1

Principles of Palliative CareA Tasting Menu

Kyle P. Edmonds, MDAssistant Clinical Professor

Doris A. Howell, MD, Palliative Care Consultation Service

2

Specialist Palliative Care

• A team that can help your patients and families manage the pain, symptoms, and stress of serious illness.

• Available at any age and at any stage in a serious illness and can be provided along with curative treatment.

• Expert communication for challenging situations.• Partnering with you for better outcomes by helping your

patients tolerate curative treatment.

Dr. Doris Howell, pediatric oncologist (and all-around pioneer)

3

Generalist / Specialist

Palliative Care

Hospice

•Symptom management•Whole person plan of care•No relation to prognosis•Not a philosophy of care

•Funding mechanism•Strictly <6mo prognosis•Home-based•Teaches caregivers

4

When to Call?

Time

Palliative

Care

Routine Medical Care:antibiotics, dialysis, chemotherapy, surgery

“Dying”?

“Nothing more to do”?

“Pt / family request”?

“Really sick”?

“Really, really sick”?

5

Routine Medical Care

Generalist Palliative

CareSpecialist Palliative

Care

•Fluids•Antibiotics•Etc.

•ACP/GoC•opioids•Ondansetron•Routine MDM

•Complex pain•High dose opioids•Limit setting•Hope & Prognostication•Complex MDM

6

When to call

• Patient is seriously ill • AND• You feel uncomfortable w /

• Symptom mgmt• Breaking bad news• Eliciting goals of care• Whole person needs

7

General OR Specialty Palliative

Care

Routine Medical CareHospic

eBereaveme

nt

Decision Maker

Goals of Care

Nausea Mgmt

Psychosocial Needs

Care coordination

Prognostication

Bowel Obstruction

Mgmt

Legacy Work

Family Meetings

Hospice Education

POLST

Spiritual Support Mgmt: Vomiting,

Pain, Ascites, Delirium, Anxiety

Care Transitions

1

2 3

45

7

6

EquipmentTeaching

MedicationsHome AidesVolunteersPrognosisSymptoms

24/7 Access

Preparing Children

Support Groups

Counseling Resources

Dx

Death

Adapted from Landzaat, 2013.

The Course of Illness

8

Palliative principles are appropriate for all patients with serious illness

Principle

9

Assessing Symptoms

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control

10

Whole-person Assessment

11

Unfortunately, disease does not exist in a vacuum

Principle:

11

12

Managing Symptoms

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•Nausea has resolved since NGT placed

13

• Constant

• Constant + Acute

• Intermittentacute

Time Course

14

For acute symptoms, treat with frequent, fast-acting (PRN) meds

Principle:

14

15

For constant symptoms, treat with constant (scheduled) meds

Principle:

15

16

Example: Pain

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•You want to start morphine…

17

Plas

ma

Con

cent

ratio

n

0 Time

AbsorptionExcretion

First Order KineticsWhen biological effect

follows plasma concentration

18

Plas

ma

Con

cent

ratio

n

0 Time ( hours )

Time to MaximumConcentration ( t Cmax )

20

10

1

= time it takes to get to maximum concentration

Cmax MorphinePO / PR

Cmax = 1 hour

19

Plas

ma

Con

cent

ratio

n

0 Time

IV

PO / PR60min

Time to MaximumConcentration ( t Cmax )10min

20

Plas

ma

Con

cent

ratio

n

0 Time

Cmax

Treating Acute Pain

PO / PR≈ 1 hr

IV~10 min

21

For acute pain, dose every C-max with short-acting meds

Principle:

21

22

Aberrant Drug-taking

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•On PRN hydrocodone/APAP at home•You start morphine PCA 1mg basal, 2mg bolus•Nursing calls: patient requesting Dilaudid, because she’s had it before…

2323

Aberrant Drug-Taking behavior

• Desperation over sxs

• Aggressively complaining

• Requesting specific drug

• Buying opioids on street

• Doctor shopping

• Prescription forgery

Passik et al. JClinPain. 2006.

ADDICTED.

24

• Low health literacy

• Physiologic dependence

• Receptor heterogeneity

• Chemical coping

• Pseudo-addiction

• Drug diversion

• Substance use disorder

• Addiction

DDx: Aberrant Drug Taking Behavior

25

Maintain DDx for drug-related behaviors you don’t like

Principle

26

Goals of Care

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•“I want to get back to how I was!”

27

Potential Goals of Care

Restorative or Cure

Return to Baseline

Improve Survival

Improve Function

Relieve Symptoms

Allow Natural Death Adapted from Mulkerin, 2011.

28

• Perception of patient/family

• Exploration of life before illness

• Relating patient story to medical situation

• Sources of worry for the future

• Outline the plan concretely

• Notify those who need to know

Goals…How?

