The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.

1. What Can Palliative Do For You?
Mike Aref, MD, PhD, FACP
Palliative Medicine Service, IU Health University Hospital
Assistant Professor of Clinical Medicine, Indiana University School of
Medicine

2. Disclosure of Financial Relationships and
Conflicts of Interest
None

3. TRANSPLANT
SURGERY
AND
PALLIATIVE
CARE?!?

4. “Every day with liver failure is agony. I’ve
disrupted my family’s life. It will only be worth it if
I get a transplant.”

5. “Are They Going Palliative?”
• Is a philosophy of care for seriously ill patients, it is
– NOT a place
– NOT a status
– NOT limited by curative intent

6. Suffering
Goal-of-Care

7. Suffering
Goal-of-Care
Palliative Care

8. Palliative Care
• The area of medicine that deals with
alleviating the physical, mental, spiritual and
familial suffering of patients with chronic,
progressive illness.
• Symptom management and setting goals of
care in “life-limiting” illness.
• Palliative care is concerned with three things:
the quality of life, the value of life, and the
meaning of life.
• “Sufferology”.
Doyle D, Oxford Textbook of Palliative Medicine, 3 ed.

9. Choosing Wisely
• Don’t delay palliative care for a patient
with serious illness who has physical,
psychological, social or spiritual distress
because they are pursuing disease-
directed treatment.
http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-hospice-palliative-medicine/

10. 08/27/14 10
Type Goal Investigations Treatments Setting
Active
(Blue)
To improve quality of life with possible
prolongation of life by modification of
underlying disease(s). Ex: Pt. who has
potentially resectable pancreatic carcinoma.
May require immediate symptom control or
need guidance in setting future goals.
Active (eg, biopsy,
invasive imaging,
screenings)
Surgery, chemotherapy,
radiation therapy, aggressive
antibiotic use,
Active treatment of
complications (intubation,
surgery)
In-patient facilities,
including critical
care units; Active
office follow-up
Comfort
(Green)
Symptom relief without modification of
disease, usually indicated in terminally ill
patients. Ex. Pt. who has unresectable
pancreatic carcinoma, no longer a candidate
for or no longer desires chemo or radiation
therapy.
Minimal (eg, chest
radiograph to rule out
symptomatic effusion,
serum calcium level to
determine response to
bisphosphonate
therapy)
Opioids, major tranquilizers,
anxiolytics, steroids, short-
term cognitive and behavioral
therapies, spiritual support,
grief counseling, noninvasive
treatment for complications
Home or homelike
environment
Brief in-patient or
respite care
admissions for
symptom relief and
respite for family
Urgent
(Yellow)
Rapid relief of overwhelming symptoms,
mandatory if death is imminent. Shortened
life may occur, but is not the intention of
treatment (this must be clearly understood
by patient or proxy). Ex. Patient who has
advanced pancreatic carcinoma reporting
uncontrolled pain (8 on a scale of 10),
despite opioid therapy.
Only if absolutely
necessary to guide
immediate symptom
control
Pharmacotherapy for pain,
delirium, anxiety. Usually given
intravenously or
subcutaneously and in doses
much higher than most
physicians are accustomed to
using.
Deliberate sedation may need
to be used and may need to be
continued until time of death.
In-patient or home
with continuous
professional support
and supervision
Victoria Classification of Palliative Care

11. Palliative Care and Hospice
Rosenberg, M et al, Clin Geriatr Med 2013; 29:1–29
Palliative Care
Symptom Management of Life Limiting Illness
End of Life Care/Hospice
Symptom Management and Comfort Care

12. Palliative Perception
 The patient:
– is not a candidate for curative therapy
– has a life-limiting illness and chosen not to have life prolonging
therapy
– has uncontrolled symptoms
– has uncontrolled psychosocial or spiritual issues
– has been readmitted for the same diagnosis in last 30 days
– has prolonged length of stay without evidence of progress
– has Catch-22 criteria: the indicated treatment of one potentially
fatal problem is contraindicated by another
http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/ Central Baptist Hospital Palliative Care Screening Tool

13. DO IT!
Palliative care is like intubation, if you think it
needs to be done,

14. And not or
 Of the 151 patients who underwent
randomization, 27 died by 12 weeks and
107 (86% of the remaining patients)
completed assessments. Patients
assigned to early palliative care had a
better quality of life than did patients
assigned to standard care (mean score
on the FACT-L scale [in which scores
range from 0 to 136, with higher scores
indicating better quality of life], 98.0 vs.
91.5; P=0.03). In addition, fewer patients
in the palliative care group than in the
standard care group had depressive
symptoms (16% vs. 38%, P=0.01).
Despite the fact that fewer patients in
the early palliative care group than in
the standard care group received
aggressive end-of-life care (33% vs.
54%, P=0.05), median survival was
longer among patients receiving early
palliative care (11.6 months vs. 8.9
months, P=0.02).

