tag:blogger.com,1999:blog-70030733744052370232024-02-20T13:26:47.950-06:00Fast Facts and Concepts Discussion BlogA discussion and feedback blog about Fast Facts and Concepts, a series of peer-reviewed monographs on palliative care topics.Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comBlogger34125tag:blogger.com,1999:blog-7003073374405237023.post-5459300427367105902013-02-04T16:44:00.000-06:002013-02-04T16:44:53.638-06:00test from google docs<iframe src="https://docs.google.com/document/d/1xkW2phRHpFfQsAECl37ZYODOp-LStsMjoxVXxLjGe5E/pub?embedded=true"></iframe>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-11679984474235254982010-04-05T11:53:00.000-05:002010-04-05T11:53:50.074-05:00#229 Seizure Management in the Dying Patient<div style="text-align: center;">FAST FACTS AND CONCEPTS #229</div><div style="text-align: center;"></div><div style="text-align: center;"><br />
</div><div style="text-align: center;">SEIZURE MANAGEMENT IN THE DYING PATIENT</div><div style="text-align: center;"><br />
</div><div style="text-align: center;">Jennifer Connelly MD and David E Weissman MD</div><br />
<strong>Background</strong><br />
Management of seizures in the dying patient without intravenous access, such as is in the home environment, is challenging. Seizures in this population can be due to primary or metastatic brain cancers, strokes, toxic/metabolic causes including hypoglycemia, or pre-existing seizure disorders. The actual incidence of seizures in dying patients is unknown, and while likely uncommon, they can cause tremendous distress to patients and families. This Fast Fact reviews management strategies for seizures near the end of life. <br />
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<strong>Seizure Prophylaxis</strong><br />
Up to 40% of patients with brain tumors have a seizure at the time of diagnosis and another 20% develop seizures during the course of the illness. Although antiepileptic drugs (AEDs) are commonly started as prophylaxis at the time of brain tumor diagnosis, they have not been found to prevent seizures and the American Academy of Neurology Clinical Practice Guidelines do not support this practice (1). Thus, prophylactic AEDs can be safely discontinued in patients with brain tumors who have never had a seizure. For patients with a seizure history, including those with brain tumors, AEDs should be continued as long as possible. For patients who lose an enteric route and have no intravenous access, rectal administration of prophylactic AEDs is possible. Clinical judgment should be used as to whether to continue AEDs in this setting; it can be appropriate to simply stop them, particularly if the patient’s prognosis is very short. Phenobarbital, pentobarbital, carbamazepine, valproic acid, and lamotrigine can all be given rectally. Rectal absorption of other prophylactic AEDs is undefined and they should not be administered. None of the aforementioned AEDs need dose adjustments for rectal administration. Carbamazepine should be divided into small doses administered 6-8 times a day. Lamotrigone is administered rectally by crushing and suspending the chewable tablets in 10 mL of water. When clinically indicated, drug levels of lamotrigine should be monitored as rectal absorption is erratic.<br />
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<strong>Seizure Management</strong><br />
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• Single self-limited seizure: Check for treatable causes such as hypoglycemia. If no reversible cause is identified, initiation of maintenance AED therapy should be considered, particularly if the patient is expected to survive more than a few weeks.<br />
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• Acute seizure or status epilepticus: <br />
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o Non-intravenous routes: Rectal diazepam (0.2 mg/kg or 10-20mg) is the drug of choice for status epilepticus and acute seizures lasting greater than two minutes due to its bioavailability, ease of administration, and short time to peak serum concentration (< 20 minutes). Diazepam can be repeated hourly until the seizure stops. Some authors suggest continuing 20 mg per rectum nightly to reduce the occurrence of further seizure events. Other rectal benzodiazepines are available (clonazepam, lorazepam, and midazolam), but take longer to reach peak serum levels. Sublingual lorazepam and intranasal midazolam are also available, but their use in the adult population is not well-studied. <br />
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o Parenteral therapy: When available, intravenous and subcutaneous benzodiazepines can be used and are usually effective at stopping a seizure in progress; intravenous lorazepam is preferred due to its long half-life. Clonazepam and midazolam can be given subcutaneously at doses similar to the intravenous route. If seizure activity persists, additional anti-epileptic medication should be provided using a loading and then maintenance dose. Patients with refractory seizures who have short prognoses and comfort-oriented goals of care should be considered for an anti-epileptic sedative such as midazolam or a barbiturate with the goal of deep sedation (see Fast Facts #106,107).<br />
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<strong>Parenteral AED Dosing and Routes:</strong><br />
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Drug Status loading dose Maintenance dose<br />
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Diazepam 0.2 mg/kg or 10-20 mg PR 20 mg PR nightly<br />
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Lorazepam 0.1 mg/kg IV or IM<br />
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Midazolam 0.1-0.3 mg/kg IV or SC Titrate to control refractory seizures if needed<br />
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Clonazepam 1 mg IV or SC <br />
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Phenytoin 20 mg/kg IV 4-5 mg/kg/day IV divided TID<br />
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Fosphenytoin 20 mg/kg IV or IM 4-5 mg/kg/day IV or IM divided TID<br />
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Phenobarbital 10-15 mg/kg 1-3 mg/kg/day IV or IM<br />
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1200 mg/day SC (2)<br />
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<strong>Family Education</strong> <br />
Family members should be counseled that all medications used to manage seizures can cause sedation and cardiopulmonary depression. Family members who have witnessed prior seizures often have great fear about seizure recurrence. Many hospice agencies have established seizure protocols and medication kits which can be stored at home, and will collaborate with physicians and families on establishing a ‘seizure plan’ for acute seizures. It is important to review with the family seizure safety, including not putting anything in the patient’s mouth and making sure the patient is in a safe environment. <br />
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<strong>References</strong><br />
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1. Glantz MJ, Cole BF, Forsyth PA, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol. 2000; 54:1886-1893.<br />
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2. Krouwer H, Pallagi J, Graves N. Management of seizures in brain tumor patients at the end of life. J Palliat Med. 2000;3:465-475.<br />
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3. Davis M, Walsh D, LeGrand S, et al. Symptom control in cancer patients: the clinical pharmacolog and therapeutic role of suppositories and rectal suspensions. Support Care Cancer. 2002; 10:117-138.<br />
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4. Brown L, Bergen DC, Kotagal P, et al. Safety of Diastat when given at larger-than-recommended doses for acute repetitive seizures. Neurol. 2001; 56:1112.<br />
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5. Voltz R, Borasio GD. Palliative therapy in the terminal stage of neurological disease. J Neurol. 1997; 244[Suppl 4]:S2-S10.<br />
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6. Droney J, Hall E. Status epilepticus in a hospice inpatient setting. J Pain Symptom Manage. 2008; 36:97-105.<br />
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Author Affiliations: Medical College of Wisconsin, Milwaukee, WI.<br />
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Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com). <br />
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Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Connelly J, Weissman DE. Seizure Management in the Dying Patient. Fast Facts and Concepts. April 2010; 229. Available at: http://www.eperc.mcw.edu/fastfact/ff_229.htm.Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-83385538192595908872010-04-05T11:51:00.000-05:002010-04-05T11:51:13.218-05:00#228 Tapentadol<div style="text-align: center;">FAST FACTS AND CONCEPTS #228</div><div style="text-align: center;"><br />
</div><div style="text-align: center;">TAPENTADOL</div><div style="text-align: center;"><br />
</div><div style="text-align: center;">Rohtesh S Mehta MD, MPH and Robert M Arnold MD</div><br />
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<strong>Background</strong> <br />
Tapentadol is a newly available oral analgesic, approved by the FDA in 2009 for the management of moderate to severe acute pain in adults. This Fast Fact reviews its pharmacology and use.<br />
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<strong>Pharmacology </strong><br />
Tapentadol is a centrally-acting, synthetic, oral mu-opioid receptor agonist which also inhibits norepinephrine and serotonin reuptake within the CNS. It is structurally and pharmacologically similar to tramadol. <br />
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Oral bioavailability ranges from 32% to 42%, with a half-life of 4 ½ hours. <br />
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The drug is metabolized in the liver (97% by Phase-2 conjugation) and excreted in the urine. <br />
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Tapentadol has no known pharmacologically active metabolites, no relevant CYP interactions, and no drug-drug interactions through cytochrome induction or inhibition (1). <br />
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There are no dosing adjustments required in mild-to-moderate renal or hepatic failure; it has not been studied in patients with severe impairments. <br />
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<strong>Research Data</strong> <br />
The FDA approval was based on two industry-coordinated, randomized controlled studies conducted in patients with osteoarthritis and after bunionectomy. In these studies 50 mg doses of tapentadol was shown to be non-inferior to 10 mg of oxycodone immediate-release in the treatment of pain, but the incidence of nausea, vomiting, dizziness, and constipation was significantly lower (2,3). In another single-dose study involving patients undergoing molar extraction, tapentadol 200 mg demonstrated improved analgesia but higher sedation than 60 mg of oral morphine (4). Total daily doses greater than 700 mg on the first day of therapy and 600 mg on subsequent days have not been tested, nor has tapentadol been studied in children. Tapentadol has not been tested in cancer pain or in palliative care settings. There are not enough data to comment on whether the drug has a ceiling effect, or on its long-term safety and efficacy (the longest study was only 90 days). Finally, it has not been comparatively studied against tramadol.<br />
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<strong>Side Effects and Cautions</strong> <br />
Tapentadol’s side effect profile is generally similar to opioids’ (although with milder GI side effects): nausea, vomiting, constipation, respiratory depression, pruritus, dizziness and drowsiness. As with tramadol, there is a theoretical increased risk of seizures, as well as serotonin syndrome if given with other serotonergic agents (e.g. antidepressants, drugs with monamine oxidase inhibitory effects). Abuse and addiction are possible as with any opioid agonist. An abstinence syndrome has not yet been described; in one study drug tapering was not required after 90 days of treatment (2). <br />
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<strong>Dosing and Cost</strong> <br />
Tapentadol is available as 50, 75 and 100 mg immediate-release tablets. The initial dose is 50-100 mg every 4 hours (although a second dose can be given one hour after the initial dose). The average wholesale pricing for tapentadol is approximately $2 per 50 mg tab, $2.40 per 75 mg tab, and $3.20 per 100 mg tab. For comparison, tramadol costs $0.07/tab (50 mg), oxycodone costs $0.70 (15 mg tab), and morphine costs $0.18 (15 mg tab). <br />
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<strong>Summary</strong> <br />
Tapentadol is a novel analgesic, with a 50 mg dose similar in efficacy to 10 mg of oxycodone. Currently its only clearly defined benefit over established opioids is its gentler GI side effect profile. Its cost, potential ceiling effect, safety concerns with drug interactions, and uncertainty about long-term efficacy and safety limit its current application otherwise, particularly in patients with chronic cancer pain. <br />
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<strong>References</strong><br />
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1. Kneip C, Terlinden R, Beier H, Chen G. Investigations into the drug-drug interaction potential of tapentadol in human liver microsomes and fresh human hepatocytes. Drug Metab Lett. 2008; 2(1):67-75. PMID: 19356073.<br />
2. Hale M, Upmalis D, Okamoto A, Lange C, Rauschkolb C. Tolerability of tapentadol immediate release in patients with lower back pain or osteoarthritis of the hip or knee over 90 days: a randomized, double-blind study. Curr Med Res Opin. 2009; 25(5):1095-104. PMID: 19301989<br />
3. Daniels S, Casson E, Stegmann JU, Oh C, Okamoto A, Rauschkolb C, Upmalis D. A randomized, double-blind, placebo-controlled phase 3 study of the relative efficacy and tolerability of tapentadol IR and oxycodone IR for acute pain. Curr Med Res Opin. 2009; 25(6):1551-61. PMID: 19445652.<br />
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4. Kleinert R, Lange C, Steup A, Black P, Goldberg J, Desjardins P. Single dose analgesic efficacy of tapentadol in postsurgical dental pain: the results of a randomized, double-blind, placebo-controlled study. Anesth Analg. 2008; 107(6):2048-55. PMID: 19020157.<br />
Author Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA.<br />
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Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc. <br />
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Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Rohtesh MS, Arnold RM. Tapentadol. Fast Facts and Concepts. XXXX 2010; 228. Available at: http://www.eperc.mcw.edu/fastfact/ff_228.htm.Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-59419500580504344112010-02-05T09:10:00.002-06:002010-02-05T09:11:44.637-06:00#227 The Family Meeting: End of Life Goal Setting and Future Planning<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #227<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">The Family Meeting: end of life Goal Setting and Future planning<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">David E Weissman MD, <span class="style91"><span style="">Timothy E Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></span></b></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><span style=""> </span>End-of-life goal setting is a key palliative care skill, typically occurring as part of a family meeting (see <i style="">Fast Facts </i>#16, 65, 222-226).<span style=""> </span>This <i style="">Fast Fact</i> discusses an approach to goal setting when the expected length of life is short. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Establishing patient-centered goals</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Here is an example of how to start the conversation (the patient should be given sufficient time to respond to each of these questions): <o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">I/we have discussed your current condition and that time may be short.<span style=""> </span>With that in mind – <o:p></o:p></span></i></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">What are you hoping for now?<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">What is important to you?<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">What do you need to accomplish?<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Who do you need to see in the time that is left?</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></li></ul> <p class="MsoNormal" style="margin-top: 6pt;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Common responses invoke family, home, and comfort; often surviving until a specific future family event/date or visit with a key family member is described as an important goal.<span style=""> </span>Re-state your understanding:<span style=""> </span><i style="">What I hear you saying is that you want to be home, comfortable, and survive until your daughter gives birth – you hope to meet your next grandchild</i>.<span style=""> </span><b>Note:</b> if you believe the patient’s goal of survival to a specific event/date is not practical, it is important to say so and discuss alternative plans.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Recommend a care plan based on the goals<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Once the goal(s) is/are established, you can then review the patient’s current treatments (e.g. antibiotics, chemotherapy), monitoring (e.g. pulse oximetry), planned tests (e.g. colonoscopy), and medications (e.g. anti-hypertensives), and decide which will help meet, or not, the patient’s goals.<span style=""> </span>Anything that will not help meet the goals should be discussed for potential discontinuation. Depending on the specific disease/patient condition, other issues that are naturally discussed at this point include:<o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Future hospitalizations, ICU admissions, laboratory and radiology tests.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Resuscitation orders/code status (see <i style="">Fast Facts </i>#23-24).<span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Current/future use of blood products, antibiotics, artificial hydration/nutrition.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">If present, the potential continuation or stopping of dialysis or cardiac devices.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Role of a second (or third) opinion. <o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Exploration of experimental therapy.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Exploration of treatment options the patient or family may bring into the conversation.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disposition options to best meet the goals (e.g. home hospice referral).<o:p></o:p></span></li></ul> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Note:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> There is <i style="">no</i> need to ask about each option as a yes/no question (<i style="">Do you want blood products?</i>).<span style=""> </span>Based on what you know about the patient’s goals, make a recommendation about what should and should not be done in light of the patient’s goals, condition and prognosis. If you are unsure, you can explore the issue with the patient/family (<i style="">Given that your dad wanted to get home as soon as possible and yet he was also willing to do easy things that might help him live longer, I am unsure whether it makes sense to stay in the hospital an extra day or two to finish the antibiotics. What do you think he would say?</i>).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">‘Long-shot’ goals<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">If patients are going to pursue ‘long-shot’ or experimental therapy, perhaps even against the recommendation of the treating team, it is useful to ensure the following:<o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Reinforce the team’s respect for the decision, and desire to make sure the treatment has the best possible chance of working.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Simultaneously try to maximize quality of life <i style="">in the present</i>, including the best possible pain and symptom management and support.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Encourage the patient and family to prepare in case treatment is not successful and the patient dies sooner rather than later.<span style=""> </span>Useful language is to say, <i style="">I’d encourage us all to hope for the best, but prepare for the worst</i>.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Reinforce that the team will not abandon the patient and family even if the decision is not what is being recommended.<o:p></o:p></span></li></ul> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Close the meeting<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Following this discussion, restate your understanding of the patient’s goals and agreed-upon next steps to meet those goals, invite and answer questions, and close the meeting.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Discussion & documentation<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Discuss the goals with key staff not in attendance (e.g. consulting physicians, patient’s nurse, discharge planner, primary care provider).<span style=""> </span>Document the goals, preferably using a templated family meeting note (see Reference 1): who was present, what was discussed (e.g. treatment options, prognosis), what was decided, next steps.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Debriefing</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>A useful step after every family meeting is to debrief the process – what went well, what could have been improved and, most importantly, addressing the emotional reaction and needs of the care team. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Clinical Tools.<span style=""> </span>Center to Advance Palliative Care.<span style=""> </span>Available at: <a href="http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/">http://www.capc.org/tools-for-palliative-care-programs/clinical-tools/</a>.<span style=""> </span>Accessed August 4, 2009.<span style=""> </span>Free registration required.<o:p></o:p></span></li></ol> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back A, Arnold R, Tulsky J.<span class="subnavlink1"><span style="font-family: "Arial","sans-serif";"><span style=""> </span></span></span><span class="subnavlink1"><i style=""><span style="font-family: "Arial","sans-serif"; color: black;">Mastering communication with seriously ill patients: balancing honesty with empathy and hope</span></i></span><i style=""><span style="color: black;">.