care relieves symptoms such as pain and depression, improves quality of life, increases satisfaction with care, and reduces resource utilization including ICU length of stay and costs of care [8–11]. Such an impact is easy to imagine when thinking about Mrs Morton. In addition, palliative care and conversations between patients and physicians about goals and preferences for care not only improve quality of care and life for patients but also improve outcomes for loved ones of patients who die [12, 13]. Those loved ones are less likely to experience complicated grief and depression 6 months after their loved one died.
1.3 THE ROLE OF THE HOSPITAL-BASED CLINICIAN IN PALLIATIVE CARE
Hospitalists, intensivists, and other hospital-based clinicians frequently care for patients with serious illness and those approaching at the end of life like Mrs Morton. Hospitalists recognize the importance of palliative care to their practice and acknowledge a relative lack of education in pain management and palliative care during training [14]. Hospital-based clinicians can interact with palliative care in following four ways.
Refer to a Palliative Care Team
: At a basic level, these clinicians need to identify patients who need palliative care and make appropriate referrals. Mrs Morton would be just such a patient. Many patients, like her, who need palliative care have complex symptom management and communication needs that require an interdisciplinary team of palliative care experts. In addition, when hospitalists are too busy with other patients to have extended goals of care conversations and family meetings, palliative care teams can assist to ensure that patient needs are met.
Work as a Member of a Palliative Care Team
: Many hospitalists and other hospital-based clinicians will have extensive experience with palliative care and develop a strong interest in it. While currently the only path physicians in the US have to board certification in palliative medicine is through a 1-year clinical fellowship, many palliative care teams are challenged to find qualified physicians and advance practice nurses and would likely welcome experienced hospitalists dedicated to gaining continued education and experience in palliative care. Hospitalists, intensivists, and others can split their time between their primary specialty and working with a palliative care team, diversifying their professional responsibilities and income streams.
Become Board Certified in Palliative Care
: Hospital-based clinicians who find palliative care compelling can pursue fellowship training in palliative care. The 1-year clinical fellowship is open to physicians from nearly all hospital-based disciplines. Understandably, taking a year away from practice to be a clinical fellow may be difficult financially. Some hospitals that have had difficulty hiring a board-certified palliative care physician have offered to supplement the salary of a hospital-based physician during fellowship in exchange for a guarantee of a certain number of years of work on the palliative care team. Given the shortage of palliative medicine-trained physicians, this arrangement can be a win–win for the hospital and the clinician and is often the fastest way of recruiting a board-certified palliative medicine physician. Nurses can also pursue board certification in palliative care. In addition, there are excellent educational courses for nurses in palliative care (End-of-Life Nursing Education Consortium (ELNEC)
http://www.aacn.nche.edu/elnec
), although there are few fellowships in palliative care for nurses.
Provide Primary Palliative Care
: This option is the one that applies to all clinicians and could have the greatest impact on ensuring that all patients who need palliative care receive it [15]. For example, regardless of whether a hospital had a palliative care team, and many still do not [16], Mrs Morton needed to receive palliative care. All hospital-based clinicians should have a basic knowledge and facility with palliative care issues including pain and symptom management, discussing prognosis and goals of care, ensuring psychosocial and spiritual support to patients and families, and providing care that is culturally aware and sensitive. The tools, knowledge, and skills associated with palliative care—such as pain management and good communication—apply to the care of many, if not all, hospitalized patients. In addition to being able to address pain, hospital-based physicians should have facility with management of dyspnea, nausea, vomiting, bowel obstruction, depression, and anxiety. A thorough knowledge of good communication techniques including sharing bad news, running a family meeting, and discussing goals of care are critical activities for all hospital-based clinicians. Finally, addressing and attending to patients’ psychological, social, emotional, and spiritual needs is important not only for patients nearing the end of life but also for many seriously and acutely ill patients. The fundamental goal of this book is to provide hospital-based clinicians with that knowledge base in an easy-to-use, evidence-based way with sufficient specificity and direction that will help guide care at the bedside.
