Archive for February, 2011

Building Bridges, Breaking Barriers…February 16 preconference

Although I was faculty rather than participant, this workshop about horizontal and vertical violence (“Bullying”) was a learning experience for me. As the only physician on the panel I expected to be isolated, to feel like a concentration-camp guard at the Holocaust Museum; instead I was surprised at the number of physicians in the room, often, it seemed, with experience on both sides of the bullying divide.

While the literature suggests that nurse-on-nurse bullying is slightly more common in health care, that has not been my experience. Trained in an environment in which bullying was a norm, physicians have a tough time escaping from that practice. It was clear that this group of physicians was determined to heal, and the that the others on the palliative care team were equally determined to travel on the same journey. Most of us experience bullying in our work, and the nursing studies which dominate the literature suggest this is a significant factor in leaving the profession.

Modern teaching theory suggests that adult learners do well with short doses of didactic material and much better with “showing” rather than “telling.” In the interest of “showing” we inserted an episode of “horizontal violence” into the didactic session as an unannounced role play, with one presenter harrassing another to the extent that the room became visibly tense and uncomfortable, while the undermined presenter grew more flustered, shaky, dropping her materials. We stopped almost immediately to debrief. One of the participants asked “what could we have done to stop this,” and we spent much of the rest of the meeting examining this question in parallel experiences of “real life.”

Reflective practices which teach us to move toward appropriate action in spite of our ever-present fears are the foundation of resistance to bullying. Gifted teacher Don Marks helped us understand the effect of these practices, actually decreasing the activity and size of the amigdyla, the brain’s “fear center,” increasing the size of the insula, the compassion center.

Again, understanding that “showing” works better than “telling,” we demonstrated two practices, reflective writing and a meditation. Participants were enthusiastic, understanding how these practices could well move them to a place where they could better intervene in bullying episodes on behalf of themselves or others.

Discontinuing Treatment in Patients with End Stage Illness: The Art and Science of Reconfiguring Therapy

A very engaging conversational topic was presented.

Some key items to be considered at this point in a patient’s illness:

  • Ambulatory, Palliative, Hospice or Comfort Care
  • The Goals of Care as described by the patient/family
  • Clinical Expertise
  • Best Practice Evidence

Barriers may include:

  • Patient Related: psychological attachment to medications they have been taking as well as families perception of effectiveness
  • Clinician Related: Concern about patient’s/other clinicians resistance to change; Prescribing as a social expression of caring and concern
  • System Related: Lack of data to support discontinuation of medications no consensus

Consider diagnosis and disease trajectory and when reviewing medications the:

Indication

Risks

Benefits

Consider first stopping OTC medications (remember patients thoughts about quality of life)

What are your thoughts about inhalers and nebulizers?

Do you sometimes feel the need to change their minds and convince them, negotiations???

Would early palliative care maybe help in later decisions about care goals and later discontinuation of medications?

Cost and effects of medications and some of the touchy ones such as Aricept and Namenda when families want the patient to still recognize them

Three thought provoking cases were presented that might also generate good discussions in your own teams. It did in our session. No right or wrong answers but a good way to determine for your team are best to support your patients.

PalliMed reception

The PalliMed/ GeriPal co-sponsored reception last night was a success. As repeatedly and succinctly put by social networking guru Christian Sinclair, the purpose of this event was to meet those with whom we’ve been communicating for the past 12 months, whether by Twitter, List-serve, blog or Facebook. Plus it’s fun! Present were PalliMed contributors and its principals Drew Rosielle and Christian Sinclair. GeriPal’s Alex Smith mingled with the crowd of more than 50 (I arrived late so may have been more earlier) with drinks and hors d’oeuvres that were gone by 9:30 pm. Others from the Social Media presentation were in attendance.

Putting real (vs virtual) faces with names is a luxury in this era of social media, where opinions are rife but the exchange usually one-sided (instead of truly listening one is busy crafting a response) so hope we can use these associations to further our personal and professional life skills.