</span></i><span style=""> </span>New York, NY: Cambridge University Press; 2009.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ);<span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, Medical College of Wisconsin. For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.<span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, are available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span>The Family Meeting: End of Life Goal Setting and Future Planning.<span style=""> </span><i style="">Fast Facts and Concepts</i>.<span style=""> </span>February 2010; 227.<span style=""> </span>Available at:<span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_227.htm">http://www.eperc.mcw.edu/fastfact/ff_227.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-60173364814930380562010-02-05T09:09:00.003-06:002010-02-05T09:44:57.378-06:00#226 Helping Surrogates Make Decisions<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >FAST FACTS AND CONCEPTS #226<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >Helping Surrogates Make decisions <o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >David E Weissman MD, <span class="style91"><span style=";font-family:";" >Timothy E Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></span></b></p> <p class="MsoNormal"><b><span style=";font-family:";font-size:10;" >Background<span style=""> </span></span></b><span style=";font-family:";font-size:10;" >Surrogate decision makers are often placed in the difficult position of making what feels to them as life or death decisions.<span style=""> </span>This <i style="">Fast Fact</i> reviews an approach to help surrogates through the decision process when patients cannot participate in decision-making themselves.<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style=";font-family:";font-size:10;" >Surrogate decision making</span></b><span style=";font-family:";font-size:10;" ><span style=""> </span>The surrogate’s role is clearly to exercise “substituted judgment” – that is, to make decisions as the patient would make them using the patient’s values and preferences as previously expressed.<span style=""> </span>The challenge was clearly expressed by the New Jersey Supreme Court in the Quinlan case:<span style=""> </span><i style="">if (the patient) could wake up for 15 minutes, understand his current medical situation completely, and then had to go back<b> </b>into it, what would he tell us to do? </i>In the case of children, surrogate decision makers (usually parents) are expected to make decisions that represent the child’s ‘best interests’; depending on the age and capacity of the child to participate in his/her own healthcare decision making, the applied ‘best interest’ judgment by the surrogate and healthcare providers may incorporate the patient’s values and preferences to the extent possible, or may be solely based on the decision maker’s interpretation of best interest. If there is conflict about what is in a child’s best interest, or in cases of developmentally disabled adults who have never had capacity, consultation from ethics and law may be appropriate, as the rules governing decision-making vary considerably.<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style=";font-family:";font-size:10;" >Helping surrogates<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">1.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Before making a recommendation, make sure there is a common understanding of the patient’s condition and prognosis.<span style=""> </span>Following this, the next step is to try to understand the patient’s goals in light of these medical facts.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">2.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Bring the patient’s “voice” into the decision process even if he/she cannot participate directly: <i style="">If your father were sitting here with us, what would he say? </i>If available, share a copy of any advance care planning document with the surrogate.<span style=""> </span>Realize that it is common for the surrogate never to have seen the document.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">3.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Whenever possible, frame the decision around the treatment goals (e.g. life prolongation, allowing a peaceful death) in light of the patient’s current condition, rather than focusing on very specific treatments (e.g. thoracentesis, antibiotics).<span style=""> </span>The details of the medical plan should flow from the overall goals of care.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">4.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Do not make the surrogate feel that they are taking full responsibility for medical decisions, especially those which may result in the death of their loved one (<i style="">We can do option a or b; what would like me to do?</i>)<i style="">.<span style=""> </span></i>Once you have a sense of the patient’s goals in light of his/her medical condition, offer to make a recommendation that reflects those goals. <i style=""><span style=""> </span></i><b>Note: </b>Many families are looking for support and guidance from medical professionals, especially the physician. <i style="">Given what you have told me about your mother, and what we know about her medical condition, I would recommend…. </i>Start with what you <i style="">are</i> going to do to achieve the patient’s goals and then talk about what does not make sense given those goals. Remember, however, that some families may want information but not your recommendation.<span style=""> </span>It is therefore important to offer your recommendation (<i style="">Would it be helpful for me to say what medically makes the most sense, given what you’ve told me about your Dad?).<o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">5.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Remember that we are talking about the potential death of the surrogate’s loved one. Emotions – sadness, frustration and guilt – are normal.<span style=""> </span>Use previously discussed emotion management skills to acknowledge, legitimize, empathize and support the family’s emotional response (see <i style="">Fast Facts </i>#29 and #224). <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">6.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Do not argue over the facts; repeating the facts over and over again is not likely to be effective.<span style=""> </span>When the surrogate says <i style="">He is a fighter</i>, acknowledge that he is and has really fought hard. The surrogate saying <i style="">I want you to do everything</i> is as much a sign of emotional desperation as it is a factual request.<span style=""> </span>Respond with empathy: <i style="">It seems this is really hard for you</i>.<span style=""> </span>If hope for a miracle is expressed, it is appropriate to acknowledge that you hope for an unancticipated recovery as well, but that a miracle is truly what it would take at this point. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">7.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Rather than reiterating what medicine cannot do, consider using “<i style="">I wish”</i> statements to keep you in touch with the surrogate’s feelings, while simultaneously expressing medicine’s limitations (<i style="">I wish our medicines were more effective; I wish we had more medical treatment to offer than we do…).</i><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">8.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Recognize the importance of time and support for surrogates to do their necessary grief-work. Offer counseling services, either informal through the work of a palliative care team, or more formal resources available at your institution. Bring together your clinical care team and strategize potential resources for support such as chaplaincy, social services, psychology, palliative care or ethics consultation.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in;"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style=";font-family:";font-size:10;" >Remember that time is your ally.</span></b><span style=";font-family:";font-size:10;" ><span style=""> </span>The surrogate needs to process that their loved one is dying and conceptualize what life will be like without him or her. This grief work takes time and psychological support.<span style=""> </span>Often, letting people think about what you have said and talking again over subsequent days provides them the space to do grief work.<span style=""> </span>It also allows them to see for themselves that what you have advised is coming true (e.g. the patient is not getting better).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b style=""><span style=";font-family:";font-size:10;" >References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style=";font-family:";font-size:10;" >Quill TE, Brody H. Physician recommendations and patient autonomy:<span style=""> </span>Finding a balance between physician power and patient choice. <i style="">Ann Intern Med</i>. 1996; 125:763-769.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style=";font-family:";font-size:10;" >Quill TE, Arnold RM, Platt FW. "I wish things were different": Expressing wishes in response to loss, futility, and unrealistic hopes. <i style="">Ann Intern Med</i>. 2001; 135:551-555.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style=";font-family:";font-size:10;" >Fisher R, Ury W. <i style="">Getting to Yes: Negotiating Agreement Without Giving In.</i> Boston, MA: Houghton-Mifflin; 1981.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style=";font-family:";font-size:10;" >Quill TE, Arnold RM, Back A.<span style=""> </span>Discussing treatment preferences in patients who want "everything".<span style=""> </span><i style="">Ann Intern Med</i>. <span style=""> </span>2009; 151:345-349.<o:p></o:p></span></li></ol> <p class="MsoNormal"><o:p> </o:p></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Author Affiliations: </span></b><span style=";font-family:";font-size:10;" >Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ);<span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style=";font-family:";font-size:10;" >Fast Facts and Concepts</span></i></b><b><span style=";font-family:";font-size:10;" > </span></b><span style=";font-family:";font-size:10;" >are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, Medical College of Wisconsin. For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.<span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, are available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style=";font-family:";font-size:10;" >Copyright/Referencing Information</span></b><span style=";font-family:";font-size:10;" >: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span>Helping Surrogates Make Decisions.<span style=""> </span><i style="">Fast Facts and Concepts</i>.<span style=""> </span>February 2010; 226.<span style=""> </span>Available at:<span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_226.htm">http://www.eperc.mcw.edu/fastfact/ff_226.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style=";font-family:";font-size:10;" >Disclaimer:</span></b><span style=";font-family:";font-size:10;" > <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size:10;"><o:p></o:p></span></p> <p class="MsoNormal"><o:p> </o:p></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-19236713233881096712010-02-05T09:09:00.002-06:002010-02-05T09:10:06.004-06:00#225 The Family Meeting: Causes of Conflict<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #225<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">THE FAMILY MEETING: causes of Conflict <o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">David E Weissman MD, <span class="style91"><span style="">Timothy E Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></span></b></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">When family meetings are conducted with the goal of helping a patient/family cope with a shift in goals from life-sustaining treatments to a more comfort focused approach, communication can break down.<span style=""> </span>This <i style="">Fast Fact</i> reviews the common causes of conflict.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Recognizing Conflict<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">W<span style="">hen the patient/surrogates are not psychologically ready to accept the limits of medical interventions or the finality of the impending death, you will hear comments such as these:<span style=""> </span><i style="">There must be some mistake; I know there are other treatments available; We want a second opinion; We believe in miracles; She is fighter, she will never give up; There must be something (medically) you can do. </i><span style=""> </span>Health professionals may interpret these statements as ‘denial.’<span style=""> </span>But the term denial, by itself, is insufficient to help the clinician understand what is causing the impasse.<span style=""> </span>Understanding the cause is essential in planning an effective strategy to move beyond the conflict to meet the needs of the patient and surrogates. <o:p></o:p></span></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Information Gaps<o:p></o:p></span></b></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Inaccurate understanding of the patient’s medical condition (e.g. overly optimistic or pessimistic prognosis).<span style=""> </span><span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Inconsistent information (<i style="">One doctor tells us one thing and another something else.</i>).<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Confusing information (e.g. use of medical jargon, multiple treatment options presented without a clear recommendation).<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Excessive information (well-meaning family/friends/clinicians providing information without full awareness of the problems).<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Genuine uncertainty (e.g., predicting functional outcome from a brain injury in its immediate aftermath may be impossible).<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Language/translation/cultural issues (<i style="">We never tell someone they are dying in our culture.</i>).<span style=""> </span><span style=""><o:p></o:p></span></span></li></ul> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Treatment Goal Confusion</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Inconsistent treatments and unclear goals, often due to physician/patient/surrogate emotional issues (see below):<span style=""><o:p></o:p></span></span></li><ul style="margin-top: 0in;" type="circle"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Clinician initiated: <i style="">We will keep your husband on blood pressure raising medicine but stop antibiotics.</i><span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Family initiated: <i style="">We want you to do CPR, but not <span class="SpellE">intubate</span> her.</i><span style=""><o:p></o:p></span></span></li></ul><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Differing priorities about disease-directed treatment and comfort-oriented treatment between clinicians and patient/family. <span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lack of clarity about goals when several things are going on simultaneously (advanced cancer, severe infection, respiratory failure – <i style="">Isn’t the pneumonia potentially treatable?</i>) <b style=""><o:p></o:p></b></span></li></ul> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Emotions<o:p></o:p></span></b></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Grief (<i style="">I don't know how I will live without him.</i>)<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fear/anxiety (<i style="">I don't want to be responsible for ending my father's life.<span style=""> </span>My family will be angry at me for doing th<b style="">i</b>s.</i>)<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Guilt (<i style="">I haven't visited my sister in 20 years. I should have been here for her.</i>)<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Anger (<i style="">My mother was very abusive, I've never forgiven her; you are just giving up on her.</i>)<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hope (<i style="">I’m still hoping and praying she can pull through this.</i>)<span style=""><o:p></o:p></span></span></li></ul> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Family/Team dynamics</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Patient/family conflicted within themselves; may want different things at different times<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dysfunctional family system (family members unable to put the patient's needs/values/priorities above their own).<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Surrogate lack of ability (cognitive deficit, psychological/psychiatric trait/illness). In pediatrics, this can be conflict between what is in the best interest of a child vs. a caregiver or family. <span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Consulting teams disagree about the optimal approach, putting the patient/family in the middle of the dispute.<o:p></o:p></span></li></ul> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Relationship between the Clinician and the Patient/Surrogate<span style=""><o:p></o:p></span></span></b></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lack of trust in the health care team/health care system.<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Past experiences where the patient has had a better outcome than predicted.<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Genuine value differences: <span style=""><o:p></o:p></span></span></li><ul style="margin-top: 0in;" type="circle"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cultural/religious values concerning life, dying, and death.<span style=""><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Clinician value of wanting to protect the patient from invasive, non-beneficial treatment while the family values wanting to prolong life no matter how much suffering it might entail.<span style=""><o:p></o:p></span></span></li></ul></ul> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">All of these issues represent a degree of conflict and will need to be addressed before proceeding to set end-of-life goals. See <i style="">Fast Facts</i> #183,184 for additional discussion on managing conflict.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Debriefing</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Conflicts are stressful for all involved health professionals. It is helpful to debrief the process – what went well, what could have been improved, and – most importantly – addressing the emotional reaction and needs of the care team.<span style=""> </span>See<i style=""> Fast Fact</i> # 203 on managing clinician emotions.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -27pt;"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill. <i style="">JAMA</i>. 2005; 293:1374-1381.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lazare</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> A, <span class="SpellE">Eisenthal</span> S, Frank A. Clinician/Patient Relations II:<span style=""> </span>Conflict and Negotiation. In: <span class="SpellE">Lazare</span> A, ed. <i style="">Outpatient Psychiatry</i>. Baltimore, MD: Williams and Wilkins; 1989.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fisher R, <span class="SpellE">Ury</span> W. <i style="">Getting to Yes:<span style=""> </span>Negotiating Agreement Without Giving In.</i> Boston, MA: Houghton-Mifflin; 1981.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Quill TE. Recognizing and adjusting to barriers in doctor-patient communication. <i style="">Ann Intern Med</i>. 1989; 111:51-57.<o:p></o:p></span></li></ol> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">5.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back A, Arnold R, Tulsky J.<span class="subnavlink1"><span style="font-family: "Arial","sans-serif";"><span style=""> </span></span></span><span class="subnavlink1"><i style=""><span style="font-family: "Arial","sans-serif"; color: windowtext;">Mastering communication with seriously ill patients: balancing honesty with empathy and hope</span></i></span><i style="">.</i><span style=""> </span>New York, NY: Cambridge University Press; 2009.<o:p></o:p></span></p> <p class="MsoNormal"><o:p> </o:p></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); <span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, Medical College of Wisconsin. For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.<span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, are available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>. <span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span>The Family Meeting: Causes of Conflict.<span style=""> </span><i style="">Fast Facts and Concepts</i>.<span style=""> </span>January 2010; 225.<span style=""> </span>Available at:<span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_225.htm">http://www.eperc.mcw.edu/fastfact/ff_225.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><o:p> </o:p></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-9004188712542990302010-02-05T09:09:00.001-06:002010-02-05T09:09:36.324-06:00#224 Responding to Emotions in Family Meetings<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #224<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">Responding TO EMOTION IN FAMILY MEETINGS<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">David E Weissman MD, <span class="style91"><span style="">Timothy E Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></span></b></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Family meetings are stressful events, often provoking strong emotional reactions.<span style=""> </span><i style="">Fast Fact</i> #29 presents a general outline on the topic of how clinicians can respond to emotions.<span style=""> </span>The <i style="">Fast Fact</i> will provide a more detailed approach to emotions that arise during family meetings.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Consider your role.<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">It is important to reflect on the role of clinicians in responding to patient/family emotions at the time life-altering information is shared.<span style=""> </span>The goal is not to prevent a patient/family from having those emotions.<span style=""> </span>Sadness, fear, anger, and loss are normal responses to unwelcome news.<span style=""> </span>Instead your role is: 1) to maintain a trusting therapeutic relationship and safe/supportive environment that allows emotions to be expressed in a way that meets the patient’s/family’s needs; and 2) not to worsen the experience for the patient/family by ignoring or delegitimizing their responses, or confusing them with medical information when they are not ready to hear it.<span style=""> </span>Recognize that most families find clinicians’ expressions of empathy tremendously supportive and these are associated with family satisfaction.