Fortunately, there is large overlap in the knowledge, skills, and practice of hospital medicine, other hospital-based specialties, and palliative care. Clinical care in each realm includes interdisciplinary collaboration, seriously ill patients and those near the end of life, a wide range of clinical conditions, and a focus on improving quality of life and quality of care. This synergy across specialties can reinforce practice in each setting and help clinicians improve care overall.
1.4 THE STRUCTURE OF THIS BOOK
This book is divided into three parts that map the issues most important to seriously ill patients and their families and the major focus of palliative care: symptom management, clear communication, and psychosocial–spiritual support. The goal is to provide useful, practical, evidence-based information for busy hospital-based clinicians that forms the foundation of care for seriously ill patients and those near the end of life. This book also provides the science and the art of medicine and the science behind the art. In addition to evidence-based medicine, the authors share their clinical expertise and pearls of wisdom to put the evidence in context and offer guidance where evidence is lacking; akin to what they would impart in a consultation.
1.5 REWARDING PRACTICE
The care of seriously ill patients and those approaching the end of life can be challenging and richly rewarding [17]. Working with Mrs Morton and her family to help ease her respiratory distress; pausing the resuscitation long enough to understand her preferences for care; providing support, compassion, and empathy to her family; and implementing a plan consistent with her wishes allow the clinicians to use their heart as well as their head to provide the best possible care to patients and their families. In our technological age, it is easy to think that the only important aspects of medical care and the ones that patients value the most are the things we do to them. Such thinking grossly underestimates the importance that patients place in the human side of medicine and the caring that clinicians demonstrate by relieving symptoms and eliciting patient preferences carefully enough to really understand their goals and values and develop a plan to make those happen. In these cases, hospitalists and other hospital-based specialists can bring their humanism to bear on the care of the patient and can provide healing even, and especially, if cure is not possible.
1.6 CARING FOR MRS MORTON
A hospitalist or other hospital-based clinician well versed in palliative care can see the case of Mrs Morton as an opportunity to stop the onslaught of medical intervention for a patient who is dying and understand what her preferences would be to ensure she receives the care she and her family want. The hospitalist might start by asking, “How were you hoping we could help?” That question, much better in this situation than the one asked, could begin to elicit Mrs Morton’s preferences as expressed by her family [18]. The hospitalist could order opioids for the tachypnea and respiratory distress. If the family expresses understanding that Mrs Morton is dying and states that her wish in this setting is to have her care focused on comfort and dignity, the hospitalist might recommend admission or explore the possibility of Mrs Morton returning home with hospice services. The hospitalist might also ask about spiritual and religious issues to ensure that these are addressed in case Mrs Morton dies soon. The hospitalist could provide a best estimate of prognosis and explain about the dying process. Finally, the hospitalist could provide guidance to the family about what they can say and do at the bedside to promote comfort, dignity, and healing. The skills and knowledge essential for providing this type of care are the essence of this book.
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Section 1Symptom Management
Chapter 2Pain Management: A Practical Approach for Hospital Clinicians
Solomon Liao, Kira Skavinski, Jamie Capasso, and Rosene D. Pirrello
2.1 ETIOLOGY AND TYPES OF PAIN
Pain is “localized physical suffering associated with a bodily disorder” or “acute mental or emotional distress or suffering” [1]. A comprehensive approach to diagnosing and understanding pain therefore requires evaluating not only the medical disorder causing the physical pain but also the psychosocial distress that contributes to the patient’s overall suffering. Since every patient has a psychosocial aspect and a spiritual/existential component to their pain, the question is not whether the patient has nonphysical pain but how much. For example, a postoperative patient’s pain may be 98% physical, 1.5% emotional, and 0.5% spiritual. A chronic cancer patient’s pain, however, may be 45% physical, 35% psychosocial, and 20% existential. In reality, the different pain domains interact (as in Fig. 2.1), and separating them is both impractical and often impossible.
Figure 2.1 Biopsychosocial model of pain.
