1.Palliative Care:What every 1st year medicalstudent needs to knowSuzana Makowski, MD MMM FACP FAAHPMAssistant Professor of MedicineSlide presentation for 1st year medical students in the Cancer Concepts Course atUMass Medical School

2. What is Palliative Care? What is Hospice? How do we care for the dying?Overview 3. an approach that improvesthe quality of life ofpatients and their familiesfacing the problemsassociated with life-threatening illness, throughthe prevention and relief ofsuffering by means of earlyidentification andimpeccable assessment andtreatment of pain and otherproblems, physical, psychosocial and spiritual.WHO definitionPalliative Care 4. Its not about killingGranny; its aboutkeeping Granny alive aslong as possible withthe best quality of life.- Diane Meier, NYTimesWhy discuss palliative care? 5. http://www.youtube.com/watch?v=XHtHXGhTIC4NEJM Study (2010): Early Palliative Care improves longevity andquality of life for patients with advanced non-small cell lung cancer 6. What is palliative care? 7. Not just end-of-life care 8. Adapted from Frank Ferris EPEC-O 9. Myth: Palliative care = just end-of-life careWe often help patients whose life expectancy is good 10. Cancer pain management 11. 50 to 90 percent of oncology inpatients reportbreakthrough pain 35 percent of community based oncology practicespatients report breakthrough pain 1 in 3 patients with active cancer report pain 3 out of 4 of patients with advanced cancer report painCancer pain prevalence 12. Bone metastases Visceral metastases Immobility Neuropathic pain Soft tissue Constipation Esophagitis Lymphedema Muscle cramps Chronic postoperative scar Adapted from Twycross R, Harcourt J, Bergl S: A survey of pain in patients withadvanced cancer. J Pain Symptom Manage 1996;12:273-282.Causes of cancer pain 13. PhysicalEmotional Existential Increased catabolic demands:DepressionSuffering poor wound healing, weakness, muscle Anxiety why me? breakdownDecreased Decreased limb movement:intimacySuicidalityincreased risk of DVT/PE Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis Sodium and water retention Decreasedgastrointestinal mobility Tachycardia and elevated blood pressure Decreased functional status Increased chronic painEffects of under treated pain 14. Intensity Location Quality Timeline Alleviating factors Meds triedPain Assessment 15. CategoryCauseSymptomExamplesPhysiologic Brief exposure to aRapid yet brief pain Touching a pin or hotnoxious stimulus perception objectSomatic or visceral tissue Moderate to severe pain, Surgical pain,Nociceptive/inflainjury with mediatorsdescribed as crushing or traumatic pain, sicklemmatoryhaving an impact onstabbing cell crisisintact nervous tissueDamage or dysfunctionSevere lancinating,Neuropathy, CRPS.Neuropathic of peripheral nerves orburning or electricalPostherpetic NeuralgiaCNSshock like pain Combinations ofLow back pain, backCombined somatic andMixedsymptoms; soft tissue plus surgery painnervous tissue injury radicular painPain Quality 16. WHO pain relief ladderNon-opioid = acetaminophen, NSAID, neuroleptic Adjuvant = steroid, etc. 17. Mrs. Dolores de Barriga is a 67 year old Peruvianimmigrant with metastatic colon cancer, who hasincreasing abdominal pain. She has a colostomy and hasregular bowel movements. Her current pain regimen is: Morphine ER 15mg twice daily Percocet (oxycodone 5mg + acetaminophen 500mg) 1-2tablets every 4 hours as needed. She has been taking 2tablets every 4 hours for the last week.Why is this dangerous? 18. Opioid Pharmacology 19. Short-actingLong-acting Hydrocodone/APAP Transdermal fentanyl Oxycodone +/- APAP methadone Morphine morphine ER Hydromorphone oxycodone ER Oral transmucosal fentanyl Cmax ~ 45 min Cmax and T1/2 vary based on T1/2 ~ 2-4 hours formulation and drug Except fentanyl Opioid Pharmacology 20. What is the half life (range) for opioids? 2-4 hoursHow many half lives to get to steady state? 4-5What do you base your scheduled dosing on: Cmax or C? t1/2What do you base your breakthrough dosing on: Cmax or t1/2? CmaxA quick quiz 21. Follow first order kinetics Conjugated by liver 90-95% excreted in urine Dehydration, renal failure, severe hepatic failure Decrease interval/dosing size Why is morphinecontraindicated in If oliguria/anuriarenal failure? STOP routine dosing (basal rate) of morphine Use ONLY PRNOpioid pharmacology(except methadone) 22. Morphine 3-glucoronide Not an opioid agonist Stimulates the GABA/glycinergic system Can cause neuro-excitation agitation, hyperalgesia, myoclonus, se izures. Morphine 6-glucoronide Active metabolite that acts as an opioid agonist especially against the mu-opioid receptorMorphine metabolitesbuild-up disproportionately in renal failure 23. Optimal symptom Same rules applymanagement CMO Continuous Morphine OnlyPersonalized Goals of care based healthcare Not problem based Whole-person Bio-psycho-social-spiritual approachcare Interdisciplinary Palliative Care 24. Myth: Palliative care = no more treatmentWe assess the values & goals of a patient, designing care around them 25. On an average day in Massachusetts:1 A fewinfant children 144 people dieSome Most middleover 75agedMassachusetts facts 26. MA: 67% want to die at home 27. MA: only 24% die at home 28. In the United States, hospice is a form of care provided topatients whose life expectancy is 6 months or less. It is generally provided in the patients home, but can bereceived in nursing homes, hospices houses, etc. It is a Medicare benefit (that many other insurancescover) Its approach is to help people live as well as possible, forthe time they have left: alleviating symptoms, reachinggoals, supporting family, addressing spiritual needs. As long as a persons prognosis remains 6 months, thebenefit does not run out. A patient may be full code, DNR/DNI according totheir goals and preferences on hospice.Hospice care:1 way to help stay home 29. HospiceHome Palliative (VN)Requires Prognosis