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Acknowledge that emotion is being expressed.</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>If you have a good sense of what the emotion is, then it is useful to name it.<span style=""> </span>If not, using more general language is preferable.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">I can see this is really affecting you.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This information is very upsetting.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Legitimize the appropriateness and normalcy of the reaction. </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Medical professionals are in a powerful position to help patients and families feel that strong emotions under these circumstances are normal and to be expected.<b><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Anyone receiving this news would feel devastated.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">It is completely expected to be very distressed by this kind of news.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Explore more about what is underneath the emotion.</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>It is tempting to try to limit the emotion, and be prematurely reassuring.<span style=""> </span>But it is generally more helpful and ultimately more time-efficient to allow the patient and family to more deeply explore their feelings and reactions.<b><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-left: 13.5pt; text-indent: 0in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tell me what is the scariest (most difficult) part for you.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tell me more about that…. </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">(Keep the exploration going until it is fully expressed and understood.)<i><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Empathize (if you genuinely feel it).</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Empathy means being able to emotionally imagine what the patient is going through.<span style=""> </span>Clinicians can initiate the prior responses (acknowledge, legitimize, explore) without having a clear feeling for the patient’s experience.<span style=""> </span>These responses can be adequate in themselves.<span style=""> </span>If the clinician cannot imagine the patient’s experience, he or she can still sensitively explore the experience and provide caring and support. But if you have a strong sense of what the patient is experiencing, it can be very therapeutic to express it. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This seems really unfair.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">I can imagine that you might feel very disappointed.<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Explore strengths/coping strategies.<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This may occur at this phase of the interview, or it may be postponed to a later phase when planning for next steps begins.<span style=""> </span><b><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">In past circumstances, what has helped?<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">How have you adapted to difficult circumstances in the past?<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0in; text-indent: 13.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Verdana","sans-serif";"><span style="">•<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">What are you hoping for now?<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 1in;"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></i></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back A, Arnold R, Tulsky J.<span class="subnavlink1"><span style="font-family: "Arial","sans-serif";"><span style=""> </span></span></span><span class="subnavlink1"><i style=""><span style="font-family: "Arial","sans-serif"; color: black;">Mastering communication with seriously ill patients: balancing honesty with empathy and hope</span></i></span><i style=""><span style="color: black;">.</span></i><span style=""> </span>New York, NY: Cambridge University Press; 2009.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. <i style="">JAMA</i>. 1997; 277:678-682.<o:p></o:p></span></p> <p class="MsoBodyText" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=""><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="">Hardee JT. An overview of empathy. <i style="">The Permanente Journal</i>. 2003; 7(online).<span style=""> </span>Available at:<span style=""> </span><a href="http://xnet.kp.org/permanentejournal/fall03/cpc.html">h<span style="">ttp://xnet.kp.org/permanentejournal/fall03/cpc.html</span></a>.<span style=""> </span>Accessed August 5, 2009.</span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); <span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, Medical College of Wisconsin. For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.<span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, are available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span>Responding to Emotions in Family Meetings.<span style=""> </span><i style="">Fast Facts and Concepts</i>.<span style=""> </span>January 2010; 224.<span style=""> </span>Available at:<span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_224.htm">http://www.eperc.mcw.edu/fastfact/ff_224.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoBodyText"><o:p> </o:p></p> <p class="MsoNormal"><o:p> </o:p></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-26487284273962950752010-02-05T09:08:00.000-06:002010-02-05T09:09:13.441-06:00#223 The Family Meeting: Starting the Conversation<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #223<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">THE FAMILY MEETING: Starting the conversation<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">David E Weissman MD, <span class="style91"><span style="">Timothy Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></span></b></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Fast Fact </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">#16 gives a concise overview of running a family meeting. <i style="">Fast Fact #</i>222 provides a list of preparatory steps in planning for a family meeting to discuss end-of-life goals; this <i style="">Fast Fact</i> reviews the early steps of the actual meeting.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;"><!--[if !supportLists]--><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></b><!--[endif]--><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Introductions & setting goals for the meeting<o:p></o:p></span></b></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The meeting leader begins the meeting by introducing him or herself, and suggesting that each person present (medical team and family/community) introduce themselves including their relationship to the patient.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The meeting leader should summarize the meeting goals (e.g. <i style="">We are here to discuss next steps in the care of Mr. Jones</i>) and ask the family to confirm these goals and/or add other agenda items.<o:p></o:p></span></li><li class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Note:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> if you do not know the patient or family well, take a moment to build relationship.<span style=""> </span>Ask a non-medical question such as <i style="">I am just getting to know you. I had a chance to look at your chart and learn about your medical condition but it does not say much about your life before you got sick.<span style=""> </span>Can you tell us about the things you liked to do before you got sick?<span style=""> </span></i>Similarly, if the patient is not able to participate in the meeting, ask family to describe the patient prior to his becoming ill:<span style=""> </span><i style="">As we get started, can you describe what Mr. Jones was like before he became ill?</i><o:p></o:p></span></li></ul> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">2.<span style=""> </span><span style=""> </span>Determine what the patient/family already knows<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This step is essential as it guides you in providing a synthesis of the medical information (see below).<span style=""> </span>Always invite the patient and all family members to provide their understanding of the medical information. Examples of opening lines:<o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tell me what the doctors have told you about your condition?<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Can you describe for me your sense of how things are going?<o:p></o:p></span></i></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">For patients who have been declining from a chronic illness, you can ask<i style="">: Tell me about the past 3-6 months: what types of changes have you noted?<span style=""> </span></i>The patient or family will typically describe changes in terms of function (physical or cognitive) and quality of life.<i style=""><o:p></o:p></i></span></li></ul> <p class="MsoNormal" style="margin-left: 0.5in;"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></i></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">3.<span style=""> </span>The Medical Review<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Once you know what the patient/family understands, you are in a good position to confirm their understanding, or provide new information/correct misunderstandings. First, ask if you can bring them up-to-date about what is going on; asking shows politeness and also signals that they should attend to what you are trying to say.<span style=""> </span>The clinician most closely aligned with the patient’s ongoing treatment should begin this discussion, supplemented with information from consulting services if relevant.<span style=""> </span>Do not provide information using medical jargon or in an organ system approach (e.g. <i style="">The creatinine is improving, but there is a new pleural effusion and the heart rate has become irregular</i>).<span style=""> </span>A more patient-centered approach is to provide a succinct summary of the current condition, without any medical jargon, focusing on the issues of most importance, which are usually function/quality/time.<span style=""> </span>Give a ‘bottom-line’ statement: ‘getting worse,’ ‘not going to improve,’ ‘dying and time is likely very short.’<o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The worsening weakness and pain you describe is from the cancer which is growing despite the chemotherapy.<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">You are telling me that despite the recent hospitalization, you are not able to do as much around the house; unfortunately your lung disease is getting worse despite all our best treatments.<o:p></o:p></span></i></li><li class="MsoNormal" style=""><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Despite our best efforts, your wife’s brain injury from the car crash is getting worse.<span style=""> </span>She can no longer stay awake or move her arms/legs.<span style=""> </span><o:p></o:p></span></i></li></ul> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Using the ‘D word’ if relevant:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> when a patient is clearly deteriorating and death is likely within the next days to weeks, or even a few months, it is appropriate to use the word <i style="">dying</i> in the conversation.<span style=""> </span>Both patients and surrogates find that saying the word <i style="">dying</i>, if done compassionately, is helpful in clearing what is often a confusing and frightening situation.<span style=""> </span><i style=""><span style=""> </span>I’m afraid we have run out of options to shrink the cancer. Based on your declining function, I believe you are dying.</i><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">4.<span style=""> </span>Silence</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Whether or not you use the word <i style="">dying</i>, when you have presented bad news (such as information about disease progression), the next step is for you to allow silence, and let the family/patient respond.<span style=""> </span>In truth, no matter what you might imagine the response from the patient/family to be once the bad news is delivered, you really cannot predict their emotional reaction (e.g. relief, anxiety, anger, regret, fear).<span style=""> </span>This silence can be uncomfortable; resist the urge to fill it with more facts as they will not be heard.<span style=""> </span>Not all patients/families express emotions at this point and instead respond practically (<i style="">Well, what happens next then?</i>).<span style=""> </span>This is fine, but you need to wait, silently, to see what response the patient/family demonstrates.<span style=""> </span>In addition, even practical questions have underlying emotions (<i style="">Are you sure? </i>Or – <i style="">There must be something you can do?</i>). It is important to respond to both the factual aspect of the question (<i style="">Yes I am sure. </i>Or – <i style="">There are no more effective treatments available</i>.), as well as the emotional level (<i style="">I wish I had better news for you. </i><span style=""> </span>Or – <i style="">I wish our treatments worked better than they do.).</i><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">When the patient/surrogates openly acknowledge that current treatments are no longer effective, that death is coming, they will generally ask one or all of the following questions:<i style=""> How long?<span style=""> </span>What will happen?<span style=""> </span>Will there be suffering? What do we do now?<span style=""> </span><span style=""> </span></i>Your response at this point should be to address prognosis in terms of time, function, and symptoms, as best you can (see <i style="">Fast Facts </i>#13,141,143,149,150).<span style=""> </span>This will answer the first two questions; the last questions will require more discussion of patient-centered goals (see <i style="">Fast Fact </i>#227)<i style="">.<o:p></o:p></i></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back A, Arnold R, Tulsky J.<span class="subnavlink1"><span style="font-family: "Arial","sans-serif";"><span style=""> </span></span></span><span class="subnavlink1"><i style=""><span style="font-family: "Arial","sans-serif"; color: black;">Mastering communication with seriously ill patients: balancing honesty with empathy and hope</span></i></span><i style=""><span style="color: black;">.</span></i><span style=""> </span>New York, NY: Cambridge University Press; 2009.<o:p></o:p></span></p> <p class="choice" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt;"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt;">Quill TE, Townsend P. Bad news: delivery, dialogue and dilemmas. <i style="">Arch Intern Med</i>. 1991; 151:463-468.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";" lang="FR">Curtis JR, Patrick DL, Shannon SE, et al. </span><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. <i style="">Crit Care Med</i>. 2001; 29(2 Suppl):N26-33.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lautrette</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> A, <span style="">Ciroldi</span> M, <span style="">Ksibi H</span>, <span style="">Azoulay E</span>. End-of-life family conferences: rooted in the evidence. <i style="">Crit Care Med</i>. 2006; 34(11):S364-S372.<o:p></o:p></span></p> <ol style="margin-top: 0in;" start="5" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">King DA, Quill T. Working with families in palliative care: one size does not fit all. <i style="">J Pall Med.</i> 2006; 9:704-715.<o:p></o:p></span></li></ol> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Quill TE, Arnold RM, Platt FW. "I wish things were different": Expressing wishes in response to loss, futility, and unrealistic hopes. <i style="">Ann Intern Med</i>. 2001; 135:551-555.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); <span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, Medical College of Wisconsin. For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.<span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, are available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span>The Family Meeting: Starting the Conversation.<span style=""> </span><i style="">Fast Facts and Concepts</i>.<span style=""> </span>December 2009; 223.<span style=""> </span>Available at:<span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_223.htm">http://www.eperc.mcw.edu/fastfact/ff_223.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><!--[if supportFields]><b style="'mso-bidi-font-weight:normal'"><span style="'font-size:10.0pt;font-family:"><span style="'mso-element:field-begin'"></span><span style="'mso-spacerun:yes'"> </span>ADDIN REFMGR.REFLIST <span style="'mso-element:"></span></span></b><![endif]--><!--[if supportFields]><b style="'mso-bidi-font-weight:normal'"><span style="'font-size:10.0pt;font-family:"><span style="'mso-element:field-end'"></span></span></b><![endif]--><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></b></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-44657659699280135332010-02-05T09:06:00.001-06:002010-02-05T09:06:52.555-06:00#222 Preparing for the Family Meeting<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #222<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">PREPARing FOR THE FAMILY MEETING<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><b style="">David E Weissman MD, <span class="style91"><span style="">Timothy E Quill MD, and Robert M Arnold MD</span></span><o:p></o:p></b></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">A cornerstone procedure in Palliative Medicine is leadership of family meetings to establish goals of care, typically completed at a time of patient change in status, where the value of current treatments needs to be re-evaluated.<span style=""> </span>As with any procedure, preparation is essential to ensure the best outcome.<span style=""> </span>This <i style="">Fast Fact</i> reviews how to prepare for a Family Meeting. <span style=""> </span>See also <i style="">Fast Fact</i> #16 for a concise overview of family meetings, as well as <i style="">Fast Facts </i>223-227 for discussion of additional aspects of family conferences.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Data Review<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Review the medical history relevant to the current medical situation (e.g. history of disease progression, symptom burden, past treatments, treatment-related toxicity, and prognosis).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Review all current treatments (e.g. renal dialysis, artificial nutrition, antibiotics) and any positive and/or negative treatment effects.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Review all treatment options being proposed.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Determine the prognosis with and without continued disease-directed treatments. Prognostic information includes data concerning future patient function (physical/cognitive), symptom burden, and time (longevity).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Solicit and coordinate medical opinions about the utility of current treatments among consultants and the primary physician. If possible, families need to hear a single medical consensus—all relevant clinicians should be contacted and consensus reached prior to the meeting.<span style=""> </span>If the consultants do not agree, then prior to the family meeting they should meet to negotiate these differences and attempt to reach consensus regarding the plan. If there is no consensus, a plan should be developed for how to describe these differences to families.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">If the patient lacks capacity, review any Advance Directive(s), with special attention to discover if the patient has named a surrogate decision maker, and if the patient has indicated any specific wishes (e.g. DNR status, ‘no feeding tubes’).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Seek out patient/family psychosocial data.<span style=""> </span>Focus on psychological issues and family dynamics (e.g. anger, guilt, fear) potentially impacting decision making.<span style=""> </span>These issues may be long-standing, or due to the current illness. <b>Note:</b> talking to the patient’s social worker, bedside nurses, and primary and consulting physicians can help you get a better sense of the family and how they make decisions.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Review what transpired in prior family meetings. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Learn about particular cultural/religious values and/or or social/financial issues that may impact decision making.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Information Synthesis</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Based on your review of the medical and prognostic data, make an independent determination of which current and potential tests/treatments will improve, worsen, or have no impact on the patient’s function/quality of life (physical/cognitive) and time (longevity).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Meeting Leadership</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Leading a family meeting requires considerable flexibility to ensure that all relevant participants have the opportunity to have their points of view expressed.<span style=""> </span>Though it is useful to have one person designated as the main orchestrator and coordinator of the meeting, the essential skills for making a family meeting successful can come from more than one participant.<span style=""> </span>These skills include:<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Group facilitation skills.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Counseling skills. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Knowledge of medical and prognostic information.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Willingness to provide leadership/guidance in decision making.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Invitations</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><span style=""> </span><span style=""> </span>A decisional patient can be asked who he/she wants to participate from his/her family/community, including faith leaders; in general it is wise not to set any arbitrary limits on the number of attendees.<span style=""> </span>The medical care team should likewise decide who they want to participate.<span style=""> </span><b>Note:</b> it is important not to overwhelm a family with too many health professionals. On the other hand, a physician from the primary team as well as a nurse and social worker should attend when possible; these individuals can help ensure the consistency of information as well as help deal with complicated dynamics.