However, understanding the different pain domains allows for a structured approach to address all of the patient’s sources of pain. Screening for depression and anxiety is important in all pain patients, but particularly in chronic pain patients. Generally when a patient rates their pain higher than a 10 out of a maximum 10 scale, they are saying they have more than just physical pain. The most important existential question to ask a pain patient is the meaning the patient gives to their pain. People are able to tolerate horrible pain, such as in childbirth, if they give the pain a positive meaning and see a purpose to their pain. However, if a patient gives a negative meaning to their pain, such as a cancer patient who interprets their pain as progression of their disease, then their ability to tolerate their pain worsens.
Even for physical pain, different categories have been suggested to divide the types of pain based upon etiologies and mechanisms. These categories include such terms as somatic, neuropathic, inflammatory, visceral, and nociceptive. However, the most useful or practical dichotomy of pain type is whether the pain is opioid responsive or opioid refractory. From a management standpoint, this distinction is the first point in the algorithm of treatment. If the patient’s pain is opioid responsive, then the issue is finding the opioid dose needed to control the pain. If the patient’s pain is opioid refractory, merely giving the patient more opioids gets the patient and the prescriber into more trouble, a phenomenon that occurs all too often.
The differential diagnosis for opioid refractory pain is relatively short. Neuropathic pain has an incomplete response to opioids, in that most patients with significant neuropathic pain say that opioids “take the edge” off the pain but do not relieve it [2]. The majority of patients with opioid refractory pain have some component of neuropathic pain. The second most common type of opioid refractory pain is inflammatory pain, such as metastatic bone pain, and the third is nonphysical pain. Less common but important causes of opioid refractory pain are complex regional pain syndrome (CRPS) and central pain syndrome. CRPS, previously called reflex sympathetic dystrophy, is an autonomic mediated pain from the sympathetic nervous system and thus presents with the classic triad of color and temperature changes, edema, and vague pain involving an entire limb. It occurs after trauma to a limb, particularly neurological or vascular trauma, regardless of severity. Central pain syndromes occur after damage to the central nervous system including spinal cord injury or strokes. Paradoxical pain occurs with opioids from accumulation of neurotoxic metabolites. This opioid-induced hyperalgesia typically occurs with chronic high-dose opioid use. Patients complain of escalating pain with increasing opioid doses.
Pain can also be divided by chronicity: acute, subacute, or chronic. Appreciating the chronicity of the pain allows for an appropriate response. In the hospital, clinicians often mistakenly respond to chronic pain with acute pain measures. Similarly, patients may have the erroneous expectation that their uncontrolled chronic pain will be controlled just because they are in the hospital. Overreacting to chronic pain with aggressive acute interventions can not only be nonbeneficial but also actually harmful to the patient and to the health system. On the other end of the spectrum, delays in diagnosing or treating a new or acute pain often occur, especially in patients who have chronic pain at baseline or those who are confused or nonverbal.
2.2 A PRACTICAL GENERAL APPROACH TO PAIN
Pain is the most common and important complaint for hospitalization and presentation to the emergency room. The consequences of pain include reduced quality of life, impaired physical function, extended recovery time, and high economic costs from hospital readmissions, longer lengths of stay, and repeated emergency room visits [3]. As patients’ pain satisfaction scores become publicly reported, hospitals will be increasingly evaluated and ranked by their ability to manage pain. Improving pain management requires system changes in our hospitals. Fortunately acute care hospitals now have more resources to evaluate and address pain. Palliative care or pain consultations are increasingly available in hospitals for complex or refractory cases. Patients now have access to sophisticated pain therapies, such as ketamine or lidocaine infusions, epidural or intrathecal analgesia, and even surgical interventions for pain management.
The acute care setting poses challenges to good pain management. Acute illness not only increases the likelihood of pain but also increases the likelihood of complications from pain management. The ability of acutely ill patients to metabolize medications decreases when they develop acute kidney injury or acute hepatic failure. They are more sensitive to side effects of medications when they have exacerbations of their heart failure, COPD, or sleep apnea or when they have delirium or toxin-producing infectious colitis. Ironically when the patient most needs aggressive pain management, clinicians and hospital staff are the most fearful of giving them sufficient pain medications. The balance between the patient’s comfort and an iatrogenic complication requires not only clinical skill but also an understanding of the patient’s goals of care.
