Aggressive Symptom Management and Palliative Sedation

Aggressive Symptom Management and Palliative Sedation

6. D.V., a 35-year-old man with gastric cancer metastasized to the esophagus with periaortic involvement is hospitalized. He was diagnosed 10 months ago, and his disease has progressed despite multiple courses of chemotherapy (most recently, irinotecan and Erbitux). A double-lumen peripherally inserted central catheter line has been inserted. He has lost 65 lb since diagnosis, weighs 150 lbs at 6 ft tall, and presents with abdominal pain, severe nausea, vomiting, obstipation (intractable constipation), and general malaise. D.V. describes his pain as a 7/10 in intensity and as “burning like a knife through my stomach.” He uses 50 to 75 patient-controlled analgesia (PCA) bolus doses Q 24 hr. He has no other medical problems. D.V. is referred to hospice care because he and his wife have agreed to stop chemotherapy and do not want to go back to the hospital. He states a history of allergic reactions to morphine, ondansetron, and diphenhydramine, although these reactions are not noted. He is presently receiving hydromorphone 2 mg/hour in an IV infusion with 1 mg PCA bolus dose Q 5 min, hydromorphone 4 mg PO Q 4 hr PRN pain, fentanyl transdermal 275 mcg/hour Q 3 day, ketamine 20 mg PO Q 3 hr, senna two tablets PO BID, docusate sodium 250 mg PO BID, MiraLax 17 g PO daily, lactulose 15 mL PO PRN constipation, lorazepam 2 mg PO Q 4 hr PRN nausea or vomiting, metoclopramide 10 mg Q 6 hr PRN nausea or vomiting, promethazine 25 mg IV Q 4 hr PRN nausea or vomiting, baclofen 10 mg Q 8 hr as needed for hiccups, and Protonix 40 mg once daily. What is your assessment of his medication regimen?

D.V.'s drug regimen is unnecessarily complicated for a patient at home. It may be possible to simplify it by looking at each problem anew. His pain is poorly managed as evidenced by his complaint of pain intensity at 7/10 (on a scale of 0-10), the use of multiple opioids, and the use of excessive PCA boluses. Once an infusion with PCA dosing is started, there is no need to continue other long-acting opioids (i.e., transdermal fentanyl), or oral agents for breakthrough pain. The PCA doses are serving as the rescue doses for breakthrough pain, and pain relief should be titrated using this method alone. Once pain is well controlled, an oral long-acting agent can be considered if the patient is able to swallow. To do otherwise creates a chaotic approach. Patients reporting allergic reactions to opioids should be carefully asked to describe the precise nature of the purported allergic reaction. True allergies to opioids are rare; patients often refer to an adverse reaction as an allergy or have experienced an effect from the histamine release that is associated with opioids. Hydromorphone, especially injectable hydromorphone, is much more expensive than morphine and is best reserved for use in patients who have a genuine allergy to morphine.

Although D.V. had been prescribed ketamine Q 3 hr in the hospital, it is unrealistic to expect that this can be continued in the home setting. D.V. and his wife would probably be glad to discontinue it and replace it with an alternative due to his need to be dosed Q 3 hr.

D.V.'s constipation is currently treated with multiple medications within the same therapeutic class. It would be more prudent to maximize the use of a single agent within a category, rather than using two at less than the maximally recommended dose. D.V. can use a higher dose of senna (up to four tablets BID), and then, if necessary, add sorbitol (which is more cost effective than lactulose).

D.V. also takes multiple medications for his nausea and vomiting. The injectable promethazine can be converted to suppositories for use at home. He had also been directed to take lorazepam for his nausea and vomiting; however, benzodiazepines are not effective antiemetics. They are given to manage the anxiety associated with nausea and vomiting, and are particularly useful in managing the anticipatory nausea and vomiting that is commonly encountered during chemotherapy administration. Metoclopramide can be useful for D.V.'s nausea and vomiting if his physical examination reveals hypoactive bowel sounds. It is also useful for treating hiccups, and the need for baclofen can be reassessed.

