Palliative Patient in Emergency Department

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?

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 lifelimiting 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 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. 4 3 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 2 1

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 km 2 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

The ideal practice for end of life care is.. Review Identify needs Implement Assess need Plan Start the Discussion Early Follow-up for many Months Advancing disease Increasing Morbidity Last Days of Life First Days of Death Bereavement Discussions with patient & family making plans about EoLC / GoC / PPoC & PPoD End of Life Care - EoLC Goals of Care - GoC Preferred Place of Care - PPoC Preferred Place of Death - PPoD

End of Life Care & Hospital admissions Preferred Place of Care & Preferred Place of Death 1 st Group 2 nd Group 3 rd 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 3 rd 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 1 st 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 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 Short acting: Oral Medications: Dilaudid Tablets [HCL] RPBS/PBS 2, 4, 8mg [20] Dilaudid oral liquid RPBS/PBS 1mg/mL 473mL [1] 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: 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 Injection Preparation: Oxynorm Inj HCL [NOT ON PBS] 10mg/ml 1ml amp [5] 20mg/2ml amp [5] 50mg /ml amp Injectable Preparations Dilaudid inj PBS / RPBS 2mg/mL 1mL[5] 10mg/mL 1mL[5] 50mg/mL 1mL[5] 500mg/mL 1mL[5] Injectable Preparations: Alfentanil Inj [NOT ON PBS] 500mcg/ml (2ml&10ml) + 5mg/ml (1ml vial) 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!] 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] Long acting: Oral Preparations: Jurnista Tablets Once a day (do not crush or chew) 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

Drugs used in Palliative Care to Control N / V Metoclopramide D 2 Antagonist, 5HT 3 at high doses + (5HT 4 - gut) For Prokinetic Activity (Gastric stasis / External Compression) 10-20mg tds or Qid Domperidone Similar to Metoclopramide For Prokinetic Activity (Gastric stasis) & 10-20mg (But.. does not cross BBB) Parkinson disease tds or Qid Prochlorperazine D 2 receptor antagonist Used for motion sickness, post-operative vomiting. Buccal tablet 3mg is available ( Buccastem ) Haloperidol D 2 Antagonist For Biochemical Causes (Hypercalcaemia / Renal Failure / Liver impairment) 5-10mg tds 0.5mg -1mg Nocte (6mg/24 hr) Cyclizine H 1 Antagonist, For Central Causes (Increased ICP) 50mg tds Anticholinergic antagonist Levomepromazine D 2 + H 1 + 5HT 2 Antagonist + Acetylcholine 2 nd line drug due to its multiple receptor activity 6.25mg Nocte (25mg/24hr) Ondansetron 5HT 3 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

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) 1 st line: Midazolam inj sc 2.5 mg Q2H or 10-20mg via S/driver over 24 h 2 nd line: Levomepromazine via S/driver 12.5-25mg over 24h 3 rd 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?