Palliative Patient in Emergency Department

Dr Thiru Thirukkumaran Palliative Care Services – NW THO

Northwest Regional Hospital, Burnie

Northwest Tasmania

Outline the Session

Introduction What is palliative care?

Outline the NW- Tasmanian Service model?

How do you refer the patient to the Service?

Palliative Patient in the Emergency Why they are coming to Emergency?

What are the issues in palliative care patients?

What is the aim of management?

How do we integrate our services?

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=IYDac757hznDsM&tbnid=QfxJ-21sY7AH2M:&ved=0CAUQjRw&url=http://about.itriagehealth.com/consumer-patient-engagement/palliative-care-program-poster-child-patient-engagement/&ei=6pTvUrmEDoOZkQW0z4DABQ&bvm=bv.60444564,d.dGI&psig=AFQjCNHSdeiDNzUgPoxTCHftm1t5qkYXRA&ust=1391518606919545

“An active and total approach to the care of a person with a life

limiting illness that embraces physical, psychological, emotional,

social, cultural and spiritual elements”

PCA 2005

“Holistic approach to Care” / “Comfort Care” / “Supportive Care”

Example: Consider a 38 years old man with young family,

diagnosed with advanced cancer & coming to you (ED)

with pain, anxiety, fear & frustration…..

Here, you are dealing with “Total Pain”

Physical pain from tumour & secondaries

Psychological pain

Social pain

Spiritual pain

DO NOT… expect that the patient is going to be better

with ‘IV Morphine protocol’ or NSAID Regimes in the ED

We may not be able to the triage their category by

physical factors! OR not be able to send the patient

back home after few hours of observation

What is ‘Palliative Approach’?

An attitude to care that concentrates on

quality of life for patients facing life-

limiting illness.

Active treatment may be provided

concurrently. This approach does not

necessarily need to involve the

specialist Palliative Care Services.

There is an understanding that dying,

death and bereavement are a part of life

NW- Tasmanian Palliative Care Service model

My Team – One F/T Doctor (0.4 + 0.1); NUM; 3 x P/T CNCs + 3 x P/T CNSs; One F/T social worker; Admin Assistant ; Hospice – volunteers

“Hospice without walls” - Model

Levels of Service Delivery

1

2

3

4

Level-2: Consultation and advice for primary care

providers, but primary provider remains

first contact for client.

Level-1: Information / resources / training and

professional development

Level-4: Direct Care (including community and

In- patient) by the Palliative specialist

Service.

Level-3: Shared Care with PCS team and other

Primary care providers.

NW- THO Palliative Care Service(PCS) Statistics

National Standard Assessment Program (NSAP) indicate there are unmet needs in terms of access with widely dispersed population in NW Tassie!

Approx. 350 patients are registered with PCS at any time in the 25,000 km2 area & 70- 80 % are still die at Home environment.

We manage, not only advanced cancer patients but also End Stage COPD / End Stage Heart Failure /Advanced Neurological diseases (MND /MS / Parkinson disease) / End Stage Liver Failure / End Stage Renal Failure

Increasing more non-malignant referrals – all over the world!

There are on average 80 clients need ‘home visits’ by PCS per month and predicted referrals for this year is over 1000.

We are hoping to manage the increasing referrals through on-going education to the health professionals in NW-THO and improving our rapport with GPs / CNs & Hospital colleagues.

How do we access to Palliative Care Services?

The service can be accessed by phone, fax, email from:

The patient Patient’s family GP Medical Specialist Hospital Staff Community Health Nurse Rural Aged Care Staff Other Health Care Professionals (allied health)

Phone: 03 6440 7111 Fax: 03 6440 7113

What palliative care can offer to Patient/family & carers?

Palliative Care is offered to “The unit of care.”