Thanks for the break.

Feeling Our Fire

Earthy, dynamic, funny, rich in the wisdom of connection, reflection, and rejuvination…This describes this morning’s plenary by Dr. Sherry Showalter. Her words and movements celebrated this work we do. She reminded us that that which is to provide light, must endure burning, and that we who strive to heal, must, each day, heal ourselves.

Her message invigorated us with renewed purpose, inspiring us to go forward with fresh eyes and weightless spirit, to bear witness and share strength, to open the door with an open heart and open mind, to achieve comfort, to offer hope, to create healing.

Wado Dr. Sherry “Charles” Showalter. Wado!

Karen Whitley Bell, RN, CHPN

After the Bad News… When Patients Hear Something Different than What Was Said

How many times have you begun a conversation with a patient or family, only to discover their understanding of the situation is far different from what the referring physician has shared with you?

All too often, it seems, judging from the large attendance at this informative, lively session that led attendees through the labyrinth of difficult, high stakes conversations. The role-play exercise—a PC consult with a determined mother of teens who believes she’s discharging to rehab to “get stronger for chemo” — stimulated a discussion that identified techniques, pitfalls, and ethical boundaries.

The take-away of techniques included three communication approaches: offering a hypothetical situation (have you thought about what you’d want if the chemo isn’t effective?), offering hope/worry language (I’m hoping you’ll feel better and be able to go home to spend time with your family, but I’m worried that your body is very sick, and this might not be possible) and naming the dilemma.

Some techniques to avoid common pitfalls included communication with the team after to conversation to ensure a common message and reduce team distress, and avoiding splitting, even bringing the referring physician to the meeting, if possible.

The concept of planting a seed—taking the conversation only as far as the patient appears able—emerged as we explored the ethical boundaries of sharing unwanted news, weighed with our duties to the patient and family to provide accurate information to empower informed decision making.

While we recognize that some patients and families may stay “stuck,” the goal of these conversations, and indeed all care, is to maximize the chances for better outcomes. Thank you Drs Jacobson, Thomas & Jackson for an enlightening session.

Karen Whitley Bell, RN, CHPN

Compassion in Canada

Sometimes when you think outside the box with the right intentions, things happen for the good. The session “Showcase Canada: Introducing Canadian Initiatives in Hospice Palliative End-of Life Care was a great overview of such a vision. The presentation was dispersed with great facts about Canadians and great pictures of many areas I want to add for my next trip.

In Canada, the current median age is 40 and the life expectancy is 81.29 years with 80% of the population living in an urban area. Health care is publically funded with very little private insurance. Did you also know that Canadians like to talk about famous Canadians such as Justin Bieber? Baby, Baby, Baby OH or is that eh?

Interestingly I took a trolley tour of Vancouver yesterday, the tour guide spoke of how he is covered by his wife’s medical plan and that if he had to buy insurance it would only cost him $110.00 per month and all things are covered including medications. He stated even surgery for any diagnosis. I have not formally checked this, but this made me wonder, how can this be possible?

I was intrigued because in many conversations in the United States we compare ourselves to this system and currently in a health care reform period. So how can you cover someone for $110 a month and they feel supported and cared for according as my trolley driver? I am open to discussion.

In 1990, the Canadian Hospice Palliative Care Association was established and in 2004 Compassionate Care Benefits were enacted, a Canadian federal program providing income for caregivers. It has limitations:

  • Limited to 6 weeks; and
  • patient should have 6 month diagnosis; but
  • the benefit can be used by multiple family members.

A Canadian national program allows a 6 week paid leave by the employer but no protection for the job, different from those who live in the United States who can apply for FMLA (Family Medical Leave Act) which is a 12 week program that does not pay for your time away from work, but does protect your job. There is also another program (at least in California) CESLA which allows for use of sick time (percentage) and not vacation time, to be away and care for family members. The CESLA program was unknown to me until I needed to care for my father last year and is not just for end of life care. It appears no matter where you live there is no perfect answer but that there are different levels of support. I think many programs are not known about until the need arises which makes our understanding and knowledge of these programs even more important to help families care for their loved ones.