7. A few days after arriving home, D.V. asks his hospice nurse, “Can't you just give me something to end it all?” He has not been sleeping well, is tired of taking so many medications, and wants to alleviate the burden he feels he is imposing on his wife.

In patients who are terminally ill, suffering may continue despite maximal palliative efforts. As a result, practitioners continually encounter patients' requests for the ending of their lives because of overwhelming suffering. Although controversial, most clinicians are significantly averse to this practice both ethically and legally.^62-67 State and national professional organizations have not been helpful in providing guidance for managing this ultimate end-of-life decision. Each clinician, therefore, must rely on his or her own ethics to decide whether to participate in facilitating a patient's death. Although substantial numbers of clinicians can imagine situations in which assisted suicide would be acceptable, few are willing to actively participate in the ending of a patient's life.^68,69

In a small number of patients, it may be desirable to reduce suffering by the thoughtful use of medications to induce sedation. It is not appropriate to increase opioid doses to achieve the desired sedated state. Medications used successfully to induce sedation for these patients include benzodiazepines, barbiturates, and phenothiazines. No drug or drug class is superior to any other for this use.⁷⁰

A trial of palliative sedation with lorazepam could be initiated at a rate of 2 mg/hour and gradually increased if needed to as much as 6 mg/hour. Although palliative sedation has a small potential to shorten life, the need to relieve terminal agitation could justify this risk. Palliative sedation should only be initiated as a last resort in severe cases not responsive to other palliative measures, and only after thorough discussion of the important clinical and ethical issues with the patient, family, and other clinical team members.

8. Repeated increases in the hydromorphone infusion basal rate (he is now at 25 mg/hour) had little effect on managing D.V.'s pain, and his consistent use of up to 120 PCA attempts over 24 hours reflects his continued pain. He describes the intensity of his pain as 8/10 (on a 0-10 scale). Before considering palliative sedation, what other therapeutic interventions can be implemented for D.V.?

Before considering palliative sedation, patients should be thoroughly assessed for insomnia and depression. Underlying reasons for insomnia should be explored and treated. Poor pain management is often to blame. In this patient, lidocaine 0.5 to 1 mg/kg/hour administered intravenously or subcutaneously might be useful to assist in the management of his severe neuropathic pain.^71-75 Lidocaine purportedly interrupts pain transmission by blocking sodium channels (see Chapter 8).

Clinical Result. D.V. was started on lidocaine 1 mg/kg/hour intravenously. A bolus dose was not given due to the short

P.6p10

half-life of lidocaine. Overnight, his use of hydromorphone boluses dropped to one. He now reported his pain as 1/10 and slept through the night for the first time in months. Over the next 2 days, the hydromorphone basal rate was tapered to 5 mg/hour. He did not develop any toxicity, such as perioral numbness, metallic taste, or somnolence. D.V. continued on lidocaine, using no hydromorphone boluses for the next 2 weeks until he died at home, surrounded by his family.

Resources for Hospice and Palliative Care

The following websites are resources for practitioners who want more information on hospice and palliative care:

• American Academy of Hospice and Palliative Medicine (AAHPM): www.aahpm.org/
• Center to Advance Palliative Care (CAPC): www.capc.org/
• Centers for Medicare & Medicaid Services (CMS): www.cms.hhs.gov/center/hospice.asp
• End-of-Life/Palliative Education Resource Center (EPERC): www.eperc.mcw.edu/staff.htm
• Hospice Foundation of America (HFA): www.hospicefoundation.org/
• Innovations in End-of-Life Care (an international journal of leaders in end-of-life care): www2.edc.org/lastacts/
• International Association for Hospice & Palliative Care (IAHPC): www.hospicecare.com/
• MedlinePlus Hospice Care: www.nlm.nih.gov/medlineplus/hospicecare.html
• National Hospice and Palliative Care Organization (NHPCO): www.nhpco.org/
• Pallimed, A Hospice and Palliative Medicine Blog: www.pallimed.org
• The Population-based Palliative Care Research Network (PoPCRN): www.uchsc.edu/popcrn/
• U.S. Department of Veterans Affairs, Office of Geriatrics and Extended Care, Hospice and Palliative Care: www1.va.gov/geriatricsshg/page.cfm?pg=65

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