The service for Patient, and family/carers/friends

Offers a support system to enable people to live as actively as

possible until their death, in the environment of their choice

Assess

need

Identify

needs

Plan

Implement

Review

Discussions with patient & family ⇰ making plans about EoLC / GoC / PPoC & PPoD

Increasing Morbidity

Last Days of Life

First Days of Death

Bereavement Advancing disease

Start the

Discussion Early

Follow-up for

many Months

Preferred Place of Death - PPoD

Preferred Place of Care - PPoC End of Life Care - EoLC

Goals of Care - GoC

The ideal practice for end of life care is…..

End of Life Care & Hospital admissions

Preferred Place of Care & Preferred Place of Death

1st Group 2nd Group 3rd Group

Most people would prefer to die at home

Some want to be at health care setting: Hospital or N-Home for safety! (“feeling safe”)

Some want to die at home but end up @ acute hospital (“Unable to cope” or

‘distressing Symptom issues’)

Aiming to reduce ED admissions of the 3rd Group through……

Through the Rescue Package - 2014

1. We are getting few more Staff to the Palliative care Service – Should be able to provide Hospital liaison CNC / CNS for Palliative patients in acute setting may be able to re-direct their PPoC & PPoD with appropriate facilities (⇩ hospital stay)

2. ‘Hospice at Home’ project is introduced from 2014– getting nursing staff / carers @ home for EoLC patients (⇩ anxiety )

3. Looking for a opportunity to get a palliative care pharmacist to NW- THO; At present, there is a MSc. research study is in progress to examine the need for this post!

Once we establish the need, we will proceed with it!

(Availability of Palliative drugs in out of hours is the main issue! )

My ultimate aim to establish a Hospice in-patient unit to NW-THO!

Palliative Patient in Emergency Unit

The Reasons for the ED admission 1. Rapidly changing Clinical Circumstances in the progressively deteriorating

patients & needing more or different routine of medications

2. There is ‘NO’ 24/7 Palliative care advisory service or in-patient unit (Hospice)

3. Non-availability of 24/7 palliative care Pharmacy…….

4. Unable to cope at home with dying phase with limited facilities….

Not every Palliative patient in ED is dying! Admissions with overwhelming symptoms

- Constant Nausea and Vomiting

- Overwhelming pain ( ‘Total pain’)

- Malignant Bowel Obstruction

- Seizures or following a seizure

- Terminal agitation

Panic attack / Anxiety

Unable to cope at Home

Not every Palliative care patient is for… ‘fixing’ or ‘getting better’

The aim is to keep them comfortable!

(Trying to improve their Physical, psycho-social & spiritual wellbeing)

How do we do in palliative care? - Improve the symptoms as much as we can! (Medics)

- Allow them to off load their anxiety (Counsellor)

- Dealing with their spiritual pain / burden (Chaplain)

- Support their Social burden ( through social worker)

(Transform their unrealistic expectations to...meaningful goals / milestones)

‘Realistic goals’ – what to expect? & make plans (ACP or GoC)

How can we do in the acute setting?

All the patients registered with NW – Palliative care are now be identified through the Digital Medical Record (DMR) alert section They may already have ‘ advance care plan’

At least six Nursing Homes in NW -Tasmania are enrolled with ‘Living Well Dying Well Program’ & every patient in these N/homes has some form of advanced care plan

We are going to adopt ‘Goals of Care’ in acute care settings. This document will be filled during their 1st hospital visit (New Clients) & kept in our DMR (Royal Hobart Hospital is using for a year & waiting to hear their feedback!)

Gradually…… We are hoping to have a data base of Goals of care in our hospital - DMR

How much we can do in ED?

In ED, you work according to your Triage system but palliative patients are little different…! (we can’t send back immediately, how much to treat…. & you may have to admit under medics!)

If any reversible symptom issue (Hypercalcaemia, infection), you can treat & refer to palliative care follow-up in the community.

