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September 29, 2010

COPD patients' symptom burden similar to lung cancer patients
A European team of palliative care experts studied the symptoms and care needs of breathless patients with advanced cancer and chronic obstructive pulmonary disease and concluded in Journal of Palliative Medicine that the two groups suffer from high symptom burden and palliative care needs, but that COPD patients lived longer. The 49 cancer patients and 60 COPD patients studied had similarly high symptom burden, with the most prevalent symptoms in addition to breathlessness being drowsiness, lack of energy, and cough. Patients with cancer survived a median of 107 days, while the COPD patients lived for a median of 589 days. Further Information


Dying at home improves quality of life
Cancer patients dying at home have a better quality of life than patients who die at the hospital, according to a study in the Journal of Clinical Oncology. Researchers from the Dana-Farber Cancer Institute, Harvard Medical School, and Brigham and Women's Hospital in Boston conducted a prospective, longitudinal, multisite study involving 342 patients with advanced cancer and their caregivers, and found that patients who died in the hospital experienced more physical and emotional distress than those dying at home with hospice care. Caregivers of patients dying in the ICU were at greater risk than caregivers of home hospice patients for post-traumatic stress disorder, and hospital deaths were associated with greater risk of prolonged grief disorder. Further Information


NHPCO responds to CMS about proposed face-to-face rule
The National Hospice and Palliative Care Organization wrote the Centers for Medicare & Medicaid Services a 13-page letter outlining its members' concerns about CMS's proposed rule for requiring hospice physicians or nurse practitioners to have face-to-face encounters with certain patients. They asked for clarification about whether the hospice could contract with a nurse practitioner to do the visits or share resources with other hospices. They also asked for clarification about who can provide the visits, the timing of such visits, the use of telemedicine to complete the requirement, and coordination of narratives needed for certification and recertification and the face-to-face visit. NHPCO also raised concerns about the challenges of making such visits in rural areas, conducting a history of a patient's prior hospice care, and reimbursement for the face-to-face visit. Further Information

PAL-MED CONNECT CASE # 1: COPD and Anxiety
Vignette:
A 55 year old woman with severe COPD is experiencing symptoms of dyspnea and anxiety / panic. She is currently receiving MS-ER 20 mg BID with morphine concentrate 5 to 10 mg doses as needed usually using  ~100 mg / day and nebulized albuterol as needed. She was taking lorazepam for anxiety and was recently switched to alprazolam 1 mg TID due to undesirable sedating side effects from lorazepam.

How is dyspnea-related anxiety distinguished from generalized anxiety disorder (GAD)?  How should this patient be managed? Please specifically discuss role of opioids and benzodiazepines?  One of our team members suggested a midazolam drip; is that unreasonable in your experience?

Discussion:
The psychiatric specialist suggested evaluating the patient to rule out cognitive impairment.  Determine from history whether this is new or long standing anxiety and whether or not the onset of anxiety coincides with the shortness of breath. If the history is consistent with GAD, consider starting traditional treatment if there is life expectancy of months. Benzodiazepine history should be determined because she should be converted to long acting medications such as clonazepam and then tapered. Non-pharmacological interventions such as guided imagery or progressive muscle relaxation are helpful. Trazodone 25-50 mg q1hr prn anxiety can be helpful if something is needed, not to exceed 300 mg in 24 hours. It is common to have anxiety and even panic with chronic dyspnea. In addition to psychiatrist's recommendations, minimize underlying illness by treating potentially correctable causes of dyspnea, e.g., anemia, bronchospasm. Maximize traditional COPD treatment up to and including the addition of steroids and / or antibiotics if indicated. Continue to titrate opioids while trying to meet the patient's goals for level of consciousness.  Assure that albuterol overuse is not contributing to anxiety; may want to consider alternate nebulized drugs.  Since the patient is already benzodiazepine-dependent and depending on symptoms and prognosis, you may not be able to wean clonazepam.  If you wish to use midazolam instead, we have added "whiff" midazolam drips @ 0.3 - 0.5 mg/hr which provides good effect without significant sedation.  In your case, the alprazolam dose would be replaced by  ~0.25mg / hr of midazolam.  Navigante et. al., (JPSM 2006), found (morphine + midazolam ) is more effective than morphine alone in controlling baseline levels of dyspnea perception in patients with advanced cancer.

Finally, we have also used chlorpromazine as adjunctive treatment (McIver et. al., JPSM 1994 and O'Neill, et. al., Br J Clin Pharmacol 1985).