I think with all the efforts put forth and as we try different options outside the box, we will someday be able to provide such support. I think this supports the palliative care programs as they try to bridge the care of patients from diagnosis to death. In the meantime, Canada has an online resource for that provides “Support and information on palliative and end-of-life care, loss and bereavement for patients, families and health care providers” at www.virtualhospice.ca. Part of the website has an “Ask the Professional” where anyone can ask a question and within 3 days receive an answer. Check it out. You can also follow their efforts on Facebook as well with the continued development Their efforts continue with the expansion of their Model to Guide Hospice Palliative Care to now include pediatrics.

Thanks to Vancouver for hosting the conference and for sharing their hard work.

NEUROTOXICANTS: Unmasking Uncommon Syndromes (333)

This lecture was very informative and was well attended.

To summarize the meeting and the clinical pearls:

Definition:

Pharmaceutical neurotoxicant

drug or drug-like entities due to its own properties or in combination with other drug or drug-like entities illicit an untoward response to its host’s nervous system

  • Many drugs used in hospice/palliative care have potential side effects. Often we are using polypharmacy and the sum of the parts can lead to neurologic syndromes. Minimize drugs used. Ask yourself: is this drug needed? is it likely to cause side effects? Is there something that we can stop if we start this drug?
  • The symptoms of Serotonin syndrome, Anticholinergic syndrome and Neuroleptic syndrome can be vague, and the clinical syndrome is usually missed. Only in the extreme cases is the diagnosis obvious. Clinicians are not well versed in the neurologic syndromes so they are often missed. There is overlap between the three syndromes.
  • Symptoms of restlessness or agitation are treated with medications such as haldol that are meant to reduce these symptoms. Often increasing or adding new medications worsen symptoms which usually leads to increasing medications. This lecture helped to point out that some of the worsening symptoms are medication related and tapering off the medication is the appropriate next step.
  • Elevated temperature is not always infection. In both NMS and Serotonin syndrome it can be side effect of drugs
  • Myoclonus is not always related to opioid toxicity
  • Careful examination to include pupillary size and reflex response can help differentiate between syndromes

Summary of the syndromes in the table below (hope it opens – I’m new at this)

table for neurotoxicants

Overall it was a good lecture that made the participants aware that these syndromes exist, that the medications we use in hospice and palliative care are often the culprits and without high level of suspicion the syndromes are missed.

A Whirlwind Tour of Pharmacology for Symptom Mangement in Pediatric Patients

Today at the AAHPM Assembly, I had the opportunity to attend a much-needed session on pharmacology for symptom management in pediatric patients. Sponsored by the Pediatric Special Interest Group, this “whirlwind tour” covered pharmacologic approaches to depression, anxiety, delirium and insomnia in children. The three presenters from San Diego Hospice – a palliative care physician, a child psychiatrist and a pharmacist – effectively used video and powerpoint to get a lot of important points across quickly. While a bit more attention could have been paid to time management, this was an important session that could easily have been 2 hours in length, and the presenters definitely conveyed the main points in a clear and easy-to-follow fashion.

In pediatrics, we suffer from a practice gap in that there remains such a dearth in evidence-based research for much of our clinical practice. So we rely on anecdotal evidence, or fly by the seat of our pants. It’s very helpful to have guidance and wisdom from a long-established program who have amassed a significant clinical history with pediatric patients. What was particularly informative was the data table that they put together and freely shared, listing all of their recommended pharmacologic choices for each symptom, along with mechanism of action, dosing guidelines, absorption/metabolism/excretion information, common adverse events, and specific clinical pearls about their use. The table also included an algorithm specifying first and second-line choices for each symptom.