<span style=""> </span>If the patient has a long-time treating physician whom he/she trusts, this person should ideally be present.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-top: 6pt;"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Setting</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>The ideal setting is private and quiet, with chairs arranged in a circle or around a table. Everyone should be able to sit down if they wish.<span style=""> </span>For non-decisional patients, the clinical team should negotiate with the surrogate whether or not to have the meeting in the presence of the patient.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The Pre-Meeting Meeting</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>The participating health care members should meet beforehand to confirm: a) the goals for the meeting (e.g. information sharing, specific decisions sought), b) who will be the meeting leader to start the meeting, and c) likely sources of conflict and initial management strategies.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Back A, Arnold R, Tulsky J.</span><span class="subnavlink1"><span style="font-size: 8pt;"><span style=""> </span></span></span><span class="subnavlink1"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Mastering communication with seriously ill patients: balancing honesty with empathy and hope</span></i></span><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">.</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>New York, NY: Cambridge University Press; 2009.<o:p></o:p></span></p> <ol style="margin-top: 0in;" start="2" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Curtis JR, Patrick DL, Shannon SE, et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. <i style="">Crit Care Med</i>. 2001; 29(2 Suppl):N26-33.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lautrette</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> A, <span style="">Ciroldi</span> M, <span class="GramE"><span style="">Ksibi</span></span><span style=""> H</span>, <span style="">Azoulay E</span>. End-of-life family conferences: rooted in the evidence. <i style="">Crit Care Med</i>. 2006; 34(11):S364-S372.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">King DA, Quill T. Working with families in palliative care: one size does not fit all. <i style="">J Pall Med.</i> 2006; 9:704-715.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. <i style="">J Pall Med</i>. 2006; 9:451-463.<o:p></o:p></span></li></ol> <p class="MsoBodyText" style="margin-left: 0.5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style=""><span style="">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="">Weissman DE. Decision making at a time of crisis near the end of life. <i style="">JAMA</i>. 2004; 292:1738-1743.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); <span style=""> </span>University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, <span class="GramE">Medical</span> College of Wisconsin. <span class="GramE">For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.</span><span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, <span class="GramE">are</span> available at EPERC: <a href="http://www.mcw.edu/eperc">http://www.mcw.edu/eperc</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span>Weissman DE, Quill TE, Arnold RM.<span style=""> </span><span class="GramE">Preparing for the Family Meeting.</span><span style=""> </span><span class="GramE"><i style="">Fast Facts and Concepts</i>.</span><span style=""> </span><span class="GramE">December 2009; 222.</span><span style=""> </span>Available at: <span style=""> </span><a href="http://www.eperc.mcw.edu/fastfact/ff_222.htm">http://www.eperc.mcw.edu/fastfact/ff_222.htm</a>. <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><o:p> </o:p></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-59941628556374888582010-02-05T09:05:00.002-06:002010-02-05T09:06:28.637-06:00#221Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #221<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">Treatment of Pain in Patients Taking Buprenorphine for OPIOID ADDICTION<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin: 6pt 0in; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Julie W Childers MD and Robert Arnold MD<o:p></o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This <i style="">Fast Fact</i> discusses treating pain in patients using buprenorphine for opioid addiction.<span style=""> </span>Buprenorphine is a mixed opioid agonist/antagonist, available in the <st1:country-region st="on"><st1:place st="on">United States</st1:place></st1:country-region> in the sublingual form as ‘<span class="SpellE">Subutex</span>,’ and formulated with <span class="SpellE">naloxone</span> as ‘Suboxone.’<span style=""> </span>It is approved for treatment of opioid addiction in the <st1:country-region st="on"><st1:place st="on">US</st1:place></st1:country-region>; such use is restricted to qualified physicians who have received training and a waiver to practice medication-assisted opioid addiction therapy.<span style=""> </span>Over the last seven years, over 10,000 physicians have been approved to use buprenorphine, with 2,103,000 prescriptions filled in 2007. Given this, clinicians are likely to encounter patients on buprenorphine therapy who also require treatment for pain.<span style=""> </span><b style="">Note:</b><span style=""> </span>buprenorphine is also used as an analgesic, particularly in <st1:place st="on">Europe</st1:place>, where a transdermal system is available.<span style=""> </span>Currently it is uncommonly used in the <st1:country-region st="on"><st1:place st="on">US</st1:place></st1:country-region> as an analgesic.<span style=""> </span><span class="SpellE">Naloxone</span> has minimal sublingual bioavailability and is included only to prevent abuse by intravenous injection; in this <i style="">Fast Fact</i> ‘buprenorphine’ refers to both sublingual products.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pharmacology<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Buprenorphine binds to mu-opioid receptors tightly but with low intrinsic activity, providing some analgesic effects but effectively preventing other opioids from binding.<span style=""> </span><span class="GramE">This ‘blocks’ the analgesic and euphoric effects of other opioids, leading to its effectiveness in opioid addiction therapy.</span> <span style=""> </span>Buprenorphine’s effect at the mu-opioid receptor lasts 24 to 60 hours, and can lengthen even further with increasing doses.<span style=""> </span><span style=""> </span>The duration of sublingual buprenorphine’s analgesic effects is shorter than its occupation of the receptor – between 6 and 12 hours. When patients on buprenorphine therapy for addiction are in acute pain, the continued interaction of buprenorphine with opioid receptors can limit other opioids’ analgesic effectiveness. <span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style="margin-right: 0.5in;"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pain Management Strategies<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">While there are no clinical studies addressing how to treat pain in patients taking buprenorphine, the strategies below are derived from expert opinion, animal studies, federal guidelines, and international experience treating breakthrough pain in patients using transdermal buprenorphine (not available in the US). <span style=""> </span>As with all patients with pain, non-<span class="GramE">pharmacologic</span> therapies and non-opioid analgesics should be used when safe and likely to work.<span style=""> </span>The following strategies should be chosen and implemented in close collaboration with the physician treating the patient’s opioid addiction.<o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">If acute pain is anticipated, such as for an elective surgical procedure, adjuvant analgesics and interventional procedures such as nerve blocks should be provided as available.<o:p></o:p></span></li><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">For patients with moderate to severe pain who are expected to require opioid analgesic therapy for the short term, federal guidelines recommend holding the buprenorphine and starting short acting opioid agonists.<span style=""> </span>While the buprenorphine’s effects diminish (20-60 hours), the patient may require higher opioid doses to compete with the presence of buprenorphine on mu-opioid receptors.<span style=""> </span>The patient should be monitored carefully in the initial period to titrate the opioid agonist dose downward as its effect becomes greater.<span style=""> </span>Before restarting buprenorphine, the patient should be opioid-free for 12-24 hours to avoid precipitating withdrawal.<span style=""> </span>This process should be overseen by an approved buprenorphine provider.<span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">For patients with mild to moderate acute pain, consider treating the pain with buprenorphine alone.<span style=""> </span>The total daily dose of buprenorphine can be increased (to a maximum of 32 mg sublingual/day); it should be given in divided doses every 6-8 hours.<span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Another option is to continue buprenorphine and use short-acting opioid agonists at high enough doses to overcome buprenorphine’s partial agonism.<span style=""> </span><span style=""> </span>Opioids that have a higher intrinsic activity at the mu-opioid receptor, including morphine, fentanyl, or hydromorphone, are all options, while opioids with less efficacy such as hydrocodone or codeine should be avoided.<span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">In a patient who is expected to have an ongoing need for pain management, consider replacing buprenorphine with methadone therapy for opioid addiction.<span style=""> </span>For analgesia, additional methadone or other ‘full’ mu-opioid receptor agonists can then be added without problems related to use of a partial opioid agonist.<o:p></o:p></span></li><li class="MsoNormal" style="margin-right: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Patients who have life-limiting illnesses that are expected to cause significant pain are not good candidates for buprenorphine therapy for addiction.<span style=""> </span>A collaborative approach, including patient preference and discussion with both addiction and pain or palliative care specialists, will best identify a therapeutic plan to achieve adequate pain relief and maintain recovery from addiction.<o:p></o:p></span></li></ul> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations:<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">University of <st1:placename st="on">Pittsburgh</st1:placename> <st1:placename st="on">Medical</st1:placename> <st1:placetype st="on">Center</st1:placetype>, <st1:place st="on"><st1:city st="on">Pittsburgh</st1:city>, <st1:state st="on">PA.</st1:state></st1:place><b style=""><o:p></o:p></b></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Alford DP, et al.<span style=""> </span>Acute pain management for patients receiving maintenance methadone or buprenorphine therapy.<span style=""> </span><i style="">Ann Intern Med.</i> 2006; 144:127-134.<i style=""><o:p></o:p></i></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: windowtext;">Center for Substance Abuse Treatment.<i style=""> <span style="">Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction</span></i>. Treatment Improv<i style="">e</i>ment<i style=""> </i>Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. <st1:place st="on"><st1:city st="on">Rockville</st1:city>, <st1:state st="on">MD</st1:state></st1:place>: Substance Abuse and Mental Health Services Administration, 2004. Available<span class="context1"><i style=""><span style="font-family: "Arial","sans-serif"; color: windowtext;"> </span></i></span><span class="context1"><span style="font-family: "Arial","sans-serif"; color: windowtext;">at <a href="http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf">http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf</a>.<span style=""> </span>Accessed June 25, 2009.</span></span></span><span class="context1"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Heit</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> HA, <span class="SpellE">Gourlay</span> DL.<span style=""> </span>Buprenorphine: new tricks with an old molecule for pain management.<span style=""> </span><span class="SpellE"><i style="">Clin</i></span><i style=""> J Pain.</i> 2008; 24:93-97.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Helm S, et al.<span style=""> </span>Opioid antagonists, partial agonists, and agonists/antagonists:<span style=""> </span>the role of office-based detoxification.<span style=""> </span><i style="">Pain Physician</i>. 2008; 11:225-235.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Johnson RE, <span class="SpellE">Fudula</span> PJ, Payne R.<span style=""> </span>Buprenorphine:<span style=""> </span>considerations for pain management.<span style=""> </span><i style="">J Pain Symptom Manage. </i>2005; 29(3):297-326.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22K%C3%B6gel%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Kögel</span></span><span style="color: windowtext; text-decoration: none;"> B</span></a>, <a href="http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Christoph%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Christoph</span></span><span style="color: windowtext; text-decoration: none;"> T</span></a>, <a href="http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Strassburger%20W%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Strassburger</span></span><span style="color: windowtext; text-decoration: none;"> W</span></a>, <a href="http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Friderichs%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Friderichs</span></span><span style="color: windowtext; text-decoration: none;"> E</span></a>.<span style=""> </span><span style="">Interaction of mu-opioid receptor agonists and antagonists with the analgesic effect of buprenorphine in mice.<span style=""> </span></span><span class="ti2"><i style=""><span style=""><a href="javascript:AL_get(this,%20'jour',%20'Eur%20J%20Pain.');"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Eur</span></span><span style="color: windowtext; text-decoration: none;"> J Pain.</span></a></span></i></span><span class="ti2"><span style=""> 2005; 9(5):599-611.<o:p></o:p></span></span></span></li><li class="MsoNormal" style=""><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;">Mark, TL, <st1:place st="on"><st1:city st="on"><span class="SpellE">Kassed</span></st1:city> <st1:state st="on">CA</st1:state></st1:place>, <span class="SpellE">Vandivort</span>-Warren R, et al.<span style=""> </span><a name="bcor1"></a>Alcohol </span></strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">and opioid dependence medications: prescription trends, overall and by physician specialty.<span style=""> </span><i style=""><a href="http://online5.hsls.pitt.edu:2066/science/journal/03768716"><span style="color: windowtext; text-decoration: none;">Drug Alcohol Depend</span></a>.</i> 2009; 99<strong><span style="font-family: "Arial","sans-serif"; font-weight: normal;">:</span></strong>345-349.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><a href="http://online5.hsls.pitt.edu:2059/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mercadante%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Mercadante</span></span><span style="color: windowtext; text-decoration: none;"> S</span></a>, <a href="http://online5.hsls.pitt.edu:2059/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Villari%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Villari</span></span><span style="color: windowtext; text-decoration: none;"> P</span></a>, <a href="http://online5.hsls.pitt.edu:2059/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ferrera%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation"><span class="SpellE"><span style="color: windowtext; text-decoration: none;">Ferrera</span></span><span style="color: windowtext; text-decoration: none;"> P</span></a>, et al.<span style=""> </span><span style="">Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine.<span style=""> </span></span><i style=""><a href="javascript:AL_get(this,%20'jour',%20'J%20Pain%20Symptom%20Manage.');"><span style="color: windowtext; text-decoration: none;">J Pain Symptom Manage.</span></a></i> 2006; 32(2):175-9.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Schumacher MA, <span class="SpellE">Basbaum</span> AI, Way WL.<span style=""> </span>Opioid analgesics and antagonists.<span style=""> </span><span class="ti2"><span style="">In: <span class="SpellE">Katzung</span> BG, ed. <i style="">Basic and clinical pharmacology</i>.<span style=""> </span><st1:place st="on"><st1:city st="on">New York</st1:city>, <st1:state st="on">NY</st1:state></st1:place>: McGraw-Hill; 2007.</span></span><o:p></o:p></span></li></ol> <p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, <span class="GramE">Medical</span> College of Wisconsin. <span class="GramE">For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.</span><span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, <span class="GramE">are</span> available at EPERC: <a href="http://www.eperc.mcw.edu/">www.eperc.mcw.edu</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span><span class="GramE">Childers JW, Arnold R.</span><span style=""> </span><span class="GramE">Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction.</span><span style=""> </span><span class="GramE"><i style="">Fast Facts and Concepts</i>.</span><span style=""> </span><span class="GramE">November 2009; 221.</span><span style=""> </span>Available at:<span style=""> </span>http://www.eperc.mcw.edu/fastfact/ff_221.htm.<o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. <o:p></o:p></span></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-21824609613731331562010-02-05T09:05:00.001-06:002010-02-05T09:05:30.864-06:00#220 Hypodermoclysis<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #220<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">HYPODERMOCLYSIS</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Arif H Kamal MD and Eduardo <span class="SpellE">Bruera</span> MD</span></b><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></u></p> <p class="MsoNormal" style="margin-bottom: 6pt;"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">This <i style="">Fast Fact</i> discusses subcutaneous fluid infusions, also known as hypodermoclysis (HDC).<span style=""> </span>The use of parenteral hydration in dying patients is controversial and is discussed in <i style="">Fast Fact</i> #133.<span style=""> </span>While this <i style="">Fast Fact</i> discusses subcutaneous fluid infusions for purposes of hydration, similar techniques can also be used to deliver medications (see <i style="">Fast Fact</i> #28). <u><o:p></o:p></u></span></p> <p class="MsoNormal" style="margin-bottom: 6pt;"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Historical and Current Practice<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hypodermoclysis was a widely accepted route for parenteral hydration in the 1940s and 1950s before falling out of favor after several reports of adverse reactions, likely related to the use of hypertonic and electrolyte-free solutions.<span style=""> </span>Due to its ease of use, and subsequent research demonstrating its safety and efficacy, HDC has become more widely used. <span style=""> </span>In the <st1:place st="on"><st1:country-region st="on">US</st1:country-region></st1:place>, HDC is mostly used in geriatric and palliative care settings, although it is used more widely elsewhere in the world.<span style=""> </span><u><o:p></o:p></u></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">HDC vs. Intravenous Hydration<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Decisions for parenteral hydration in dying patients are complex and individual decision making is paramount.<span style=""> </span>When parenteral hydration is indicated, clinicians are generally faced with a decision to use HDC or intravenous (IV) hydration (see <i style="">Fast Fact </i>#134).<span style=""> </span><o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Advantages of HDC over IV</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>Starting and maintaining a subcutaneous infusion catheter is relatively pain-free.<span style=""> </span>It can be done by trained patients or family caregivers, preventing the need for frequent skilled nursing visits or trips to medical centers to maintain a working IV.<span style=""> </span>HDC provides greater potential sites for needle placement (arm, back, abdomen, thighs), and equipment costs are generally lower than with IVs.<span style=""> </span>Subcutaneous catheters can be easily disconnected from IV tubing and re-used later, allowing a patient to receive intermittent fluid treatments.<span style=""> </span>Portable infusion devices are not needed with HDC.<span style=""> </span>HDC infusions may also cause less agitation in patients with dementia versus IV </span><span style="font-family: "Helvetica","sans-serif";">(</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";">1).<span style=""> </span><span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style="margin-bottom: 6pt;"><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disadvantages</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>HDC is limited by a continuous infusion rate of 1-2 ml/min or 1.5-3 L/day (2).<span style=""> </span>This is adequate for most clinical situations, and additional catheters can be added if needed.<span style=""> </span>Bolus infusions (up to 500 ml/hour) are possible with HDC, but often require hyaluronidase (see below).<span style=""> </span>Both HDC and IV infusions have similar rates of local adverse events (e.g. erythema, cellulitis) and lifespan of infusion site (3).<span style=""> </span>HDC can be technically difficult in patients with substantial peripheral edema, as well as in cachectic patients with little subcutaneous tissue. <span style=""> </span>Patients and families may have pre-conceived attitudes about greater benefits with IV routes even while acknowledging increased burden (4).<span style=""> </span><u><o:p></o:p></u></span></li></ul> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Technique</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <o:p></o:p></span></p> <ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style=""><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Equipment needed</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>Small butterfly needle (usually 22 <span class="GramE">gauge</span>) or angiocatheter, skin preparation (alcohol or iodine), sterile occlusive dressing, solution bag (saline or saline-dextrose combination), tubing with drip chamber.<span style=""> </span>The use of electrolyte free solutions (e.g. 5% dextrose) is discouraged due to third-spacing risks which can cause tissue sloughing or rarely circulatory collapse.