Palliative Pulse - October 2023

Clinical Pearl

• 79-year-old male, with known metastatic lung cancer (metastases to his liver and spine w/ cord compression), currently on hospice. Brought in by family to the ED with multiple complaints, most concerning is inadequate analgesia (severe back pain) with frequent periods of severe drowsiness in which he is unable to spend any meaningful time with his family. Due to increasingly drowsiness, they have been trying to cut back his opioid use; however, his pain significantly worsened over today and has not responded to oral narcotics at home. Patient and family very distressed, come in with multiple pill bottles (MSER 60 mg BID, MSIR 15 mg q4h PRN). Family report constipation, but deny any extremity weakness, vomiting, urinary issues, or falls. Patient and family still desire to remain on hospice and focus on comfort care but request assistance with symptom management. Physical exam notable for cathectic-appearing male, moaning in pain, tachypneic, moving all extremities. 
• You suspect erratic medication compliance – i.e. periods of severe pain followed increased opioid intake, followed over-sedation.
• While waiting for the hospice coordinator to call back, you devise a plan to manage the patient’s symptoms.
  • Calculate the total daily dose (TDD) in oral morphine equivalents (OME)
  • Select narcotic agent of choice and use the opioid equianalgesic table to calculate equivalent dosing.
  • If switching to a different opioid, reduce the calculated dose by 25-50%
  • IV Hydromorphone was used this case, but the same morphine can be used.
  • Provide short-acting bolus that is 10% TDD.
  • Repeat every 15 minutes until goal-concordant analgesia is achieved.
  • Then, calculate the hourly dose required.
  • Optimize supportive care (e.g. hydration) and adjuvant treatments (e.g. Senna, enema, miralax,, lactulose) if you think patient is not actively dying
  • Consider SQ methylnaltrexone if you have access if patient unable to tolerate po medications.
• Clarify the pain management goal.
• Optimize adjuvant therapies.
• Opioid Treatment ¹
• Constipation

Education/Training

ACEP 2023

• Palliative Care Lecture: Dying with Dignity: Incorporating Palliative Care Into Your Practice. 
• Wednesday, Oct 11^th, 12:30 PM — 01:20 PM EST @ location TBA 
• Abstract/Oral Presentation: Trends in Hospice and Palliative Medicine Consults Initiated in the Emergency Department: A Seven-Year Utilization Analysis
• Presenter: Dr. Abe Al-Hage, DO
• Wednesday, Oct 11^th, 12:00 PM EST in Room 106AB. 

Education in Palliative and End-of-life Care (EPEC) Conferences & Professional Development Workshop: 

• Sep. 28-30, 2023, Hyatt Lodge, Oak Brook, IL

Book chapter: “Primary Palliative Care in the Emergency Department and Acute Care Setting"

• Co-Authors: Satheesh Gunaga, DO & Jonathan Zygowiec, DO, MPH
• Textbook: "Understanding End of Life Practices: Perspectives on Communication, Religion and Culture” to be published in Nov 2023
• Editor: Dr. Chandana Banerjee, MD.

ED Palliative Program Highlight

Hospital: Prisma Health Richland Hospital/University of SC School of Medicine, Columbia

Site Specifics: 641-bed regional community teaching hospital with university affiliation. Level 1 trauma center with a 75-bed ED (over 90,000 visits annually).
The palliative care team consists of 10 providers (including 3 fellows) and 5 allied health professionals.

Model: Currently piloting a quality improvement project to embed palliative care within the ED with the goal of demonstrating that earlier access to palliative care would improve goal concordant care and facilitate early shared decision-making.

Funding: Prisma Health system, fellowship driven initiative. No additional funding.

Lessons Learnt: There is real value in having palliative care medicine available within the ED to have earlier goals of care conversations that set the trajectory for patient treatment courses to reduce their length of stay, de-escalate treatments that do not add quality or coincide with the goals of the patient or family. The ED staff love having us available for additional support in these time sensitive cases and we are also seeing the impacts of primary palliative care with our presence.

Contact: Krysten Hinton, DO

Research Article of the Month

Article: Nursing Home Residents with Dementia at End of Life: Emergency Department Visits, Hospitalizations, and Acute Hospital Deaths ².

• What the authors did: Authors carried out a retrospective observational study to examine ER visits, admissions, and place of death in a nursing home resident population to see if the presence of dementia affected unplanned admissions in the last month of life
• Why it matters: Dementia was associated with a higher odds ratio of ER visits and acute admissions. Comorbid tatus and frailty were associated with an increase in hospital deaths.

Salaj D, Schultz T, Strang P. Nursing Home Residents with Dementia at End of Life: Emergency Department Visits, Hospitalizations, and Acute Hospital Deaths. J Palliat Med. 2023 Jul 27. doi: 10.1089/jpm.2023.0201. Epub ahead of print. PMID: 37504957. 

Announcements

Celebrations

• Our Former Pall Care section chair, David Wang, MD, is now Chief Medical Officer at Mass Advantage, where he’ll be overseeing population health and clinical management.
• Our chair elect, JustinKenneth Brooten, welcomed a new baby this year! Congratulations!
• Jessica Tu, MD, Palliative care fellow at Montefiore Medical Center Bronx, NY, recently welcomed a baby!

In Memoriam

• Jonathan Zygowiec died in June 2023 at the age of 40.
  • He was a husband, father of 3 young boys, a US Airforce Captain, a practicing EM physician, a Hospice Medical director, and a champion of early access to primary palliative care and HPM resources. He was graduated from the EM Residency program at Henry Ford Hospital.
  • Here is a 9-minute reading of his reflective essay which tells of his experience as a patient at the end of his life ³.

 Events

• ACEP 2023 
  • Wednesday, Oct 11^th, 5:00 - 7:00 pm EST @ location TBA 
  • Dinner provided by MIDEO Health
• Palliative Care Section meeting: 
• SAEM Palliative Care Virtual Meeting:
• September 19th at 3pmET / 2pmCT / 1pmMT / 12pmPT 
• American Academy of Hospice and Palliative Medicine – Special Interest Group Meeting
• Sept 25th. Time TBA (likely afternoon)

Opportunities

• Education in Palliative and End-of-life Care (EPEC): - Call for volunteers for future conferences!
• Please contact Dr. Satheesh Gunaga.
• EM–Geriatric and Palliative Care in partnership with SAEM Academy of Geriatrics and ACEP: Define research questions around EM and Palliative Medicine using PICO strategy and make recommendations.
• If interested, please contact Kei Ouchi at Harvard. 
• EMRA resident magazine articles: Please bring ideas to next meeting.

Deadlines

• ACEP course proposal 2024: Due Oct 20^th, 2023. Click here for the form.
• Compassion Extubations.  
• EM-Simulation  
• Language skills – communication phrases  
• If interested in collaborating, please contact Rebecca Goett and bring ideas to next meeting.
• SAEM 2024 Didactics: Submission opens 8/15 and closes 10/2 

References

1. McKillip, K. Palliative Clinical Pearls for Pain Management. Online Presentation. Creighton University.
2. Salaj D, Schultz T, Strang P. Nursing Home Residents with Dementia at End of Life: Emergency Department Visits, Hospitalizations, and Acute Hospital Deaths. J Palliat Med. 2023 Jul 27. doi: 10.1089/jpm.2023.0201. Epub ahead of print. PMID: 37504957.
3. Jonathan Zygowiec. Resilience After Defeat. Ann Intern Med.2023;176:874-875. [Epub 18 April 2023]. doi:10.7326/M23-0559