Edmonds, Ajayi, Cain, Yeung, & Thornberry. 2014.

29

Values

Hopes

Wishes

Personhood

Lifestory

Goals of Care

Medical Options

Patient/Family Us

Ventilator

Pressors

Code Status

Antibiotics

Disposition

The Plan of Care

30

The plan of care is a negotiation of GOC & realistic medical options

Principle:

31

Sharing Prognosis

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•PMHx of CHF•Needs help around the house and with dressing PTA•Albumin 2.4 g/dL

32

Formulating Prognosis: How…?

• ePrognosis.org

• myPCNow.org

Covinsky et al., 2011.

33

Prognostic Awareness

• Higher when:• Less time to live• Cognitively intact• At peace with life• Not depressed

Fisher et al., 2015. Jackson et al., 2013.

34

Goals: Require Time

Steinhauser et al., 2000.

35

…Prognosis: How?

• Control symptoms, alleviate worries

• Ask permission

• Use SPIKES protocol

• (Hedge if you like)

• Give ranges• Days-to-weeks• Months, less-than-six• Years

• Celebrate when they live longer!

36

Hope is not fragile

• More than medicine• “I hope”• Positive future• Patient

• The subject of• Relatedness

•Focus on Life

Adapted from Table 1: Eliott & Olver, 2006.

37

Formulating & sharing prognosis is the standard of care

Principle

38

“Just do everything”

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•You broach the concept of hospice with her

•“Oh no, doctor I still have HOPE to get stronger and have more chemo…•“I want to do EVERYTHING possible!”

39

DDx for “Do Everything”

• Affective• Abandonment (Don’t give up on

me)• Anxiety (I don’t want to leave my

family)

• Cognitive• Incomplete understanding• Wanting reassurance

• Spiritual• Vitalism (I value every moment of

life)• Faith in God’s will (Only He can

decide)

• Family• Family conflict (My husband will

never let me go)• Children or dependents (I don’t want

to bother my children)

Quill et al., 2009.

40

Align, Reassure, Reframe

• “Hoping for the best and planning for the worst”

• Align with patient

• Explore & reframe “everything”

41

“Do everything” is a statement of emotion to be explored, not a medical directive

Principle:

42

Realistic Communication

•58yo mother of three with metastatic colorectal CA•Admitted with recurrent SBO (being medically managed) and pain out of control•3rd admission in 3 months for SBO•Chemo on hold•Increasing dependence•Prognosis: months, less than 3

43

Crucial Conversations©

• A discussion between people where• Stakes are high• Opinions vary• Emotions run strong• Outcome greatly impacts lives

Patterson, Grenny, McMillan & Switzler. 2002.

44

Crucial Conversations©

• 3 ways to handle• Avoid• Face & handle poorly• Face & handle well

Patterson, Grenny, McMillan & Switzler. 2002.

45

Crucial Conversations©

• Why they can go poorly• Biology: fight-or-flight• No warning• No rehearsal• Self-defeating behavior

Patterson, Grenny, McMillan & Switzler. 2002.

46Multiple Goals Theory of Communication

Action Mill. 2014.

47

Communication: Palliative Consults

• More accurate prognostic understanding1

• Addressed QOL2

• Contained more “pessimistic” cues2

1. Temel et al., 2011.2. Gramling et al., 2012.

48

Anxiety = Not always bad

49

Reality sometimes need to cause anxiety for good decision-making.

Principle:

50

Maladaptive Coping…

• Cognitive• Cognitive delay• Medically naïve• Extremes of age

• Emotional/Psychological• Emotional reactivity• Serious mental illness• Substance abuse history

• Social/Cultural• High degree of mistrust• Collectively-focused• Defer to authority• Those who believe only option

is a miracle

Roeland, Cain, Onderdonk, Kerr, Mitchell, & Thornberry. 2014.

51

Relying on your expertise

Roeland, Cain, Onderdonk, Kerr, Mitchell, & Thornberry. 2014.

52

Tailor your communication approach appropriately

Principle

53

Howell Palliative Care Consultation Services

• Multi-disciplinary teams• Licensed Clinical Social Worker• Nurse Practitioner• Fellowship-trained physician• Pharmacist

54

• Palliative principles are for all patients with serious illness

• Acute symptoms PRN meds

• Constant symptoms scheduled meds

• Maintain DDx for drug-related behaviors you don’t like

• The plan of care is a negotiation of goals of care & realistic medical options

• “Do everything” is a statement of emotion

• Reality sometimes needs to cause anxiety

• Tailor your communication approach

Principles

55

“Palliative Care is a team of specialists who help with symptoms, coping with serious illness &

planning for the future.”

How to describe us?

56

Principles of Palliative CareA Tasting Menu

Kyle P. Edmonds, MDAssistant Clinical Professor

Doris A. Howell, MD, Palliative Care Consultation Service