<span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style=""><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Procedure</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>After cleaning the local site, insert the needle bevel up into the subcutaneous tissue.<span style=""> </span>Attach to fluid and tubing and cover with occlusive dressing.<span style=""> </span>Select an infusion fluid and set drip rate or fluid bolus.<span style=""> </span>Normal saline (NS) is typically used although half-normal saline or 2/3 D5W in 1/3 NS have been used in clinical practice.<span style=""> </span>Drip rates can be set to 20-125 ml/hour with gravity (no pump required) or 1-2 ml/minute.<span style=""> </span>Some patients may prefer drips set to gravity 24 hours per day at a low rate (e.g. 50 ml/hour), overnight hydration (e.g. 100 ml/hour), or intermittent fluid boluses (e.g. 500 ml).<span style=""> </span>The volume of infusion needed to keep acceptable levels of hydration in many palliative care patients is lower than healthy patients and postulated to be ~1 L/day (5).<span style=""> </span>No evidence exists for the frequency of site change.<span style=""> </span>Some change only when there are symptoms or needle displacement while others choose a fixed time (e.g. every 3 or 7 days) or fluid volume (e.g. every 1.5 L)<span style=""> </span>Teflon cannulas, although expensive, can be used for a week and are helpful for patients who have trouble maintaining a catheter site (6).<span style=""> </span>Local anesthetic creams may be helpful during catheter placement to reduce discomfort, especially in children.<span style=""> </span><span style=""> </span><o:p></o:p></span></li><li class="MsoNormal" style="margin-bottom: 6pt;"><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Recombinant human hyaluronidase</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>RHH is an enzyme that temporarily lyses the subcutaneous interstitial space to promote diffusion of fluid.<span style=""> </span>It can be used for site discomfort or if a faster rate of absorption is desired.<span style=""> </span>Previous preparations were of bovine origin and were associated with local allergic reactions, anaphylaxis, and pain, making its role controversial.<span style=""> </span>RHH has shown no human allergenicity (7).<span style=""> </span>Recent studies have investigated RHH versus placebo in a randomized trial with gravity-driven infusion.<span style=""> </span>The RHH group showed higher obtainable fluid rates, decreased discomfort, and similar local reactions.<span style=""> </span>Doses of 150 U to 750 U given as steady push prior to the infusion can yield fluid rates of 380 to 520 ml/hour (8).<span style=""> </span><u><o:p></o:p></u></span></li></ul> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cautions</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <span style=""> </span>Uncommon local reactions include edema, local pain, or erythema.<span style=""> </span>Interventions include slowing the rate, changing the site, or using RHH.<span style=""> </span>Rare complications include cellulitis and vascular puncture.<span style=""> </span>Systemic complications such as pulmonary edema can occur with all types of parenteral hydration.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">O'Keeffe ST, <span class="SpellE">Lavan</span> JN. Subcutaneous fluids in elderly hospital patients with cognitive impairment. <i style="">Gerontology. </i>1996; 42(1):36-39.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Berger EY. Nutrition by hypodermoclysis. <i style="">J Am <span class="SpellE">Geriatr</span> Soc. </i>1984; 32(3):199-203.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Slesak</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> G, <span class="SpellE">Schnurle</span> JW, <span class="SpellE">Kinzel</span> E, Jakob J, Dietz PK. Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomized trial. <i style="">J Am <span class="SpellE">Geriatr</span> Soc.</i> 2003; 51(2):155-160.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Mercadante</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> S, <span class="SpellE">Ferrera</span> P, <span class="SpellE">Girelli</span> D, <span class="SpellE">Casuccio</span> A. Patients' and relatives' perceptions about intravenous and subcutaneous hydration. <i style="">J Pain Symptom Manage. </i>2005; 30(4):354-358.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dalal</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> S, <span class="SpellE">Bruera</span> E. Dehydration in cancer patients: to treat or not to treat. <i style="">J Support <span class="SpellE">Oncol</span>. </i>2004; 2(6):467-479, 483.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Macmillan K, <span class="SpellE">Bruera</span> E, Kuehn N, <span class="SpellE">Selmser</span> P, Macmillan A. A prospective comparison study between a butterfly needle and a Teflon cannula for subcutaneous narcotic administration. <i style="">J Pain Symptom Manage. </i>1994; 9(2):82-84.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Yocum</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> RC, Kennard D, Heiner LS. Assessment and implication of the allergic sensitivity to a single dose of recombinant human hyaluronidase injection: a double-blind, placebo-controlled clinical trial. <i style="">J <span class="SpellE">Infus</span> <span class="SpellE">Nurs</span>. </i>2007; 30(5):293-299.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Thomas JR, <span class="SpellE">Yocum</span> RC, Haller MF, von Gunten CF. <span class="GramE">Assessing</span> the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. <i style="">J <span class="SpellE">Palliat</span> Med. </i>2007; 10(6):1312-1320.<o:p></o:p></span></li></ol> <p class="MsoNormal"><!--[if supportFields]><span style="'font-size:10.0pt;"><span style="'mso-element:field-begin'"></span><span style="'mso-spacerun:yes'"> </span>ADDIN EN.REFLIST <span style="'mso-element:"></span></span><![endif]--><!--[if supportFields]><span style="'font-size:10.0pt;font-family:"><span style="'mso-element:field-end'"></span></span><![endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations: Mayo Clinic, Rochester, MN (AK) and University of Texas M.D. Anderson Cancer Center, Houston, TX (EB). </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, <span class="GramE">Medical</span> College of Wisconsin. <span class="GramE">For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.</span><span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, <span class="GramE">are</span> available at EPERC: <a href="http://www.eperc.mcw.edu/">www.eperc.mcw.edu</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span><span class="GramE">Kamal AH, <span class="SpellE">Bruera</span> E.</span><span style=""> </span><span class="GramE">Hypodermoclysis.</span><span style=""> </span><span class="GramE"><i style="">Fast Facts and Concepts</i>.</span><span style=""> </span><span class="GramE">October 2009; 220.</span><span style=""> </span>Available at:<span style=""> </span>http://www.eperc.mcw.edu/fastfact/ff_220.htm.<o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-66280387199296978642009-09-04T11:28:00.001-05:002009-09-04T11:28:58.251-05:00#219 Responding to Requests for Non-disclosure<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #219<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">RESPONDING TO REQUESTS FOR NON-DISCLOSURE OF MEDICAL INFORMATION</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Elizabeth Chaitin DHCE and Drew A Rosielle MD<o:p></o:p></span></b></p> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">What do you do when a family member asks you not to tell your patient important medical information such as a diagnosis or prognosis?<span style=""> </span>Requests for non-disclosure can represent a loving family’s efforts to protect a patient from emotional harm, an inaccurate assessment by the family about a patient’s preferences or emotional resilience, or an accurate reflection of how the patient would prefer to make decisions. This <i style="">Fast Fact</i> will introduce readers to a practical approach to these clinical dilemmas.<o:p></o:p></span></p> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The Problem</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Contemporary medical ethics and professional standards dictate that patients have the right to choose the medical care that best allows them to meet their life goals.<span style=""> </span>To make such choices requires they be fully informed of their condition, prognosis, and reasonable treatment options (see <i style="">Fast Facts </i>#164, 165).<span style=""> </span>One needs to differentiate the right to such information from the duty to hear the information, however.<span style=""> </span>Patients have different preferences for medical decision-making, ranging from individualistic, to paternalistic (doing whatever the physician recommends), to communal (sharing, or deferring, important medical decisions to family members or religious/community leaders).<span style=""> </span>Truly respecting patient autonomy requires clinicians to identify and respect patient wishes to share or defer decision-making, including a patient’s preference to not be informed of key medical information.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Prevention<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Negotiate with the patient <i style="">before</i> the results of testing arrive as to how much information they would like and who they would like to have present for information sharing<i style="">. Are you the kind of person who wants to know the results of the test or would you rather I talk to your children?</i> <b style=""><o:p></o:p></b></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Managing Requests for Non-Disclosure </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">(adapted from Hallenbeck and Arnold, 2007):<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Stay Calm</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">. These situations can be confusing and emotional for clinicians.<span style=""> </span>The calmer you remain the more information you will gain from the family as to why they do not want their loved one to be informed of the bad news. Demonstrating frustration or implying that the request is inappropriate can break trust and derail your efforts to resolve the situation.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Try to understand the family’s viewpoint</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">.<span style=""> </span>They know the patient best and can provide insight into the cause of the request. Politely ask questions to understand the nature of the request. <i style="">Can you tell me more about why you feel this way? How does your family typically handle difficult information? How are important decisions made by your family? </i>Ask about how the patient has responded in the past to bad news and if they have made specific statements to others about what they want to know. Is the family more worried more about <i style="">how </i>the information is given rather than the information itself (e.g. given to the patient when alone, use of ‘death’ or ‘dying,’ the disclosure of specific prognostic time-frames)?<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Clarify what the patient already knows. </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Politely ask questions to understand what the family believes the patient already knows. Does the family think the patient already knows or strongly suspects what is going on and would rather not talk further about it, or is the patient completely in the dark?<span style=""> </span>Have other clinicians already told or implied to the patient what is going on?<span style=""> </span>How did the patient respond to that?<span style=""> </span>Is the patient talking with the family about their concerns? A patient’s reluctance to talk with family members may represent an attempt to protect them. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Respond empathically. </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>A family’s request to not tell their loved ones usually comes from a kind and loving place; they are often frightened for themselves and the patient. Responding empathically (see <i style="">Fast Fact </i>#29) allows them to recognize that you care about them. It may allow them to see your ability to give information to their loved one in a compassionate way. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">State your views openly, but as your own views.<span style=""> </span></span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclose any discomfort you have with the family’s request; explain your professional obligation to ensure the patient is able to make informed decisions in the manner they prefer.<span style=""> </span>Disclose this specifically in the context of you wanting what is best for the patient, including respecting how she or he would like to hear information.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Be willing to brainstorm possible solutions. </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Rigidly informing the family that you must tell the patient breaks trust and is inaccurate.<span style=""> </span>There is no ‘one-size-fits-all’ solution to these scenarios. Often, there are solutions neither of you have thought about that will meet everyone’s goals. In other cases, the family may not have thought about the implications of the request (e.g. giving Mom chemotherapy but not telling her she has cancer). <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -12.75pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Negotiate a solution.<span style=""> </span></span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Recommend to the family that you, in their presence, share with the patient a limited amount of information, and then specifically ask the patient if they would like to hear more.<span style=""> </span>Tell the family what you plan on saying, i.e. – <i style="">You came to the hospital because you were not eating well and became dehydrated. We have been trying to figure out what is going on.<span style=""> </span>Some people want to know everything about their medical condition, others prefer the doctors talk with family members about what is happening and the best way to help a patient.<span style=""> </span>What would you prefer?<span style=""> </span></i>Contract with the family that they, and you, will respect the patient’s decision.<span style=""> </span><i style=""><span style=""> </span></i><o:p></o:p></span></p> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bok S. <i style="">Lying: Moral Choice in Public and Private Life</i>. <st1:place st="on"><st1:city st="on">New York</st1:city>, <st1:state st="on">NY</st1:state></st1:place>: Vintage Books; 1989.<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hallenbeck J, Arnold R. A request for nondisclosure: don’t tell mother. <span style=""> </span><i style="">J <span class="SpellE">Clin</span> <span class="SpellE">Oncol</span>. </i>2007; 25(31):5030-34.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lagarde</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> SM, <span class="SpellE">Franssen</span> SJ, van <span class="SpellE">Werven</span> JR, et al.<span style=""> </span>Patient preferences for the disclosure of prognosis after <span class="SpellE">esophagectomy</span> for cancer with curative intent.<span style=""> </span><i style="">Ann <span class="SpellE">Surg</span> <span class="SpellE">Oncol</span>. </i>2008; 15(11):3289-3298.<span style=""> </span><o:p></o:p></span></li></ol> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations:<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">University of Pittsburgh Medical Center, Pittsburgh, PA (EC); Medical College of Wisconsin, Milwaukee, WI (DAR).<o:p></o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, <st1:place st="on"><st1:placename st="on">Palliative</st1:placename> <st1:placename st="on">Care</st1:placename> <st1:placetype st="on">Center</st1:placetype></st1:place>, <span class="GramE">Medical</span> College of Wisconsin. <span class="GramE">For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.</span><span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, <span class="GramE">are</span> available at EPERC: <a href="http://www.eperc.mcw.edu/">www.eperc.mcw.edu</a>.<span style=""> </span>Readers can comment on this publication at the <i style="">Fast Facts and Concepts Discussion Blog</i> (<a href="http://epercfastfacts.blogspot.com/">http://epercfastfacts.blogspot.com</a>). <o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-70094377229834956602009-08-07T10:49:00.000-05:002009-08-07T10:50:29.961-05:00#218: Managing Wound Odor<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #218<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">MANAGING WOUND ODOR<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bansari Patel APN and Deon Cox-Hayley DO</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p><br /></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Foul-smelling non-healing wounds are common in patients nearing the end-of-life, whether from pressure ulcers, vascular disease, or tumors. Strong wound odors can lead to social and physical isolation, altered patient body image and self-worth, and can challenge caregivers. This Fast Fact will discuss a practical approach to ameliorating wound odors. See also <i style="">Fast Facts</i> #40 and #41 (pressure ulcers), #46 (malignant wounds), and #185 (topical opioids).<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pathophysiology</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>Most wound odors are thought to be due the metabolic processes of anaerobic bacteria, which colonize devitalized tissue.<span style=""> </span>Deeper infection (e.g. cellulitis, necrotizing infections) are not necessary for significant odor generation.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Management</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>While it should be addressed, treatment of the underlying cause of the wound is often limited in patients with advanced illnesses.<span style=""> </span>In all circumstances, attempts at ameliorating wound odor are important – whether by treating the cause of the odor or hiding the odor. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Addressing the cause of the odor:<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Remove the wound bed contaminants</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> (e.g. debride the wound of necrotic tissue).<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Control infection</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">. There are several approaches, all aimed at controlling anaerobic growth.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Topical <span class="SpellE">Metronidazole</span></span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> is available as a commercially produced gel.<span style=""> </span><span class="SpellE">Metronidazole</span> gel is applied directly to the wound once or twice daily. Studies have shown decreases in wound odor in 2-3 days, and application is usually continued for up to 2 weeks. Courses can be repeated if needed. In one study, 63% of patients had complete eradication of odor after a course of metronidazole gel, with the remainder reporting improvements. Costs can range from dollars for compounded gels to ~$45-$75 for 45 gm of commercial gel.<span style=""> </span><span class="SpellE">Metronidazole</span> tablets can also be broken and the powder contents sprinkled into the wound.<span style=""> </span>Applying dressings soaked in a mixture of normal saline and metronidazole has also been reported as helpful for controlling odor.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Systemic <span class="SpellE">Metronidazole</span></span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> can be used if there is evidence of deep tissue infection causing foul odor. 500 mg 3 or 4 times daily IV or orally is used, instead of or in addition to topical metronidazole.<span style=""> </span>Systemic side effects such as nausea and diarrhea can occur.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Topical Silver Sulfadiazine</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> has been shown to be helpful in controlling odors of superficial wounds.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cadexomer</span></u></span><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> Iodine</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> is an antimicrobial agent containing slow release iodine and has been shown to decrease bacterial counts and odor from venous ulcers. Ointment, powder and impregnated bandage forms are available. <span class="SpellE">Cadexomer</span> iodine has the added benefit of <span class="GramE">absorbing</span> <span class="SpellE">exudate</span> and can be particularly helpful when <span class="SpellE">exudate</span> absorption and odor control are both needed. It can cause a burning sensation upon application.<i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Yogurt or buttermilk</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">, applied for 15 minutes after a wound is cleaned, <span class="GramE">have</span> been reported to control malignant wound odor, though studies are limited. They are thought to control bacterial proliferation by lowering a wound’s pH.<span style=""> </span><span style=""> </span><i style=""><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 45pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Honey</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> can be <span class="SpellE">bacteriocidal</span>, and has been increasingly studied for wound healing.<span style=""> </span>There is some evidence that it decreases odor.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.4in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hiding the odor:<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Aromatics</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>Scented candles, air freshener sprays, peppermint and other essential oils, coffee beans or grounds, and cider vinegar in a pan are all used to hide odors.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Courier New";"><span style="">o<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Adsorbents:</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> Charcoal adsorbs aromatic molecules. A basket of charcoal (briquettes) can be placed discreetly in a patient’s room. Various commercially available charcoal dressings are also available, although expensive. These dressings are applied over the primary dressing and may be re-used as long as they remain dry. Baking soda can be applied between dressing layers to help absorb odor. Cat litter can also be used similarly to charcoal briquettes.