15. Quality has quantitative benefit
 Poor pain control is associated with
delayed wound healing.
 After bypass surgery, depressive
symptoms are associated with infections,
impaired wound healing, poor emotional
and physical recovery.
 Interventions to reduce the patient's
psychological stress level may improve
wound repair and recovery following
surgery. McGuire L, Ann Behav Med, 2006;31(2): 165-72
Doering LV, Am J Crit Care, 2005;14(4): 316-24
Broadbent E, Psychosom Med, 2003; 65(5): 865-9

16. Curative and Palliative
Sympto
m
YesNo
Disease
modifiable
?
Review
Alleviate symptom
through disease-
specific intervention
Alleviate symptom
through
global/systemic
intervention
J Palliat Med. 2012; 15(1):106-14

17. Curative or Palliative?
• Morphine
– No mortality benefit.
• Oxygen
– No mortality benefit (unless hypoxic).
• Nitrates
– No mortality benefit.
• Aspirin
– OK, now we start decreasing mortality (anti-platelet effects onset
of action is 2 hours, analgesic effect is 10-15 minutes).

18. Total Symptoms
Pain
• Physical problems (multiple)
• Anxiety, anger and depression—
elements of psychological distress
• Interpersonal problems — social
issues, financial stress, family
tensions
• Nonacceptance or spiritual
distress
Dyspnea
• Physical symptoms
• Psychological concerns
• Social impact
• Existential suffering
Curr Opin Support Palliat Care. 2008; 2(2):110-3

19. Physical
Cause?
Assoc. Sx
Debility and Fatigue
Social
Role
Relationship
Occupation
Financial Cost
Spiritual
Existential
coping
Religious
beliefs
Meaning of
life/illness
Personal value
Psychological
Emotional
Response
Comorbid mood
disorder ± anxiety
Adjustment to new
baseline
Symptom
Chaplaincy
Art & Music Therapy
Social Work
Financial Navigator
Occupational Therapy
Social Work
Psychology
Psychiatry
Acute Pain Service
Chronic Pain Service
Palliative Care
Other Specialties
Pharmacy
Physical Therapy

20. Maslow’s Hierarchy of Needs
Self-Actualization
Esteem
Love / Belonging
Safety
Physiological
Physical
Psych
Social
Spiritu
al

21. FICA
• Faith and Belief
Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs that
help you cope with stress?" If the patient responds "No," the health care provider might
ask, "What gives your life meaning?" Sometimes patients respond with answers such as
family, career, or nature.
• Importance
"What importance does your faith or belief have in our life? Have your beliefs
influenced how you take care of yourself in this illness? What role do your beliefs play in
regaining your health?"
• Community
"Are you part of a spiritual or religious community? Is this of support to you and how?
Is there a group of people you really love or who are important to you?" Communities
such as churches, temples, and mosques, or a group of like-minded friends can serve as
strong support systems for some patients.
• Address in Care
"How would you like me, your healthcare provider, to address these issues in
your
healthcare?"
Spiritu
al
http://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool

22. Social Factors
• Tail-light Test
• Transitions of Care
– Communicating with patient, family, and
provider
22
Social

23. Physiologic versus Pathologic
Emotions
• Happiness
• Sadness
• Anger
• Fear
Disorders
• Bipolar with mania
• Depression / Bipolar
• Anxiety
• Personality disorders
Psychologica
l

24. Hospital Anxiety and Depression Scale
Psychologica
l

25. 2-for-1 Specials
• Itching + anxiety = hydroxyzine
• Neuropathic pain + muscle spasm = gabapentin
• Neuropathic pain + anxiety = pregabalin
• Depression + neuropathic pain = duloxetine
Physical

