Palliative Care Pearls: What Works, What Doesn t

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1 : Steven Pantilat, MD Kates-Burnard and Hellman Distinguished Professor of Palliative Care Director, Palliative Care Program and Palliative Care Quality Network Department of Medicine University of California, San Francisco Disclosure I have no disclosures to report Oxygen for shortness of breath Atropine for rattle IV Fluids for dehydration at end of life Supplemental Oxygen for Shortness of Breath Helpful for patients No evidence for relief in patients that are not Adds discomfort May prolong dying Abernethy A et al. Lancet. 2010;376: Cranston JM, et al. Cochrane Database Syst Rev. 2008(3):CD004769

2 Treatment of Shortness of Breath Treat the underlying cause Pleural effusion, PE, pna, ascites Opioids work in all cases Low dose: morphine 2mg po q3hrs prn Safe even in COPD Sitting upright Fan and/or fresh air Cold cloth to face Atropine for rattle IV Fluids for dehydration at end of life Ekstrom M et al. Ann Am Thoracic Soc. 2015; Bausewein C, et al. Cochrane Database Syst Rev. 2008(2):CD Treatment of (Death) Rattle Distressing sound in people near end of life Likely not distressing to patient Poor prognostic sign 57 ± 82 hrs (23 hrs median survival) Atropine sublingual does not reduce rattle Neither do any other meds Turn patient Limit IVF IV Fluids for dehydration at end of life Heisler et al. JPSM. 2013;45(1):14-22 Lokker et al. JPSM. 2014;47(1):

3 IV Fluids at End of Life Significant controversy Stopping to eat and drink is normal at end of life Associated with edema, effusions and ascites Does not reduce thirst Management challenge at discharge Requires IV access IV Fluids at End of Life Trial of 1000ml/day vs 100ml/day IV fluids in hospice patients with advanced cancer unable to take po fluids No difference in symptoms, quality of life, or survival Median survival 17 days Minimize IV fluids at end of life Bruera et al. J Clin Oncol. 2013;31: Bruera et al. J Clin Oncol. 2013;31: IV Fluids for dehydration at end of life: no Treatment of Constipation Very important to patients Bowel regimen for patients on opioids is a quality measure Bowel stimulants are essential Senna and docusate are commonly used Dy SM et al. JPSM. 2015;49:

4 Treatment of Constipation Evidence that docusate not helpful RCT of senna vs senna and docusate Senna alone superior Docusate tastes horrible Ruins applesauce Start with senna Add polyethylene glycol, lactulose, or sorbitol Treatment of Constipation Methylnaltrexone For stimulant resistant, opioid induced constipation Weight-based dosing, subcutaneous Once daily, every other day Works quickly when it works Works half the time Hawley and Byeon. J Palliat Med. 2008;11: Thomas J et al. NEJM 2008;358(22): IV Fluids for dehydration at end of life: no : no Chemotherapy at End of Life Goal is to improve quality of life and extend survival Considered more helpful in patients with better functional status Chemo in last weeks of life marker of poor quality Study: association of chemotherapy in last 6 months of life with QoL and survival Prigerson HG et al. Jama Oncol 2015; doi: /jamaoncol

5 Chemotherapy at End of Life Half of patients received chemo in last six months of life Patients with good functional status more likely to receive chemo No difference in survival chemo vs none Chemo associated with worse QoL for patients with better functional status at baseline Question chemo in very sick patients IV Fluids for dehydration at end of life: no : no : no Prigerson HG et al. Jama Oncol 2015; doi: /jamaoncol Communication about Palliative Care Issues Patients want to talk Discussions increase patient satisfaction Absent explicit conversations, patients infer and misunderstand Increased Family Satisfaction Satisfaction Lo et al. Arch Int Med 1986;146: Tierney et al. JGIM 2001;16:32-40 % time family talks McDonagh et al. Crit Care Med 2004;32:

6 The Golden Questions When you think about the future, what do you hope for? When you think about what lies ahead, what worries you the most? Oxygen for SOB only if patient is Opioids work No pharmacologic treatments for rattle are effective- turn the patient Little benefit to IVF at end of life Stop using colace for constipation Chemotherapy in last months of life provides little benefit Communicate with patients about palliative care issues Publication date: Valentine s Day 2017 Pre-order at amazon.com life after the diagnosis Expert Advice on Living Well with Serious Illness for Patients and Caregivers Steven Pantilat, MD