But, if you know… this is a recurrent resistant ⇧ Ca status, you can’t cure from your calcium Rx likely ‘Poor prognostic state’

You may have to treat their overwhelming symptoms to keep them comfortable (Pain / Anxiety / Nausea / Excessive secretions)

Pain Opioid Use in Palliative Care Patients - Opioid escalation is not the path for every palliative patient in ED with pain!

- What is ‘total pain’?

- How much opioids (per 24 hours) they already on? (Regular & top-ups)

- Why treatment failure occurred? (Oral malabsorption…. dif. type of pain….)

Whether Patient need a opioid switch or not?

Endone is used more frequently in ED & Surgical ward

Endone 5mg is = Morphine 7.5 -10 mg

For a opioid naive patient, this starting dose…

May be high!

Available opioids in NW- Tasmania

Morphine

Oxycodone

Methadone

Hydromorphone

Fentanyl / Buprenorphine/

Alfentanil Short acting:

Oral Medications:

Ordine Suspension

[Morphine HCL]

1mg/ml 200mL [1]

2mg/ml 200mL[1] RPBS

5mg/mL200mL[1] RPBS

10mg/mL 200mL[1] RPBS

Sevredol 10, 20mg tablets

Anamorph 30mg tablet

Injectable Preparations:

Morphine Sulphate inj

10mg/ml, 15mg/ml;

20mg/ml; 30mg/ml (1ml

& 2 ml vials);

1mg/ml (50ml vials)

Suppository

Morphine Sulphate HCL

Supps 10; 15; 20 & 30mg

Long acting or Sustained Release:

Oral Preparations:

MS Contin tablets:

5, 10, 15, 30, 60, 100, 200mg

MS Contin Suspension

20, 30, 100 mg sachet

Kapanol Capsule

10, 20, 50, 100mg

MS Mono Capsule

30, 60, 90, 120mg

[Available Long Acting Morphine

injections are Sulphate & Remember

sulphate allergies!]

Short acting:

Oral Medications:

Oxynorm Liquid [HCL]

Liquid 5mg/5ml [250 ml]

PBS / RPBS

Oxynorm capsules

5, 10, 20 mg[20] RPBS

Endone tablet

5mg [20] PBS / RPBS

Injection Preparation:

Oxynorm Inj HCL [NOT ON PBS]

10mg/ml 1ml amp [5]

20mg/2ml amp [5]

50mg /ml amp

Long acting or Sustained Release:

Oral Preparations:

Targin Tablet

5/2.5; 10/5; 20/10; 40/20

Oxycontin tablet

5, 10; 20; 40; 80 mg

[20] & [60] PBS /RPBS

Long acting:

Oral Preparations:

Methadone [HCL] Tablet

10mg tablet [20] PBS/RPBS

Methadone Syrup

5mg/mL 200mL [1] (Authority

PBS/RPBS for PALLIATIVE CARE

one month supply)

Injectable Preparations:

Physeptone inj

10mg/mL 1mL [5]

Short acting:

Oral Medications:

Dilaudid Tablets [HCL]

RPBS/PBS

2, 4, 8mg [20]

Dilaudid oral liquid

RPBS/PBS

1mg/mL 473mL [1]

Injectable Preparations

Dilaudid inj

PBS / RPBS

2mg/mL 1mL[5]

10mg/mL 1mL[5]

50mg/mL 1mL[5]

500mg/mL 1mL[5]

Long acting: Oral Preparations: Jurnista® Tablets Once a day (do not crush or chew)

Short acting:

Oral Medications: [NOT ON PBS]

Actiq Lozenge – Buccal route

(200; 400; 600; 800; 1200;1600 mcg)

Nasal Spray [NOT ON PBS]

Instadyl nasal Fentanyl spray

50 mcg; 100 mcg; 200mcg /dose

PenFent nasal Fentanyl spray

100; 400 mcg /dose

Injectable Preparations:

Alfentanil Inj [NOT ON PBS]

500mcg/ml (2ml&10ml) +

5mg/ml (1ml vial)