Please send your comments to info@palliativemed.org

Pal Med Connect

Spotlight supplement on palliative care beyond cancer
BMJ published a special supplement in September devoted to palliative care topics in the hope that lessons learned from end-of-life care for cancer patients can be adapted to patients dying from other conditions. A recent poll by the journal found that readers wanted to know more about palliative care beyond cancer. The first article outlines what to look for to more accurately diagnose dying. Other articles discuss talking to patients about end-of-life care and respecting the wishes of people who do not want to talk about it, understanding the spiritual needs of dying patients, and the importance of delivering high-quality care during a patient's final hours and days. Further Information


Cardiologists address patients' end-of-life care
During the 14th Annual Scientific Meeting of the Heart Failure Society of America, Larry A. Allen, MD, MHS, assistant professor at University of Colorado, presented a session about End of Life: Transition to Palliative Care. He discussed the unique nature of caring for heart failure patients nearing the end-of-life and the need for comprehensive, integrated care. "Working with the patient to manage expectations, make long-term decisions, and realize medical needs allows us to achieve our ultimate goal of improving quality of life," Allen said. "Heart failure is a highly symptomatic, case-by-case disease. Its variable nature makes the transition to palliative care difficult, but incredibly important." Further Information


Web site offers opioid prescribing advice
The Website Opioids911.org, an educational activity from Pain Treatment Topics, has posted guidance for healthcare providers prescribing opioids and using the safety education program developed by the site for patients and caregivers. The site includes an opioid-safe toolkit for providers, with materials to hand out to patients, reference documents, and addiction treatment resources. Further Information


British nurses need more education to help terminally ill patients
District nurses in the United Kingdom can play an important role in meeting cancer patients' psychological needs, but they lack the confidence and skills to do so, report nurses from the University of Manchester, School of Nursing Midwifery and Social Work and University of Cambridge Centre for Family Research in the journal Cancer Nursing. The team conducted six focus groups and observed 10 interactions between patients, their caregivers, and their nurses during home visits. During those visits, the researchers noted the nurses exhibiting avoidance behaviors when faced with patients' psychological concerns. They conclude that nurses should be taught a simple intervention based on active listening and problem solving. Further Information


Patient urges people to text donations to hospice
People all over Stourbrudge in the United Kingdom have become familiar with the face of an 80-year-old day center patient of Mary Stevens Hospice who is helping the agency raise money by encouraging people to text "Margaret" to 70099 and donate £1 to the hospice. Margaret Hill's photo is on the back of buses, telling people they can make a real difference with the simple text. Hill says that the hospice team has helped her cope with her respiratory disease and improved her quality of life. Further Information


Palliative care ICU intervention fails to improve quality of dying
A 12-center palliative care intervention designed to improve ICU end-of-life care, using clinical education, local champions, academic detailing, clinician response to quality data, and system supports failed to improve quality of dying, family satisfaction, communication, length of ICU stay prior to death, or time from admission to withdrawal of life-sustaining measures. The results were published online ahead of the print edition of the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine. "We were surprised that it was a negative study," said J. Randall Curtis, M.D., M.P.H, immediate past president of the society and lead author of the study. "It is very difficult to change busy critical care clinicians' - including both nurses and physicians - behavior patterns, because they have a lot of pressures on them. While we designed the intervention with that in mind, it was more difficult than we anticipated." The intervention focused on the clinicians' communication using a package of interventions successfully implemented at one of the institutions. The researchers found that they could not export that to other ICUs. In conclusion the authors said, "improving ICU end-of-life care will require interventions with more direct contact with patients and family." Further Information


People on the Move
George Haddad, MD, will serve as the pediatric medical director providing assistance in pediatric palliative care for Hospice Care of South Carolina...Wanda Coley has been promoted to the position of chief operating officer at the home healthcare agency WellCare. Karen Pettigrew, RN, former director of WellCare Home Care will become the director of clinical operations...A research team working on a project to improve palliative care services in First Nations communities led by principal investigators Dr. Mary Lou Kelley, research affiliate at the Centre for Education and Research on Aging and Health and professor of social work at Lakehead University, and Dr. Kevin Brazil, director of St. Joseph's Health System's Research Network and professor in the Department of Clinical Epidemiology and Biostatistics at McMaster University, has been awarded a five-year, $1.825 million Canadian Institutes of Health Research Aboriginal Health Intervention Grant...George Block, MD, a pulmonologist and intensive care unit physician who is the chief medical officer of O'Connor Hospital in San Jose, has joined the board of Hospice of the Valley, Santa Clara County, California...Helen Marie Schmidt, MD, Medical Director of the House Calls/ Mobile Medical Clinic for Family Home Care & Hospice in Washington, has been named Cambridge Who's Who Professional of the Year in Healthcare…Please send us your People on the Move news.

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