26. Nausea
Cause Receptors Drug Classes Examples
Vestibular Cholinergic, Histaminic
Anticholinergic,
Antihistaminic
Scopolamine patch,
Promethazine
Obstipation
Cholinergic, Histaminic,
likely 5HT3
Stimulate myenteric
plexus
Senna products
Motility
Cholinergic, Histaminic,
5HT3, 5HT4
Prokinetics which
stimulate 5HT4
receptors
Metoclopromide
Infection/Inflammation
Cholinergic,
Histaminic, 5HT3,
Neurokinin 1
Anticholinergic,
Antihistaminic, 5HT3
antagonists, Neurokinin
1 antagonists
Promethazine (e.g. for
labyrinthitis),
Prochlorperazine
Toxins Dopamine 2, 5HT3
Antidopaminergic,
5HT3 Antagonists
Prochlorperazine,
Haloperidol,
Ondansetron
Physical

27. Nausea
• Menthol salve for olfactory-induced nausea
• Wean IV anti-emetics for at least 24 hours prior to
discharge
• Oral anti-emetics for nausea prophylaxis
• Sublingual and rectal for acute nausea
Physical

28. Pain Classifications
Somatic
(Nocioceptive)
Visceral
(Nocioceptive)
Neuropathic
(Central)
Neuropatic
(Peripheral)
Psychogenic
Etiology
Skin and Deep
Tissue Damage
Organ Damage Nerve Damage Nerve Damage
Primary
psychological origin
or worsening due to
mood disorder
Temporal
Dependence
Acute or
Chronic
Acute
Chronic >
Acute
Chronic >
Acute
Acute or
Chronic
Characteristics
Localized dull
or aching
Diffuse, referred to
superficial structure,
sickening, deep,
squeezing, and dull
Burning, coldness, "pins n’
needles", numbness and itching
Mixed, non-
physiologic
Examples
Fibromyalgia
Tension headache
Chronic back pain
Arhtritis
Irritable Bowel Syndrome
Cystitis
Prostate Pain
Endometriosis
Central pain
syndrome 2°
stroke, MS, tumor
Diabetic neuropathy
Shingles
Complex regional
pain syndrome
Depression
Anxiety
Adjustment
disorders
Opioids First line First line Third line Second line No
Physical

29. Neuropathic Pain Criteria
Am J Med. 2009 Oct;122(10 Suppl):S3-12

30. Start Smart
• What type of pain are we managing?
• What was their level of function and regimen prior to
this hospitalization?
• Why not PO? (IV keeps you in the hospital)
• What is your patient’s goal?
• What is the plan and is everyone in agreement?

31. Opiates…
• Do not cure anything (at best they are neuro-
hormonal-psychiatric scaffolding)
• Are poor choice for neuropathic pain
• Have abuse / “self-medicating” potential
• Have social stigma

32. Dose Units Medication Route Real World
15 mg morphine PO
15 mg hydrocodone PO
10 mg oxycodone PO
4 mg hydromorphone PO
5 mg morphine IV
0.75 mg hydromorphone IV
50 mcg fentanyl IV
Dose Equivalents

33. Dose Equivalents

34. WHO Analgesic Ladder
Canadian Family Physician 2010; 56(6):514-517

35. Ascending the Ladder
• Morphine
– Initial loading dose of 0.1 mg/kg
– Subsequent dosages of 0.025 to 0.05 mg/kg every 5 minutes
• Hydromorphone
– Initial loading dose of 0.015 mg/kg hydromorphone
– Subsequent dosages of 0.0075-0.015 mg/kg every 5-15
minutes
• Fentanyl
– Initial loading dose of 1-1.5 µg/kg
– Subsequent dosages of 0.25-0.5 µg/kg every 15 minutes
75 kg 90 kg
Loading Dose PRN Loading Dose PRN
morphine 7.5 mg 2-4 mg 9 mg 2.5-5 mg
hydromorphone 1 mg 0.5-1 mg 1.5 mg 0.75-1.5 mg
fentanyl 75-100 µg 20-50 µg 100-150 µg 25-75 µg
http://www.medscape.com/viewarticle/720539

36. Patient Controlled Analgesia
• If analgesia is reached with 3 bolus doses,
the patient controlled analgesia (PCA)
equivalent is approximately:
Q12min dose 4° lockout
morphine 0.8-1 mg 16-20 mg
hydromorphone 0.15-0.25 mg 3-5 mg
fentanyl 20-30 µg 400-600 µg