Long acting or Sustained Release:

Oral Preparations:

Nil

Transdermal Preparations:

Fentanyl Patch (72 hours)

Durogesic DTrans

12; 25; 50; 75; 100 mcg/hr

Buprenorphine Patch (weekly)

Norspan Patch

5; 10; 20 mcg/hr

Pain Management

Background Pain Relief

Long acting opioids / regular NSAIDS / Neuropathic agents (Gabapentin / Pregabalin)

Top-up (prn) Pain Relief – How to Calculate? (in Palliative care patients)

Renal Impairment & Pain Relief

Nausea and Vomiting

N / V Can be multi-factorial E. g.: – ‘Cancer patient’

Cancer patient with ‘severe pain’ Induces N / V

Using Opioid Induces N / V

Opioid S/E Constipation Leads to N / V

Chemo / DXT Induces acute N /delayed N

Anxiety Issues Leads to ‘Anticipatory N / V’

Two Approaches Empirical or Mechanistic

Mechanistic Approach

- Accurate identification of the cause

- Understanding of pharmacological mechanism

- Use of most effective drug

The Emetic Process-Pathways of Emesis and the neurotransmitters involved

Baines, M. J BMJ 1997; 315: 1148-1150

Metoclopramide D2 Antagonist, 5HT3 at high

doses + (5HT4 - gut)

For Prokinetic Activity (Gastric stasis / External

Compression)

10-20mg

tds or Qid

Domperidone Similar to Metoclopramide

(But.. does not cross BBB)

For Prokinetic Activity (Gastric stasis) &

Parkinson disease

10-20mg

tds or Qid

Prochlorperazine D2 receptor antagonist Used for motion sickness, post-operative vomiting.

Buccal tablet 3mg is available ( Buccastem )

5-10mg tds

Haloperidol D2 Antagonist For Biochemical Causes

(Hypercalcaemia / Renal Failure / Liver impairment)

0.5mg -1mg

Nocte

(6mg/24 hr)

Cyclizine H1 Antagonist,

Anticholinergic antagonist

For Central Causes (Increased ICP) 50mg tds

Levomepromazine D2 + H1 + 5HT2 Antagonist +

Acetylcholine

2nd line drug due to its multiple receptor activity 6.25mg Nocte

(25mg/24hr)

Ondansetron 5HT3 Antagonist Acute Nausea (Chemo / Radiotherapy related /

Post-op nausea)

4mg tds or

8mg bd

Other Drugs used:

Hyoscine

Steroids

PPI

Lorazepam

Hyoscine Slows peristalsis & reduces

Secretions in GI tract

Steroid Combination in Chronic N

PPI Reflex disease associated N

Lorazepam anxiety induced N / V

Drugs used in Palliative Care to Control N / V

Anxiety / Agitation

Simple Anxiety: Anxiolytics – Short acting ‘pams’ are helpful (Oxazepam, Lorazepam, Alprazolam)

Short acting ‘pams’ can break

SOB ⇋ Anxiety cycle

Severe Anxiety / Agitation / Restlessness:

(if no reversible Causes…. & unable to take orally)

1st line: Midazolam inj sc 2.5 mg Q2H or 10-20mg via S/driver over 24 h

2nd line: Levomepromazine via S/driver 12.5 -25mg over 24h

3rd line: Phenobabital infusion 100 -200mg sc via S/ Driver over 24 h

(diluted with WFI)

Death rattle / secretions

Why secretions are more pronounced in terminally ill patients?

Drugs: Glycopyrronium / Hyoscine butylbromide (Buscopan)

From research evidence there is no superior drug (same response!)

Dose ? Glycopyrronium Inj 0.2-0.4mg sc stats (max of 2mg/24hr) or

S/Driver start with 600mcg – 1.2 mg/24hr

Buscopan Inj 20mg sc stats (max 240mg/24 hr) or

S/Driver 60-240mg/24 hr

Any Questions?