One of the many great things about the pediatric palliative care community is the unselfish sharing that we do – as exemplified by the resources offered at today’s presentation. At a national level, we’re currently working on ways to store and share important and widespread information that would benefit everyone, including clinical pathways/protocols, seminal presentations, program development tools, policies/guidelines, and bibliographies. Stay tuned to the AAHPM SIG webpage for updates as to how this information will be made available!

New Drugs and Drug News – The 411 and implications for palliative care (334)

This session could also be known as: a whirlwind journey through 2010 pharmacology with Mary Lynn McPherson, Pharm.D., BCPS, CPE from the University of MD. She is a very entertaining and engaging speaker, also very quick! She reviewed the FDA decision to remove propoxyphene from the market, which has been highlighted in other blogs as well. She discussed the FDA concerns and restrictions regarding acetominophen in common opiod formulations. In addition, I didn’t know there was an official definition of opiod tolerance – any one of the below:

  • 60 mg oral morphine per day
  • 25 mcg TDF every three days
  • 30 mg oral oxycodone per day
  • 8 mg oral hydromorphone per day
  • 25 mg oral oxymorphone per day

Several highlights to remember:

  • Many new and very expensive drugs on the market taking advantage of alternative delivery systems
  • Nuedexta (dextromethorphan/Quinidine) for uncontrolled laughing/crying in neurological diseases. Helpful but over $600/month
  • Abstral (SL Fentanyl) available. Extensive REMS (Risk Evaluation and Mitigation Strategies – FDA) which will include special certification for providers as well as pharmacies.
  • Exalgo – a once daily hydromorphone formulation
  • BuTrans – transdermal buprenorphine which can be worn for 7 days for pain relief
  • OxyContin reformulation – designed to prevent abuse, many patients feel it isn’t as effective.
  • Duloxetine (Cymbalta) – indication for chronic musculoskeletal pain (low back pain, etc)
  • Acetaminophen IV (Ofirmev) available – long awaited by many (including me!). Will be over $10 per dose, compared to pennies for other routes of administration. Will still be huge blockbuster!
  • Cryostat – a very effective cold pack for hemorrhoid relief

Overall, LOTS of information in a great presentation. I was only sorry it was at the end of the day (I feel much sharper earlier in the day!).

Would be curious if anyone else picked up other tips that might be helpful – please share in comments.

Serotonin Antagonist: Should They Be Used in Palliative Medicine? (327)

Nausea and vomiting is a drag! Hope no one is feeling queasy since this talk is all about N/V.

Dr. Eric Prommer is very knowledgeable about serotonin and the serotonin antagonist like ondansetron . Interestingly, serotonin, which is constantly being produced, can overcome the antagonist and this is why these medications may lose effectiveness.

At this time these medications are used for prevention of chemotherapy induce, post-op and radiation induced nausea\ vomiting. Most serotonin activity is increased in the first 24-48 hours after the insult. Therefore this is why these medications are mostly used in theses settings? The issue in palliative medicine is that we are trying to manage the problem of nausea \vomiting in a more chronic setting and not specifically related to a specific event.

Evidence Base is Limited

Opioid Induced Emesis

Ondasnsetron versus reglan may be helpful?

Bowel Obstruction

24 patients granesetron 3mg +dexamethasone 8mg

Highly effective with good control in over 80% of patients

Cancer

280 patients with advance cancer but commonly on opioids the N\V may be in part the cause of nausea\vomiting.

Total Control of N\V which was less than 3 hours of distress a day could be achieved in up 75-85 % of patients with relatively minimal side-effects. However, study flawed in several ways but very suggestive to be highly effective.

Conclusions

1) Serotonin antagonists are not all alike- Therefore it may be that when one is not working that a different drug in this class and or dose may be helpful .

2) Efficacy is studied in Opioid and bowel obstruction

3) Minimal adverse effect

4) Usable in combination with other agents and steroids.

5) The cost of the agents can be extremely high.

6) More studies are needed to use these medications wisely