Posts tagged Primer

Day Two of Intensive Review…

The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:

Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea

Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors

Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort

Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam

Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.

Suggested articles:

1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207

Other resources: website gives nice medication conversions

My thoughts on the final day at the review course will come shortly….

Tanya Stewart MD FAAHPM

A Word with the Authors: Primer Tracks Growth in Field

The fifth edition of the Primer of Palliative Care will debut at the 2010 AAHPM & HPNA Annual Assembly, March 4-6, in Boston, MA. Authored by Tim Quill, MD FACP FAAHPM; Robert G. Holloway, MD MPH; Mindy Stevens Shah, MD; Thomas V. Caprio, MD FACP; Aaron M. Olden, MD; and Porter Storey, Jr., MD FACP FAAHPM, the fifth edition has been extensively updated yet remains true to its original goal of providing foundational palliative care guidance to physicians who are interested in incorporating the basic skills of palliative medicine into their everyday practice. Since its first edition, the Primer of Palliative Care has been one of the Academy’s most popular and highly regarded books. We recently sat down with Dr. Porter Storey, the creator of the Primer and author of the first three editions, and Dr. Tim Quill, lead author of the fourth and fifth editions, to get their perspectives on the growth of hospice and palliative medicine and how they’ve responded to such growth through the evolution of this book.

The first edition of the Primer was published in 1994. At that time, how did you intend for the Primer to contribute to the palliative care literature? What were your original goals for the book?

PS: In the 80s, hospice physicians developed skillful ways of working in teams to manage symptoms and communicate with patients and families. Although there was little “evidence base,” these skills were clearly helpful to many patients facing their final months of life. This booklet was written to encourage physicians to take an active role in the care of these patients and to communicate a basic understanding of these methods to students and practicing physicians new to our field.

The field of hospice and palliative medicine has grown substantially since the first edition, and each edition has also grown. How has the Primer changed throughout its five editions, and how have you adapted the Primer to reflect the growing evidence base in palliative medicine?

PS: We have added both additional symptoms (e.g., mucositis), and many additional references, but the focus is still on helping those new to the field develop caring, confident proficiency in helping patients and families cope.

TQ: In the last two versions of the Primer, we have tried to integrate the expanding evidence base associated with palliative care, reflecting its maturation as a field. Although many areas still depend on expert opinion, more and more areas of practice are supported by scientific study. We tried in these versions to connect interested readers to recent reviews and original studies so that they could get directly to the literature that underpins many of our recommendations.

What are some of the most important changes to the Primer since it was last revised in 2007?

TQ: The 2010 version of the Primer has been edited, updated, and substantially restructured in comparison to prior versions. We screened each topic area for new evidence-based information published over the past 3 years by searching the Cochrane Database, by doing a literature review for evidence-based studies including randomized clinical trials, and by collecting the best available articles on each subject from our own files. Although not a true systematic review on each subject area, we tried to include evidence as it is emerging in palliative care and hospice since the book was last updated. In addition, the chapter on pain management has been significantly restructured, with more in-depth material on using and converting to and from fentanyl and methadone. The equianalgesic conversion card enclosed in the book has also been updated. New chapters were developed on Goal Setting, Prognosticating, and Self Care (Chapter 6) and on Care During the Last Hours of Life (Chapter 8). Other chapters on Gastrointestinal Symptoms (Chapter 4) and Delirium, Depression, Anxiety, Fatigue, and Spirituality (Chapter 5) have been substantially expanded. At the end of each chapter is a list of key articles for those seeking original sources or more in-depth information.

What audience do you hope to reach with the Primer and how did that audience affect the ways you’ve developed the content throughout each of the editions?

PS: Today there are excellent journals, textbooks, and online resources to help palliative care professionals improve their practice. This booklet is designed to focus attention on the core skills and to guide students, residents, and practicing physicians to these resources for more information.

TQ: We use the Primer with our medical students, residents, and fellows on their palliative care rotations. We have created a workbook to use along with the Primer which poses clinical questions and problems that can be solved by reading the relevant section of the book, and all of our trainees work through the questions connected to each chapter and bring their answers to two review sessions during the rotation. They keep their copy of the Primer after their rotation, and store it in the pocket of their white coats. It is also an invaluable resource for clinicians in virtually all medical fields trying to practice evidence-based palliative care alongside evidence-based medical care. Even as card carrying palliative care specialists, we carry the Primer with us on rounds in case we need to ensure basic dosing accuracy in addressing many palliative care problems, and use it regularly.

A book project of this nature takes a great deal of time in writing, editing, and review. Do you have any tips for physician-writers interested in publishing a book?

PS: Carefully think through the need for the publication and make sure there is a “niche” for this new effort. Consider other media, like blogs, online courses, or cell phone applications that might be more widely utilized. Try to recruit hard-working, experienced colleagues and publication staff to help you. Finally, anticipate it requiring lots more time and energy than you envisioned, but likely being worth all the effort.

TQ: I agree with Porter. It helps to have a passion for the topic, a clear plan for what you are trying to accomplish, and assurance that there is a demand for the product. For projects that are relatively broad and evidence-based, it helps to have a great team of reviewers, writers and editors who are devoted to the project, meet deadlines, and carry through their commitments. In our case, we have wonderful, committed co-authors as well as a publishing team from AAHPM who all really did a first rate job. This kind of project “takes a village” with everyone pulling a substantial part of the weight, and we have a wonderful team.

The Primer of Palliative Care, 5th edition, by Tim Quill, MD FACP FAAHPM; Robert G. Holloway, MD MPH; Mindy Stevens Shah, MD; Thomas V. Caprio, MD FACP; Aaron M. Olden, MD; and Porter Storey, Jr., MD FACP FAAHPM, will be available for purchase at the AAHPM Resource Center at the 2010 Annual Assembly in Boston, MA. Dr. Storey and Dr. Quill will be signing copies of the Primer and the UNIPAC QR on Wednesday, March 3, from 5:30-6:30 pm in the Exhibit Hall.

—Jerrod Liveoak, Managing Editor, AAHPM