Management of acute pain requires a proactive, interdisciplinary approach. Frequent evaluation and adjustment of the treatment is more important than which initial therapy was started. The evaluation and treatment of pain in the hospital is everyone’s responsibility, from the physician to nursing staff, case manager, pharmacist, social worker, occupational therapist, and physical therapist. Establishing expectations, an acceptable pain level, and functional goals for improvement are essential first steps for good pain management. While unidimensional pain scales, such as the visual analog or Wong–Baker FACES scale, are helpful in tracking the longitudinal severity of the patient’s pain, multidimensional scales capture a fuller picture of the patient’s pain and should be administered at least once during the hospitalization, preferably on admission or on onset of the pain. Links to different pain assessment scales are shown in Table 2.1. Attention should be given to the patient’s peak pain score of the day rather than the average pain severity, since studies show that the peak pain score correlate best with clinical outcomes, such as function and patient satisfaction.
Table 2.1 Web Resources
Opioid Conversion Calculator at
http://www.globalrph.com/opioidconverter2.htm
.
Opioid Conversion Tables
http://www.globalrph.com/narcotic.htm
http://www.nhhpco.org/opioid.htm
http://champ.bsd.uchicago.edu/documents/Pallpaincard2009update.pdf
Pain Guidelines
American Academy of Pain Medicine
http://www.painmed.org/Library/Clinical_Guidelines.aspx
WHO treatment guidelines on chronic nonmalignant pain in adults
http://www.who.int/medicines/areas/quality_safety/Scoping_WHOGuide_non-malignant_pain_adults.pdf
Management of persistent pain in older adults
http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2009/
Palliative Care Fast Facts
http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts
Free Mobile Applications
Pain Guide: Pain Management Quick
NPC Opioid Guidelines
PAIN Clinician
Pain Scales
Unidimensional
Wong–Baker FACES pain rating scale
http://www.partnersagainstpain.com/printouts/A7012AS6.pdf
Visual analog (0 to 10) scale
http://ergonomics.about.com/od/ergonomicbasics/ss/painscale.htm
Nonverbal or Observational
Pain Assessment in Advanced Dementia Scale (PAINAD)
http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf
Revised nonverbal pain scale
http://ccn.aacnjournals.org/content/29/1/59/T4.large.jpg
Multidimensional
McGill Pain Questionnaire
http://www.ama-cmeonline.com/pain_mgmt/pdf/mcgill.pdf
Brief Pain Inventory
http://www.partnersagainstpain.com/printouts/A7012AS8.pdf
Medication reconciliation is now required on admission to the hospital and is also part of good pain management. However, obtaining accurate medication reconciliation may be difficult in an acutely ill patient. Fortunately, most states now have electronic prescription drug monitoring programs (PDMP) that can help with the medication reconciliation process. These programs allow prescribers and pharmacists to look up an individual patient on the state’s controlled substance database to see what pain medications they have received, when they received them, and from whom. Studies have shown that the use of PDMP actually increases (rather than inhibits) the prescribing of pain medications by reassuring the prescriber of the appropriate use of these medications [4]. PDMP can also help the care team identify patients who are at high risk for addiction or even pseudoaddiction (the appearance of drug-seeking behavior due to undertreatment of pain).
2.3 OPIOID ANALGESICS
2.3.1 Commonly Used Opioids (in the United States)
Table 2.2 summarizes the opioid medications that are commonly used in the United States. Morphine is the gold-standard opioid. It is available in short-acting and long-acting formulations. The benefits of morphine are that it is relatively inexpensive, is available in a liquid formulation, is ubiquitous, and is well known. Its familiarity translates to less medication errors in the hospital compared with other opioids. The liquid formulation is good for people who cannot swallow pills, have a tube feeding, or have poor bowel absorption (e.g., short bowel). Morphine is metabolized and glucuronidated in the liver to morphine-6-glucuronide and morphine-3-glucuronide. Both metabolites are renally excreted and are known neurotoxins. Accumulation of the metabolites leads to opioid-induced neurotoxicity which manifests as myoclonus, delirium, and then seizure. Morphine should be avoided in patients with moderate to severe renal impairment but can be used cautiously and for short term in patients with mild renal impairment.