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Support and Education</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>There can be great psychosocial distress associated with malodorous wounds: embarrassment, shame, and isolation. In addition to wound care specialists, psychological and spiritual support services can be important in helping patients and families cope with a chronic wound. Educate the patient and caregivers about the management of chronic wounds, and commit to controlling odor as much as possible.<span style=""> </span>Health care providers should be trained to avoid demonstrating distress at odors in front of or in hearing distance of patients or families.<span style=""> </span><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Alvarez O, Meehan M, Ennis W, et al. Chronic Wounds: Palliative Management for the Frail Population Part III. <i style=""><span style=""> </span>Wounds.</i> 2002; 14(8S):13-18.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bates-Jensen B, Seaman S, Early L. Skin Disorders: Tumor Necrosis, Fistulas, and Stomas.<span style=""> </span><span style=""> </span>In: <span class="SpellE">Ferrel</span> B, Coyle N, eds. <i style="">Textbook of Palliative Nursing</i>. <st1:place st="on"><st1:city st="on">New York</st1:city>, <st1:state st="on">NY</st1:state></st1:place>: Oxford University Press; 2006: pp330-333.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cooper RA, Jenkins L. A comparison between medical grade honey and table honeys in relation to antimicrobial efficacy. <i style="">Wounds. </i>2009; Issue 2 February. Available at:<span style=""> </span><a href="http://www.woundsresearch.com/content/a-comparison-between-medical-grade-honey-and-table-honeys-relation-antimicrobial-efficacy">http://www.woundsresearch.com/content/a-comparison-between-medical-grade-honey-and-table-honeys-relation-antimicrobial-efficacy</a>.<span style=""> </span>Accessed May 12, 2009. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fonder M, <span class="SpellE">Lazurus</span> G, Cowan D, et al. <span class="GramE">Treating</span> the chronic wound: A practical approach to the care of <span class="SpellE">nonhealing</span> wounds and wound care dressings. <i style="">J Am <span class="SpellE">Acad</span> <span class="SpellE">Dermatol</span></i>. 2008; 58:185-206.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">5)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Kalinski</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> C, <span class="SpellE">Schneph</span> M, <span class="SpellE">Laboy</span> D, et al. Effectiveness of a Topical Formulation Containing Metronidazole for Wound Odor and <span class="SpellE">Exudate</span> Control. <i style="">Wounds.</i> 2005; 17(4):84-90.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">6)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">McDonald A, Lesage P. Palliative Management of Pressure Ulcers and Malignant Wounds in Patients with Advanced Illness. <i style=""><span style=""> </span>J <span class="SpellE">Palliat</span> Med. </i>2006; 9(2):285-295.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">7)<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Sussman</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> C, Jensen-Bates B. <i style="">Wound Care: A Collaborative Practice Manuel</i>. <st1:place st="on"><st1:city st="on">Philadelphia</st1:city>, <st1:state st="on">PA</st1:state></st1:place>: Lippincott Williams & Wilkins; 2006. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations:<span style=""> </span></span></b><st1:placetype st="on"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">University</span></st1:placetype><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> of <st1:placename st="on">Chicago</st1:placename>, <st1:place st="on"><st1:city st="on">Chicago</st1:city>, <st1:state st="on">Illinois</st1:state></st1:place>.<o:p></o:p></span></p> <p class="MsoNormal" style=""><b><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fast Facts and Concepts</span></i></b><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">are edited by Drew A. Rosielle MD, Palliative Care Center, <span class="GramE">Medical</span> College of Wisconsin. <span class="GramE">For more information write to: <a href="mailto:drosiell@mcw.edu"><span style="">drosiell@mcw.edu</span></a>.</span><span style=""> </span>More information, as well as the complete set of <i style="">Fast Facts</i>, <span class="GramE">are</span> available at EPERC: <a href="http://www.eperc.mcw.edu/">www.eperc.mcw.edu</a>.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Copyright/Referencing Information</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: Users are free to download and distribute <i style="">Fast Facts</i> for educational purposes only.<span style=""> </span><span class="GramE">Patel B, Cox-Hayley D.</span><span style=""> </span><span class="GramE">Managing Wound Odor.</span><span style=""> </span><span class="GramE"><i style="">Fast Facts and Concepts</i>.</span><span style=""> </span><span class="GramE">August 2009; 218.</span><span style=""> </span>Available at:<span style=""> </span>http://www.eperc.mcw.edu/fastfact/ff_218.htm.<o:p></o:p></span></p> <p class="MsoNormal" style=""><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disclaimer:</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Fast Facts and Concepts</i> provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some <i style="">Fast Facts</i> cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. </span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></b></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-82861323059903129542009-07-03T13:27:00.000-05:002009-07-03T13:28:18.650-05:00#217 Restless Leg Syndrome<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #217</span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">RESTLESS LEG SYNDROME <o:p><br /></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Jennifer Johnson MD, PhD and Robert Arnold MD<o:p></o:p></span></b></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><span style=""> </span>Restless Leg Syndrome (RLS) is a neurologic disorder characterized by unpleasant sensations in the legs causing an uncontrollable urge to move when at rest in an effort to relieve those feelings. Between 2-15% of the population have RLS, with a peak incidence between 40 and 60 years of age and a 1:2 <span class="SpellE">male<span class="GramE">:female</span></span> ratio. <span style=""> </span>It occurs more frequently in end-stage renal disease patients on chronic hemodialysis (up to 60%, depending on the series), and in patients with Parkinson’s disease (up to 20%) than in the general public.<span style=""> </span>RLS disrupts sleep, can lead to<span style="color: black;"> excessive daytime sleepiness, depression, and a decreased quality of life.<span style=""> </span>This <i style="">Fast Fact</i> will review its evaluation and management.<o:p></o:p></span></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Causes<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">The etiology of primary RLS is unknown although it is thought to be a genetic disorder involving either central or peripheral <span class="SpellE">dopaminergic</span> pathways. Common secondary causes of RLS are <span class="SpellE">polyneuropathies</span>; diabetes mellitus; rheumatologic diseases such as rheumatoid arthritis, <span class="SpellE">Sjogren’s</span> syndrome, and fibromyalgia; renal failure; pregnancy; iron deficiency; and hypo- or hyperthyroidism. Drugs including nicotine, caffeine, alcohol, 2<sup>nd</sup> generation antidepressants such as SSRIs and SNRIs, neuroleptic agents, dopamine-blocking <span class="SpellE">antiemetics</span> such as metoclopramide, and sedating antihistamines are all known to worsen RLS symptoms.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;"><o:p></o:p></span><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Symptoms and Diagnosis<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">The International RLS Study Group and the National Institutes of Health (NIH) criteria for diagnosis include: (1) an urge to move the legs, (2) temporary relief with movement, (3) onset or worsening of symptoms with rest or inactivity, and (4) worsening or onset of symptoms in the evening or night (3).<span style=""> </span>Patients describe symptoms of trouble falling asleep, trouble getting back to sleep, "a funny feeling in the legs," or a "creepy or crawly feeling in the legs."<span style=""> </span>Patients or their bed partners may also report ‘periodic limb movements of sleep’: stereotyped, repetitive flexion movements (‘jerking’) of the legs and occasionally arms, exacerbated when patients lie down for prolonged periods.<span style=""> </span>RLS is a clinical diagnosis for which there is not a confirmatory diagnostic test. It should be differentiated from <span class="SpellE">akathisia</span>, a constant and generalized feeling of motor restlessness not associated with leg discomfort or rest. It can be differentiated from peripheral neuropathies, <span class="SpellE">lumbosacral</span> <span class="SpellE">radiculopathy</span>, and ordinary leg cramps by its circadian rhythm, relief with movement, and the prominence of pain symptoms in non-RLS syndromes.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Treatment<span style=""> </span><span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Address any treatable secondary causes of RLS (e.g. with iron repletion or <span class="SpellE">levothyroxine</span>) and work with patients to avoid drugs and medications known to aggravate RLS. <span style=""> </span>Distraction activities such as playing video games or crossword puzzles can decrease symptoms during wakeful periods.<span style=""> </span>Drug treatment is recommended for patients who have not improved despite conservative interventions or <span class="GramE">who</span> have persistent, distressing symptoms.<span style=""> </span>Given the paucity of studies comparing different drugs, experts recommend the following (14):<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 31.5pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol; color: black;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Dopamine agonists</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">:<span style=""> </span>The most frequently used drugs are the dopamine agonists, <a name="OLE_LINK15"></a><span class="SpellE"><span style="">pramipexole</span></span><span style=""> and <span class="SpellE">ropinirole</span></span>. Both have been determined to be effective in industry-funded, double-blind, placebo-controlled studies (7, 8). Doses as low as 0.125 mg of <span class="SpellE">pramipexole</span> at bedtime or 0.25 mg of <span class="SpellE">ropinirole</span> are effective in improving sleep and decreasing discomfort in mild-to-moderate cases. Doses of greater than 0.75 mg/day of <span class="SpellE">pramipexole</span> or 4 mg/day of <span class="SpellE">ropinirole</span> are of unproven benefit.<span style=""> </span>Side effects are usually mild, transient, and limited to nausea, lightheadedness, and fatigue. Both drugs cost roughly $100 (US) a month at the starting dose. While there are small series showing the effectiveness of <span class="SpellE">levodopa</span>/<span class="SpellE">carbidopa</span>, experts have recommended it only be used for intermittent RLS because of worries that <span class="SpellE">levodopa</span> may cause augmentation, rebound, or recurrence of symptoms. Finally, <span class="SpellE">cabergoline</span>, a dopamine agonist with a long half life may be useful for patients who experience rebound symptoms with shorter acting agents, although it is not FDA approved for this purpose.<b style=""><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-left: 31.5pt; text-indent: -0.25in;"><!--[if !supportLists]--><span class="MsoCommentReference"><span style="font-size: 10pt; font-family: Symbol; display: none;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></span><!--[endif]--><u><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Other agents:</span></u><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;"><span style=""> </span>There are small studies indicating that benzodiazepines (9), opioids (10), and select anticonvulsants such as gabapentin and <span class="SpellE">carbamazepine</span> (11, 12, <span class="GramE">13</span>) are effective in RLS.<span style=""> </span>Expert opinion, however, generally recommends these drugs as second line agents due to the paucity of data supporting their use relative to dopamine agonists, side effects, and risk of abuse.</span><span class="MsoCommentReference"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; display: none;"><o:p></o:p></span></span></p> <p class="MsoNormal"><span class="MsoCommentReference"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; display: none;"><o:p> </o:p></span></span></p> <p class="MsoNormal"><span class="MsoCommentReference"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; display: none;"><o:p> </o:p></span></span></p> <p class="MsoNormal"><span class="MsoCommentReference"><span style="font-size: 10pt; font-family: "Arial","sans-serif"; display: none;"><o:p> </o:p></span></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Phillips B, Young T, Finn L, et al. Epidemiology of restless legs symptoms in adults. <i style="">Arch Intern Med</i>. 2000; 160:2137-2141.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Zucconi</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> M, <span class="SpellE">Ferini-Strambi</span> L. Epidemiology and clinical findings of restless legs syndrome. <i style="">Sleep Med</i>. 2004; 5:293-299.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Allen RP, <span class="SpellE">Picchietti</span> D, <span class="SpellE">Hening</span> WA, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. <i style="">Sleep Med</i>. 2003; 4:101-119.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Connor JR, Wang XS, Patton SM, et al. Decreased <span class="SpellE">transferrin</span> receptor expression by <span class="SpellE">neuromelanin</span> cells in restless legs syndrome. <i style="">Neurology</i>. 2004; 62:1563-1567.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pittock</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> SJ, Parrett T, Adler CH, et al. Neuropathology of primary restless leg syndrome: absence of specific tau- and alpha-<span class="SpellE">synuclein</span> pathology. <span class="SpellE"><i style="">Mov</i></span><i style=""> <span class="SpellE">Disord</span></i>. 2004; 19:695-699.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Silber MH, Richardson JW. Multiple blood donations associated with iron deficiency in patients with restless legs syndrome. <i style="">Mayo <span class="SpellE">Clin</span> Proc</i>. 2003; 78:52-54.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Montplaisir</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> J, Nicolas A, <span class="SpellE"><span class="GramE">Denesle</span></span> R, Gomez-<span class="SpellE">Mancilla</span> B. Restless legs syndrome improved by <span class="SpellE">pramipexole</span>: a double-blind randomized trial.<i style=""> Neurology</i>.1999; 52:938-943. <o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Adler CH, Hauser RA, <span class="SpellE">Sethi</span> K, et al. <span class="SpellE">Ropinirole</span> for restless legs syndrome: a placebo-controlled crossover trial. <i style="">Neurology</i>. 2004; 62:1405-1407.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Peled</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> R, <span class="SpellE">Lavie</span> P. Double-blind evaluation of <span class="SpellE">clonazepam</span> on periodic leg movements in sleep. <i style="">J <span class="SpellE">Neurol</span> <span class="SpellE">Neurosurg</span> Psychiatry.</i> 1987; 50:1679-1681. <o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Ondo</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> WG. Methadone for refractory restless legs syndrome. <span class="SpellE"><i style="">Mov</i></span><i style=""> <span class="SpellE">Disord</span></i>. 2005; 20:345-348.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Telstad</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> W, Sorensen O, Larsen S, et al. Treatment of the restless legs syndrome with <span class="SpellE">carbamazepine</span>: a double blind study. <i style="">BMJ.</i> 1984; 288:444-446. <o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Garcia-<span class="SpellE">Borreguero</span> D, <span class="SpellE">Larrosa</span> O, de la <span class="SpellE">Llave</span> Y, et al. Treatment of restless legs syndrome with gabapentin: a double-blind, cross-over study. <i style="">Neurology</i>. 2002; 59:1573-1579.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Eisensehr</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> I, Ehrenberg BL, Rogge Solti S, <span class="SpellE">Noachtar</span> S. Treatment of idiopathic restless legs syndrome (RLS) with slow-release <span class="SpellE">valproic</span> acid compared with slow-release <span class="SpellE">levodopa</span>/<span class="SpellE">benserazide</span>. <i style="">J Neurol</i>. 2004; 251:579-583.<o:p></o:p></span></li><li class="MsoNormal" style="color: black;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Silber MH, Ehrenberg BL, Allen RP, et al. An algorithm for the management of restless legs syndrome. <i style="">Mayo <span class="SpellE">Clin</span> Proc.</i> 2004; 79(7):916-22.<o:p></o:p></span></li></ol> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">Author Affiliations:<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;">University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.<o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;"><o:p> </o:p></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"></span><span style="font-size: 10pt;"><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; color: black;"><o:p> </o:p></span></b></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-88082569508059000782009-07-03T13:00:00.000-05:002009-07-03T13:30:05.420-05:00#216 Asking About Cultural Beliefs in Palliative Care<p class="MsoNormal" style="text-align: center;" align="center"><span class="xapple-style-span"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #216<o:p></o:p></span></b></span></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><span class="xapple-style-span"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">Asking about cultural beliefs in palliative care<o:p></o:p></span></b></span></p> <p class="MsoNormal" style="text-align: center;" align="center"><span class="xapple-style-span"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hillary <span class="SpellE">Lum</span> MD, PhD and Robert Arnold MD<o:p></o:p></span></b></span></p> <p class="MsoNormal"><span class="xapple-style-span"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b></span><span class="xapple-style-span"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Patients’ cultural backgrounds profoundly influence their preferences and needs regarding discussing bad news, decision-making, and the dying experience.<span style=""> </span>This <i style="">Fast Fact</i> offers a framework for taking a ‘cultural history’ to better understand a patient’s and family’s needs.<span style=""> </span>See also these related <i style="">Fast Facts</i>: #17 (illness experience), #19 (spiritual history), #26 (explanatory model), #183/184 (conflict resolution).<span style=""> </span><o:p></o:p></span></span></p> <p><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">C – Communication. </span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;">Identify the patient’s preferences regarding how and to whom medical information is shared. <i style="">Some people want to know everything about their medical condition, and others do not. How much would you like to know? <span style=""> </span></i>For those who request that the <span class="GramE">physician discuss</span> their condition with family members: <i style="">Would you like me to speak with them alone, or would you like to be present? </i>Identify main contacts to give information to about the patient’s condition. Carefully explore with families requests to hide information from a patient (see references 4 and 5) – a future <i style="">Fast Fact </i>will address this topic in more detail.</span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></strong></p> <p><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">U – Unique cultural values. </span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Use respectful, curious, and open-ended questions about a patient’s cultural heritage to identify their values. <em><span style="font-family: "Arial","sans-serif";">Is there anything that would be helpful for me to know about how you and your family view serious illness? Are there cultural beliefs, practices, or preferences that affect you during times of significant illness? </span></em><em><span style="font-family: "Arial","sans-serif"; font-style: normal;">If the patient is open to discussing death: </span></em><em><span style="font-family: "Arial","sans-serif";">What concerns do you have about dying? Are there things that are important to you or your family that I should know about?</span></em><em><b style=""><span style="font-family: "Arial","sans-serif"; font-style: normal;"> </span></b></em><em><span style="font-family: "Arial","sans-serif"; font-style: normal;"><o:p></o:p></span></em></span></p> <p><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">L – Locus of decision-making. </span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;">For some patients medical decision-making is communally driven rather than individualistic. Multiple family members or a community elder or leader may need to be involved, often without prior official documentation because it is assumed or understood from the patient’s perspective. <i style="">Do you prefer to make medical decisions about tests and treatments yourself, or would you prefer that others in your family or community make them for you? </i></span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></strong></p> <p><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">T – Translators.</span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"> Language barriers are extremely challenging, especially during times of severe illness. Utilize medical interpreters frequently and effectively. Refer to <i style="">Fast Fact</i> </span></strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">#154 for a detailed discussion on using interpreters in palliative care.<strong><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></strong></span></p> <p style="margin: 0in 0in 0.0001pt;"><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">U – Understanding the patient and learning as a provider.</span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"> Reassess what is being heard, understood, <span class="GramE">and</span> agreed upon frequently, from both the patient’s and clinician’s standpoint. Specifically confirm the patient’s understanding or agreement (beyond nodding or “yes” responses).