38. Descending the Ladder
• PCA can probably be weaned if one
vial is enough for > 24 hours.
• Wean IV doses by 10-33% per day.
• Wean PO dose by 25-50% per day
until 1-2 tablets Q4H of “low” dose
medication then wean dosing
interval:
✓ Q6H-Q8H-Q12H-QHS
✓ 16 “doses”
http://paincommunity.org/blog/wp-content/uploads/Safely_Tapering_Opioids.pdf

39. Day Frequency morphine (mg)
hydromorphone
(mg)
fentanyl (mcg)
1 Q2H 30 4 300
2 Q2H 20 3 200
3 Q2H 15 2 150
4 Q2H 10 1.5 100
5 Q2H 7.5 1 75
6 Q4H 30 8
oxycodone (mg)
20
7 Q4H 15 4 10
25% 50%
Example Opiate Wean

40. Opiate-Induced Bowel Dysfunction
Prophylaxis
• Non-pharmacological
– Oral hydration
– Physical activity
– Privacy/scheduled visit to commode
• Pharmacological
– Scheduled senna (stimulant laxative), hold for diarrhea
– Scheduled bisacodyl (stimulant laxative), hold if bowel
movement in the past 24°
– Scheduled MOM (or lactulose if kidney disease) or
polyethylene glycol (osmotic stool softener), hold if bowel
movement in the past 48°
– Do NOT use bulk producers (i.e. fiber)
– Consider adding mineral oil (lubricating stool softener)
http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf

41. COMPLICATIONS OF OPIATES

42. Case
• 23 y/o WF with chronic abdominal pain, nausea, and
food aversion secondary to multiple surgeries for
hereditary pancreatitis and complications thereof.
• Non-malignant abdominal pain managed with
progressive increases in opiates, now on high-dose
opiates, 200 mcg/hr fentanyl patch with 4-8 mg of
hydromorphone as needed every 2-3 hours
• Mother strong advocate for patient.
• Consulted for pain management.

43. How is she not dead?!?

44. CDC Grand Rounds, January 13, 2012 / 61(01);10-13

45. Course
• Basal opiates increased and discharged home
• Patient seen on subsequent hospitalizations for other
complications, e.g. line infection, portal vein
thrombosis. Abdominal pain continues to worsen.
• Having built a relationship with patient, discussed
concerns that opiates were worsening her pain.
Agreeable to weaning off opiates.

46. Narcotic Bowel Syndrome
Chronic or frequently recurring abdominal pain that is treated with acute
high dose or chronic narcotics and all of the following:
• The pain worsens or incompletely resolves with continued or
escalating dosages of narcotics.
• There is marked worsening of pain when the narcotic dose wanes
and improvement when narcotics are reinstituted (“Soar and
Crash”).
• There is a progression of the frequency, duration and intensity of
pain episodes.
• The nature and intensity of the pain is not explained by a current or
previous gastrointestinal diagnosis*
*A patient may have a structural diagnosis (e.g., inflammatory bowel
disease, “chronic pancreatitis”) but the character or activity of the
disease process is not sufficient to explain the pain.
Clin Gastroenterol Hepatol. Oct 2007; 5(10): 1126–1122.

47. Case
• 72 y/o WM with metastatic pancreatic cancer, admitted
for pain control.
• Patient has been on rapidly escalating doses of
morphine. Delirious, in his lucid moments he weeps,
morphine has been aggressively increased. In the past
24 hours he developed intermittent jerking of his limbs.
• Consulted for pain management.

48. Opiate-Induced Hyperalgesia
• Increasing sensitivity to pain stimuli (hyperalgesia).
Pain elicited from ordinarily non-painful stimuli, such as
stroking skin with cotton (allodynia).
• Worsening pain despite increasing doses of opioids.
• Pain that becomes more diffuse, extending beyond the
distribution of pre-existing pain.
• Presence of other opioid hyperexcitability effects:
myoclonus, delirium or seizures.
• Can occur at any dose of opioid, but more commonly
with high parenteral doses of morphine or
hydromorphone and/or in the setting of renal failure.
www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_142.htm

49. Course
• Patient was switched to fentanyl, but at 75%
equianalgesic dose.
• Pain controlled, delirium improved, myoclonic jerks
resolved.
• Patient died on in-patient hospice.

50. THANK YOU
Questions? Concerns? Comments?