Table 2.2 Commonly Used Opioid Analgesics
Opioid
Dosage Form
Strength
Starting Doses of Short-Acting Opioids for Opioid-Naïve Patients
Morphine
Oral solution
2, 4, 20 mg/ml
5–10 mg PO q 60 min as needed
Tablets ER (q 12 h)
15, 30, 60, 100, 200 mg
Tablets ER (q 24 h)
Kadian: 10, 20, 30, 50, 60, 80, 100, 150, 200 mg
Avinza: 30, 45, 60, 75, 90, 120 mg
Tablets IR
10, 15, 30 mg
Injectable SC, IV, infusion
Check hospital-specific concentrations
2–3 mg IV q 30 min as needed
Methadone
Oral solution
1, 2, 10 mg/ml
NA
TabletsInjectable IV, infusion
5, 10 (for pain); 40 mg (methadone maintenance clinics only)Check hospital-specific concentrations
Fentanyl
Transmucosal (buccal)
Actiq: 200, 400, 600, 800, 1200, 1600 mg
Transdermal
Patches: 12 (delivers 12.5), 25, 50, 75, 100 mcg/hr
Injectable SC, IV, infusion
Check hospital-specific concentrations
25–50 IV mcg q 30 min as needed
Hydromorphone
Oral solution
1 mg/ml
2 mg PO q 60 min as needed
Tablets ER (q 24 h)
8, 12, 12, 32 mg
Tablets IR
2, 4, 8 mg
Injectable SC, IV, infusion
Check hospital-specific concentrations
0.5 mg IV q 30 min as needed
Oxycodone
Oral solution
1, 20 mg/ml
5 mg PO q 60 min as needed
Tablets ER (q 12 h)
10, 15, 20, 30, 40, 60, 80 mg
Tablets IR
5, 10, 15 mg
Oxymorphone
Tablets ER (q 12 h)
7.5, 10, 15, 20, 30, 40 mg
5 mg PO q 60 min as needed
Tablets IR
5, 10 mg
The oral solutions of morphine, oxycodone, and hydromorphone are useful for enteral tube administration, and because they are short-acting, they are usually dosed every 4 h around the clock and/or as needed.
Methadone (in consultation with a palliative care specialist), because of its long duration of action, is an ideal “long-acting” opioid for enteral tube administration and is usually administered every 8 h.
Hydromorphone (Dilaudid) is more potent (mg to mg) than morphine but has no difference in efficacy. It is available in long-acting and short-acting formulations. However, the long-acting formulation is extremely expensive, not covered by insurance and cost prohibitive in most cases. Though not as neurotoxic as morphine, hydromorphone has toxic metabolites as well and is relatively contraindicated in patients with renal failure. The drawback of hydromorphone is its expense and the need to use a different opioid for long-acting pain relief.
Oxycodone is available in long-acting (OxyContin) and short-acting formulations. It is only available in oral formulations (pills and liquid) and not available in IV formulations. The disadvantage of long-acting oxycodone is its expense as it is not yet available in a generic formulation and therefore sometimes not covered by insurance. Additional drawbacks to long-acting oxycodone are its high potential for abuse and a high street value. Like hydromorphone, its metabolites are less neurotoxic than morphine’s.
Fentanyl comes in many formulations including intravenous, transdermal (TD), intranasal, sublingual, and buccal. It is estimated to be 80 times more potent than morphine as an analgesic. Its lipid solubility, high potency, and low molecular weight make it ideal for administration systemically through a relatively small area of the skin or mucosa. One of the biggest advantages of fentanyl is that its metabolites appear to be inactive, conferring neither analgesia nor toxicity. Therefore, fentanyl does not have the neurotoxicity in the setting of renal impairment as seen in the other opioids listed earlier. Table 2.3 summarizes the advantages and disadvantages of TD fentanyl compared to orally and IV or SC administered opioids. A major disadvantage of fentanyl is its expense. Its absorption is unpredictable in cachectic patients and should not be used in this population. The Food and Drug Administration (FDA) black box warns that the TD patch is not intended for opioid-naïve patients