<span style=""> </span>This is particularly important if a medical translator is involved as miscommunication is common even when using trained medical interpreters – see reference (6). <i style="">Can you tell me – in your own words – what you have heard from me and what’s most important to you about what I’ve said?</i></span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></strong></p> <p style="margin: 0in 0in 0.0001pt;"><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></strong></p> <p style="margin: 0in 0in 0.0001pt;"><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">R – Ritualized practices and restrictions.</span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"> Determine if there are specific customs the patient desires to be followed. These must be communicated to other health care providers, especially in the hospital setting. It may be necessary to advocate for the patient and negotiate with healthcare facility administrators to find an agreeable way to honor a patient’s wishes. </span></strong><em><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Are there specific practices that you would like to have in the hospital or at home? Are there aspects of medical care that you wish to forgo or have withheld because of your cultural beliefs? Is anything discouraged or forbidden? </span></em><span style="font-size: 10pt; font-family: "Arial","sans-serif";">If the patient is approaching death, and willing to discuss it: <em><span style="font-family: "Arial","sans-serif";">Are there specific practices that are important to you at the time of death or afterwards that we should know about?</span></em><em><span style="font-family: "Arial","sans-serif"; font-style: normal;"><o:p></o:p></span></em></span></p> <p><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">E – Environment at home.</span></strong><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"> Given that a majority of hospice care happens in the patient’s home environment, respectfully explore whether there are any needs that can be met by the health care system, and how open the patient, family or community is to receiving care at home. Recognize that patients may be hesitant to voice needs, or resistant to accepting help from outside the community.<span style=""> </span>Even if a trusting, collaborative relationship has developed between a patient/family and clinicians in the hospital, this may not immediately translate into the home setting.<span style=""> </span>With the patient’s permission, expectations about cultural-specific aspects of a patient’s care should be explicitly communicated to care providers outside the hospital.<span style=""> </span></span></strong><em><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-style: normal;"><o:p></o:p></span></em></p> <p class="MsoNormal" style=""><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <ol style="margin-top: 0in;" start="1" type="1"><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Searight</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> HR, <span class="SpellE">Gafford</span> J. Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians. <i style="">Am <span class="SpellE">Fam</span> Phys.</i> 2005; 71 (3)<o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Crawley LM, et al. Strategies for Culturally Effective End-of-Life Care. <i style="">Ann Internal Med.</i> 2002; 136:673-679.<o:p></o:p></span></li><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Maugans</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> TA. The <span class="SpellE">SPIRITual</span> History. <i style="">Arch <span class="SpellE"><span class="GramE">Fam</span></span> Med</i>. 1997; 5:11-16.</span><!--[if !supportLists]--><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></strong><!--[endif]--><st1:city st="on"><st1:place st="on"><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;">Arnold</span></strong></st1:place></st1:city><strong><span style="font-size: 10pt; font-family: "Arial","sans-serif"; font-weight: normal;"> R. Palliative Care Case of the Month: The Family Says Not to Tell.<span style=""> </span>University of Pittsburgh Institute to Enhance Palliative Care.<span style=""> </span>May 2006.<span style=""> </span>Available at:<span style=""> </span>h</span></strong><span style="font-size: 10pt; font-family: "Arial","sans-serif";">ttp://www.dgim.pitt.edu/SPC/cases/May 06.doc.<strong><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></strong></span></li></ol><ol start="5" type="1"><li class="MsoNormal" style=""><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hallenbeck</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> J, Arnold R. A request for non-disclosure: don’t tell mother. <a href="javascript:AL_get(this,%20'jour',%20'J%20Clin%20Oncol.');"><i style=""><span style="color: windowtext; text-decoration: none;">J <span class="SpellE">Clin</span> <span class="SpellE">Oncol</span></span></i><span style="color: windowtext; text-decoration: none;">.</span></a> 2007; 25(31):5030-4. <o:p></o:p></span></li><li class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pham K, et al. Alterations During Medical Interpretation of ICU Family Conferences That Interfere With or Enhance Communication.<cite><span style="font-family: "Arial","sans-serif";"> Chest.</span></cite><span class="slug-pub-date"><i> </i><span style=""><span style=""> </span>2008; </span></span><span class="slug-vol"><span style="">134(1):</span></span><span class="slug-pages"><span style="">109-116.</span><o:p></o:p></span></span></li></ol> <span class="slug-pages"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations:<span style=""> </span></span></b></span><span class="slug-pages"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.</span></span>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-48087019830830982052009-05-21T13:37:00.000-05:002009-05-21T13:39:14.510-05:00#215 Opioid-Poorly Responsive Cancer Pain<div class="Section1"> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">FAST FACTS AND CONCEPTS #215<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif"; text-transform: uppercase;">Opioid Poorly-Responsive Cancer Pain<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tamara Sacks MD, David E Weissman MD, and Robert Arnold MD<o:p></o:p></span></b></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Relief of cancer pain from opioids is rarely all or nothing; most patients experience some degree of analgesia alongside opioid toxicities.<span style=""> </span>When the balance of analgesia versus toxicity tips away from analgesia, the term ‘opioid poorly-responsive pain’ is invoked.<span style=""> </span>While opioid poorly-responsive pain is not a discreet syndrome, it is a commonly encountered clinical scenario.<span style=""> </span>This <i style="">Fast Fact</i> reviews key points in its assessment and management</span><span style="font-size: 10pt;">.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt;"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Differential Diagnosis of Opioid Poorly-Responsive Pain<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.5in;"><!--[if !supportLists]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></i><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cancer-related pain<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cancer progression (new fracture at site of known bone metastases).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Causes of pain (<span class="SpellE">eg</span>. neuropathic pain, skin ulceration, rectal <span class="SpellE">tenesmus</span>, muscle pain) that are known to be less responsive to systemic opioids or opioid <span class="SpellE">monotherapy</span>.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">c.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Psychological/spiritual pain related to the cancer experience (existential pain of impending death).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.5in;"><!--[if !supportLists]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></i><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Opioid pharmacology/technical problems<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Opioid tolerance (rapid dose escalation with no analgesic effect).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dose-limiting opioid toxicity (sedation, delirium, hyperalgesia, nausea – see <i style="">Fast Facts</i> #25, 142).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">c.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Poor oral absorption (for <st1:place st="on">PO</st1:place> meds) or skin absorption (e.g. <span class="SpellE">transdermal</span> patch adhesive failure).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">d.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pump, needle, or catheter problems (IV, subcutaneous, or spinal opioids).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.5in;"><!--[if !supportLists]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></i><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Non-cancer pain<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Worsening of a known non-cancer pain syndrome (diabetic neuropathy).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">New non-cancer pain syndrome (dental abscess).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.5in;"><!--[if !supportLists]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></i><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Other psychological problems<span style=""> </span><o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Depression, anxiety, somatization, hypochondria, factitious disorders.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dementia and delirium both can <span class="GramE">effect</span> a patient’s report of and experience of pain.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">c.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Opioid substance use disorders or opioid diversion.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Management Strategy<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;"><!--[if !supportLists]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span></i><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Initial Steps<o:p></o:p></span></i></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Complete a thorough pain assessment including questions exploring psychological and spiritual concerns. If substance abuse or diversion is suspected, complete a substance abuse <span class="GramE">history</span> (see <i style="">Fast Facts</i> #68, 69).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Complete a physical examination and order diagnostic studies as indicated.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">c.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Escalate a single opioid until acceptable analgesia or unacceptable toxicity develop, or it is clear that additional analgesic benefit is not being derived from dose escalation.<span style=""> </span>If this fails, consider: <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 81pt; text-indent: -81pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""><span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span>i.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Rotating to a different opioid (e.g. morphine to methadone).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 81pt; text-indent: -81pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""><span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span>ii.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Changing the route of administration (e.g. oral to subcutaneous).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">d.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Treat opioid toxicities aggressively.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">e.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Use (start or up-titrate) adjuvant analgesics, especially for neuropathic pain syndromes.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">f.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Integrate non-pharmacological treatments such as behavioral therapies, physical modalities like heat and cold, and music and other relaxation-based therapies – see <i style="">Fast Fact </i>#211.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Additional steps – </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pain refractory to the initial steps requires multi-disciplinary input and care coordination.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">a.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hospice/Palliative Medicine consultation to optimize pain assessment, drug management, and assessment of overall care goals.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">b.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Mental health consultation for help in diagnosis and management of suspected psychological factors contributing to pain.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">c.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Chaplain/Clergy assistance for suspected spiritual factors contributing to pain.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">d.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Interventional Pain and/or Radiation Oncology consultation.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 1in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">e.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Rehabilitation consultations (<span class="SpellE">Physiatry</span>, Physical and Occupational Therapy) to maximize physical analgesic modalities.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 1in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">f.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pharmacist assistance with drug/route information. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Mercadante</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> F, <span class="SpellE">Portenoy</span> RK. Opiate Poorly Responsive Cancer Pain Parts 1-3. <i style="">J Pain Symptom Management.</i> 2001; 21(2):144-150, 21(3):255-264, 24(4):338-354.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Smith TJ, <span class="SpellE">Staats</span> PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival<i style="">. J <span class="SpellE">Clin</span> <span class="SpellE">Oncol</span></i>. 2002; <span style="">20</span>(19):4040-9.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Fallon M. When morphine does not work. <i style="">Support Care Cancer. </i>2008; 16(7):771-5.<u><o:p></o:p></u></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Quigley C. Opioid switching to improve pain relief and drug tolerability. <i>Cochrane Database of Systematic Reviews.</i> 2004, Issue 3. Art. No.: CD004847. DOI: 10.1002/14651858.CD004847.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">5.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hanks%20GW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract"><span style="color: windowtext; text-decoration: none;">Hanks GW</span></a>.<span style=""> </span>Opioid-responsive and opioid-non-responsive pain in cancer. <a href="javascript:AL_get(this,%20'jour',%20'Br%20Med%20Bull.');"><i style=""><span style="color: windowtext; text-decoration: none;">Br Med Bull</span></i><span style="color: windowtext; text-decoration: none;">.</span></a> 1991; 47(3):718-31.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hanks G, Forbes K. Opioid responsiveness.<span style=""> </span><span class="SpellE"><i style="">Acta</i></span><i style=""> <span class="SpellE">Anaesthesiologica</span> Scand.</i>1997; 41:154-158.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliations:<span style=""> </span></span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";">University of <st1:placename st="on">Pittsburgh</st1:placename> <st1:placename st="on">Medical</st1:placename> <st1:placetype st="on">Center</st1:placetype>, <st1:city st="on">Pittsburgh</st1:city>, <st1:state st="on">Pennsylvania</st1:state> (TS, RA), and <st1:placename st="on">Medical</st1:placename> <st1:placetype st="on">College</st1:placetype> of <st1:state st="on">Wisconsin</st1:state>, <st1:place st="on"><st1:city st="on">Milwaukee</st1:city>, <st1:state st="on">Wisconsin</st1:state></st1:place> (DEW).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"></span></p> </div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-7905087023662191342009-05-21T13:33:00.001-05:002009-05-21T13:37:30.802-05:00#214: Prognosis in HIV Associated Malignancies<p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #214<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">PROGNOSIS IN HIV ASSOCIATED MALIGNANCIES<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><st1:personname st="on"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Steven Oppenheim</span></b></st1:personname><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> MD<o:p></o:p></span></b></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Background</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><i style="">Fast Fact </i>#213 introduced prognostic principles in HIV/AIDS, as well as gave survival data for many life-threatening complications of HIV infection.<span style=""> </span>This <i style="">Fast Fact</i> presents survival data for malignancies commonly arising in the setting of HIV/AIDS.<span style=""> </span>Before applying these data to individual patients, consideration should be given to the prognostic principles in HIV/AIDS discussed in <i style="">Fast Fact</i> #213.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Prognostic Data <o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 24pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">AIDS related</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">Kaposi’s sarcoma (KS)</i>, has become less common since the use of combination antiretroviral therapy (cART). It is a grossly <span class="SpellE">violaeous</span> spindle cell tumor, more common amongst men who have sex with men, and is associated with co-infection with human herpes virus-8. KS can involve the skin, mucous membranes, and viscera. Some patients with mild to moderate KS may have complete resolution of their disease with cART and/or chemotherapy. More extensive disease of the skin or viscera portends a poorer prognosis with a 2 year survival of 58%.<span style=""> </span>A prognostic index has been developed for patients with KS on cART.<span style=""> </span>In this index age > 50 years, developing KS as a later-stage complication of HIV infection (as opposed to KS being a patient’s first AIDS-defining illness), CD4 cell count <100 style=""> </span>Patients with all 4 poor markers had a 1 year survival of ~40%.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 24pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Primary CNS lymphoma </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">is strongly associated with Epstein Barr virus infection. Treatments include cART, whole brain radiation and chemotherapy. Median survival was 3 months before the use of cART, but has improved to16 months for those responding to cART (with ≥ 50 CD4 cell count increase over their baseline count or ≥ 0.5log</span><span style="font-size: 8pt; font-family: "Arial","sans-serif";">10</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";">* HIV viral load decrease after lymphoma diagnosis).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 24pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Systemic non-Hodgkin’s Lymphoma </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">(Diffuse Large Cell Lymphoma - DLCL) is the most common lymphoma associated with HIV infection. A decreased incidence has not been observed with cART, although survival in HIV patients is now approaching that of DLCL patients without HIV.<span style=""> </span>5 year survival with current chemotherapy regimens is approximately 50%. A well-validated tool for stratifying DLCL survival is the International Prognostic Index (IPI) which includes age, tumor stage, serum LDH, performance status, and number of <span class="SpellE">extranodal</span> disease sites. Patients with intermediate-risk IPI scores have a 50-64% 3 year survival. However patients with high-risk IPI scores have only a 13% 3 year survival, even in the cART era (see references 3, 9).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 24pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Squamous</span></i></span><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> cell carcinoma (SCC) of the cervix </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">is seen frequently in patients with HIV and is caused by the human <span class="SpellE">papilloma</span> virus. Survival data are limited for HIV infected patients, but it appears to be <span class="GramE">similar</span> to patients without HIV infection and is unaffected by the use of or response to cART. Five year survival of SCC of the cervix is 86% for locally invasive disease, 43% with regional disease, and 11% with metastatic disease.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 24pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Squamous</span></i></span><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> cell carcinoma (SCC) of the anus, </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">while not officially an AIDS-defining malignancy, is 120 times more common in HIV infected than non-infected patients and is also associated with human <span class="SpellE">papilloma</span> virus infection. Survival does not seem to be affected by HIV status, with overall 2 year survival in the ~75% range.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">* 0.5 log</span><span style="font-size: 8pt; font-family: "Arial","sans-serif";">10</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> decrease equals, for instance, a decrease of 4.0 to 3.5 log</span><span style="font-size: 8pt; font-family: "Arial","sans-serif";">10</span><span style="font-size: 10pt; font-family: "Arial","sans-serif";">, or 10,000 to 3,160 copies HIV-RNA/ml.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bernstein WB, Little RF, Wilson WH, <span class="SpellE">Yarchoan</span> R. Acquired Immunodeficiency Syndrome-related malignancies in the era of highly active antiretroviral therapy. <i style="">Int. J Hematology</i>. 2006; 84:3-11.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Biggar</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> RJ, <span class="SpellE">Engles</span> EA, Ly S, et al. Survival after cancer diagnosis in persons with AIDS. <i style="">JAIDS</i>. 2005; 39:293-299.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bower M, <span class="SpellE">Gazzard</span> B, <span class="SpellE">Mandalia</span> S, et al. A prognostic index for systemic AIDS-related non-Hodgkin lymphoma treated in the era of highly active antiretroviral therapy. <i style="">Ann Intern Med</i>. 2005; 143:265-273.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Cheung MC, <span class="SpellE">Pantanowitz</span> L, <span class="SpellE">Dezube</span> BJ. AIDS Related Malignancies: Emerging challenges in the era of highly active antiretroviral therapy. <i style="">The Oncologist</i>. 2005; 10:412-426.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">5.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Chiao</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> EY, Giordano TP, Richardson P, El-<span class="SpellE">Serag</span> HB. Human Immunodeficiency Virus-associated <span class="SpellE">squamous</span> cell cancer of the anus: Epidemiology and outcomes in the highly active antiretroviral <span class="SpellE">therpy</span> era. <i style="">J <span class="SpellE">Clin</span> <span class="SpellE">Onc</span></i>. 2008; 26:474-479.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hentrich</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> M, <span class="SpellE">Maretta</span> L, Chow KU, et al. Highly active antiretroviral therapy (HAART) improves survival in HIV-associated Hodgkin’s disease: results of a multicenter study. <i style="">Ann Oncology.</i> 2006; 17:914-919.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">7.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hoffmann C, <span class="SpellE">Tabrizian</span> S, Wolf E. Survival of AIDS patients with primary central nervous system lymphoma is dramatically improved by HAART-induced immune recovery. <i style="">AIDS</i>. 2001; 15:2119-2127.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">8.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Goldie SJ, Weinstein MC, Kuntz KM, <span class="SpellE">Freedberg</span> KA. The costs, clinical benefits and cost-effectiveness of screening for cervical cancer in HIV-infected women. <i style="">Ann Intern Med</i>. 1999; 130:97-107.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">9.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><st1:street st="on"><st1:address st="on"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Lim ST</span></st1:address></st1:street><span style="font-size: 10pt; font-family: "Arial","sans-serif";">, <span class="SpellE">Karim</span> R, <span class="SpellE">Tulpule</span> A, <span class="SpellE">Nathwani</span> BN, Levine AM. Prognostic factors in HIV-related diffuse large-cell lymphoma: before versus after highly active antiretroviral therapy. <i style="">J <span class="SpellE">Clin</span> <span class="SpellE">Oncol</span></i>. 2005; 23:8477-8482.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">10.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Mounier</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> N, <span class="SpellE">Spina</span> M, <span class="SpellE">Gisselbreght</span> C. Modern management of non-Hodgkin lymphoma in HIV-infected patients. <i style="">Br J <span class="SpellE">Haem</span></i>. 2007; 136:685-698.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">11.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Oehler-Janne</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> C, <span class="SpellE">Huguet</span> F, <span class="SpellE">Provencher</span> S, et al. HIV specific differences in outcome of <span class="SpellE">squamous</span> cell carcinoma of the anal canal: a <span class="SpellE">multicentric</span> cohort study of HIV-positive patients receiving highly active antiretroviral therapy. <i style="">J <span class="SpellE">Clin</span> <span class="SpellE">Onc</span>.</i> 2008; 26:2550-2557.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">12.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span class="GramE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Skiest</span></span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> DJ, Crosby C. Survival is prolonged by highly active antiretroviral therapy in AIDS patients with primary central nervous system lymphoma. <i style="">AIDS</i>. 2003; 17:1787-1793.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">13.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Stebbing</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> J, <span class="SpellE">Sanitt</span> A, Nelson M, <span class="SpellE">Gazzard</span> B, Bower M. A prognostic index for AIDS-associated Kaposi’s sarcoma in the era of highly active antiretroviral therapy. <i style="">Lancet</i>. 2006; 367:1495-1502.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 35.25pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">14.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Uronis</span></span><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> HE, <span class="SpellE">Bendell</span> JC. Anal cancer: an overview. <i style="">The Oncologist</i>. 2007; 12:524-534.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><o:p> </o:p></p> <b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliation:<span style=""> </span></span></b><st1:city st="on"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">San Diego</span></st1:city><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> Hospice at the Institute for Palliative Care, <st1:place st="on"><st1:city st="on">San Diego</st1:city>, <st1:state st="on">California</st1:state></st1:place>.</span>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-56862450334701903952009-03-06T09:41:00.000-06:002009-03-06T09:42:44.309-06:00<p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">FAST FACTS AND CONCEPTS #213<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">PROGNOSIS IN HIV AND AIDS<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><st1:personname st="on"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Steven Oppenheim</span></b></st1:personname><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> MD</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Introduction</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span>The prognosis of patients with HIV/AIDS (Human Immunodeficiency Virus infection/Acquired Immune Deficiency Syndrome) has improved dramatically since 1996 for those who have access to appropriate treatment. <span style=""> </span>Due to the success of combination antiretroviral therapy (cART) since 1996 as well as improvements in the prevention and treatment HIV complications, over 80% of patients are now alive 10 years after sero-conversion,. <span class="MsoCommentReference"><span style="">De</span></span>aths from opportunistic infections (OI) have declined while mortality from other co-morbidities has become more common (e.g. hepatitis B and C infection, renal failure, non-HIV-related cancers, cardiovascular disease, suicide, and complications of substance abuse). In fact, patients with CD4 counts >200 cells/mm3 are more likely to die from non-HIV-related illnesses than they are from complications of AIDS, at least over a time-frame of one decade.<span style=""> </span>This <i style="">Fast Fact</i> discusses prognostication in patients who are suffering life-threatening complications related to HIV infection using data where cART was available. <span style=""> </span><i style="">Fast Fact </i>#214 will discuss prognosis specifically for malignancies arising in the setting of HIV infection.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Prognostic Principles</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Numerous factors affect prognosis such as age, remaining antiviral treatment options, opportunistic infections’ response to therapy, the development of untreatable complications, functional status, nutritional status, CD4 cell count, and HIV viral load. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">In the pre-cART era median survival for people with a CD4 count <></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Due to the rapidly changing field of HIV medicine, close collaboration with the patient’s HIV provider is mandatory. While the following data are the best available they remain incomplete, may become outdated as therapies evolve, and should be applied to individual patients cautiously. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Survival for all the HIV associated complications discussed in this <i style="">Fast Fact</i> has improved due to the use of cART.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Common causes of death in patients with HIV/AIDS with available survival data<span style=""> </span><o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left: 18.7pt; text-indent: -9.35pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disseminated mycobacterium avium complex infection</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>median survival is ~10 months with optimal therapy.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Pneumocystis pneumonia</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">: survival for all patients presenting is 80-90%. Short-term ICU survival is 75% in patients on cART and 37% not on cART. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Disseminated cytomegalovirus infection</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">(including retinitis):</i> the largest prospective cohort study demonstrated a median survival of 35 months for all patients on cART compared with 8 months for those not using cART. Six month survival is 61-73% for patients not taking or not responding to cART, but 98% for patients with low CD4 counts who initiate and respond well to cART (CD4 count increases to over 50 cells/mm3).<span style=""> </span><span style=""> </span><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Toxoplasma</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> <i style="">encephalitis</i>: <span style=""> </span>77-90% of patients are alive after 12 months if on cART, and most who die do so within 6 months of diagnosis. Persistence of altered mental status after initiation of therapy is a strong predictor of early death. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Progressive multifocal leukoencephalopathy</span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">:<span style=""> </span>median survival is ~11 months on cART, 4 months without cART.<span style=""> </span>If cART is started after PML is diagnosed 1 year survival is 58% vs. 24% for those who develop PML already cART.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">AIDS Dementia complex: <span style=""> </span></span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">is caused by HIV and results in progressive cognitive, motor, and behavioral decline. The median survival is 40-81 months from the time of diagnosis; shorter if the CD4 cell count remains <200>5,000 copies/ml.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: Symbol;"><span style="">·<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><i style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">AIDS wasting syndrome: </span></i><span style="font-size: 10pt; font-family: "Arial","sans-serif";">is defined by the involuntary loss of >10% body weight along with fever not associated with an OI or neoplasm, and either chronic diarrhea or weakness. Patients with very low lean body mass index (mass in kilograms/height in meters squared) – less than 14.5kg/m2 – have a median survival of ~16 months.<span style=""> </span>These data are from the mid-1990s and it is unclear if the prognosis has changed in the last decade. With unintentional weight loss which does not meet the syndrome definition (loss of 5-10% body weight) there is still a four-fold increased risk of death over 6 months.<br /> <!--[if !supportLineBreakNewLine]--><br /> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">References</span></b><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Antinori A, Cingolani A, Lorenzini P, et al. Clinical epidemiology and survival of progressive multifocal leukoencephalopathy in the era of highly active antiretroviral therapy: Data from the Italian Registry Investigative Neuro AIDS (IRINA). <i style="">J Neurovirol. </i>2003; 9(suppl 1):47-53.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Antinori A, Larussa D, Cingolani A et al. Prevalence, associated factors and prognostic determinants of AIDS-related Toxoplasmic encephalitis in the era of advanced highly active antiretroviral therapy. <i style="">Clin Infect Dis</i>. 2004; 39:1681-1691.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the Risk of Death After HIV Seroconversion Compared With Mortality in the General Population. <i style="">JAMA</i>. 2008; 300(1):51-59.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Clifford DB, Yiannoutsos C, Glicksman M, et al. HAART improves prognosis in HIV-associated progressive multifocal leykoencephalopathy. <i style="">Neurology.</i> 1999; 52:623-625.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">5.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Coakley E, Samore M, Gillis J, et. Al. The values of quantitative serum HIV-1 RNA levels and CD4 cell counts of <u><</u>50 x 10 6 cells/L. <i style="">AIDS</i>. 2000; 14:1147-1153.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">D’Avignon LC, Schofield CM, <st1:street st="on"><st1:address st="on">Hospenthal DR.</st1:address></st1:street> Pneumocystis Pneumonia. <a href="javascript:AL_get(this,%20'jour',%20'Semin%20Respir%20Crit%20Care%20Med.');"><i style=""><span style="color: windowtext; text-decoration: none;">Semin Respir Crit Care</span></i><i style=""><span style="color: blue; text-decoration: none;"> </span></i><i style=""><span style="color: windowtext; text-decoration: none;">Med</span></i><span style="color: windowtext; text-decoration: none;">.</span></a> 2008; 29(2):132-40.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">7.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dore GJ, MvDonald A, Yueming L, et al. Marked improvement in survival following AIDS dementia complex in the era of highly active antiretroviral therapy. <i style="">AIDS</i>. 2003; 17:1539-1545.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">8.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Dworkin MS, Wan PC, Hanson DL, Jones JL. Progressive Multifocal leukoencephalopathy: Improved survival of human immunodeficiency virus-infected patients in the protease-inhibitor era. <i style="">J Infect Dis</i>. 1999; 180:621-625.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">9.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Gasnault J, Taoufik Y, Goujard C et al. Prolonged survival without neurological improvement in patients with AIDS-related progressive multifocal leukoencephalopathy on potent combined antiretroviral therapy. <i style="">J Neurovirol</i>. 1999; 13:1426-1428.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">10.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Hoffmann C, Ernst M, Wolf E, et al. Evolving characteristics of toxoplasmosis in patients infected with human immunodeficiency virus-1: clinical course and <i style="">Toxoplasma gondii</i>-specific immune responses. <i style="">Clin Microbiol Infect</i>. 2007; 13:510-515.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">11.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Karakousis PC, <st1:street st="on"><st1:address st="on">Moore RD</st1:address></st1:street>, Chaisson RE. <i style="">Mycobacterium avium</i> complex in patients with HIV infection in the era of highly active antiretroviral therapy. <i style="">Lancet Infectious Diseases</i>. 2004; 4:557-565.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">12.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Kempen JH, Jabs DA, Wilson LA, et al. Mortality risk for patients with cytomegalovirus retinitis and acquired immune deficiency syndrome. <i style="">Clin Infect Dis</i>. 2003; 37:1365-1373.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">13.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Krentz HB, Kliewer G and Gill MJ. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, <st1:country-region st="on"><st1:place st="on">Canada</st1:place></st1:country-region> from 1998 to 2003. <i style="">HIV Medicine.</i> 2005; 6:99-106.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">14.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><st1:street st="on"><st1:address st="on"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">MacArthur RD</span></st1:address></st1:street><span style="font-size: 10pt; font-family: "Arial","sans-serif";">, et.al. Comparison of prognostic significance of latest CD4 cell count and HIV RNA levels in patients with advanced HIV infection on highly active antiretroviral therapy. <i style="">HIV Clin Trials</i>. 2005; 6:127-135.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">15.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Melchior JC, Niyongabo T, Henzel D, Durack-Bown J, Boulier A. Malnutrition and wasting, immunodepression, and chronic inflammation as independent predictors of survival in HIV-infected patients. <i style="">Nutrition</i>. 1999; 15:865-869.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">16.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Mikaelsson L, Jacobson G, Andersson R. 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Improved survival with highly active antiretroviral therapy in HIV-infected patients with severe <i style="">Pneumocystis carinii</i> pneumonia. <i style="">AIDS</i>. 2003; 17:73-80.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">19.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Selwyn PA, Forstein M. Overcoming the False Dichotomy of Curative vs Palliative for Late-Stage HIV/AIDS “Let me live the way I want to live, until I can’t”: <i style="">JAMA.</i> 2003; 290:806-814.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">20.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Shen JM, Blank A, Selwyn PA: Predictors of Mortality for Patients with Advanced Disease in an HIV Palliative Care Program: <i style="">J AIDS</i>. 2005; 40:445-447.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">21.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Shetty SM, Vanston VJ, Alexander C. The Hospice and Palliative Medicine Approach to Caring for Patients with HIV/AIDS. UNIPAC-7, 3<sup>rd</sup> <st1:place st="on"><st1:placename st="on">Ed.</st1:placename> <st1:placename st="on">American</st1:placename> <st1:placetype st="on">Academy</st1:placetype></st1:place> of Hospice and Palliative Medicine. 2008.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">22.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tang AM, Forrester J, Spieglman D, et al. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy. <i style="">JAIDS</i>. 2002; 31:230-236.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">23.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Tozzi V, Balestra P, Serraino D, et al. Neurocognitive impairment and survival in a cohort of HIV-infected patients treated with HAART. <i style="">AIDS Res Human Retrov</i>. 2005; 21:706-713.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">24.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The Antiretroviral Therapy (ART) Cohort Collaboration. <span style=""> </span>Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. <i style="">AIDS</i>. 2007; 21:1185-1197.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">25.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">The CASCADE Collaboration. <span style=""> </span>Effective Therapy has altered the spectrum of cause-specific mortality following HIV-seroconversion. <i style="">AIDS</i>. 2006; 20: 741-749.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 36.75pt; text-indent: -19.5pt;"><!--[if !supportLists]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><span style="">26.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Welch K, Morse A, et al. The clinical profile of end-stage AIDS in the era of highly active antiretroviral therapy. <i style="">AIDS Pt Care and STDs</i>. 2002; 16:75-81.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size: 10pt; font-family: "Arial","sans-serif";"><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style="font-size: 10pt; font-family: "Arial","sans-serif";">Author Affiliation:<span style=""> </span></span></b><st1:city st="on"><span style="font-size: 10pt; font-family: "Arial","sans-serif";">San Diego</span></st1:city><span style="font-size: 10pt; font-family: "Arial","sans-serif";"> Hospice at the Institute for Palliative Care, <st1:place st="on"><st1:city st="on">San Diego</st1:city>, <st1:state st="on">California</st1:state></st1:place>.<o:p></o:p></span></p>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-49954611647895521702009-03-06T09:39:00.001-06:002009-03-06T09:41:44.435-06:00#212: Phantom Limb Pain<o:p></o:p><p></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >FAST FACTS AND CONCEPTS #212</span></b></p><p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >PHANTOM LIMB PAIN<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >Kavitha Ramchandran MD and Joshua Hauser MD</span></b><span style=";font-family:";font-size:10;" ><o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Background<span style=""> </span></span></b><span style=";font-family:";font-size:10;" >Phantom limb pain (PLP) can be a painful and debilitating consequence of limb amputation from any cause including trauma, cancer, and vascular diseases.<span style=""> </span><span style=""> </span>This <i style="">Fast Fact</i> will review the evaluation and management of PLP.<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Definition and Characteristics <span style=""> </span><span style=""> </span></span></b><span style=";font-family:";font-size:10;" >PLP describes pain which patients perceive as coming from an amputated limb as if it were still contiguous with the body. It is distinct from pain at the actual site of the amputation (‘stump pain’). Patients usually experience PLP as occurring in the distal part of the phantom limb and can describe it as feeling ‘burning,’ ‘tingling,’ ‘sharp,’ and ‘cramping.’<span style=""> </span>Uncomfortable perceptions of limb distortion (such as retraction into the stump) are also reported. PLP is most commonly seen after limb amputation, but similar syndromes can occur with the removal of other body parts including breasts, testicles, eyes, and tongue.<span style=""> </span><span style=""> </span><b style=""><o:p></o:p></b></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Epidemiology<span style=""> </span></span></b><span style=";font-family:";font-size:10;" ><span style=""> </span>PLP occurs in 50-80% of patients after amputation, but is severe in 5-10% of cases.<span style=""> </span>Risk factors for developing PLP include: tumor-related amputations, chronic limb pain prior to amputation, and significant pain the day of amputation.<span style=""> </span>Despite this, meticulous peri-operative analgesia with epidural anesthesia has not been clearly shown to prevent PLP.<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Pathophysiology</span></b><span style=";font-family:";font-size:10;" ><span style=""> </span><span style=""> </span>Both central and peripheral mechanisms are believed to mediate PLP and are incompletely understood.<span style=""> </span>Amputation can lead to reorganization of the somatosensory cortex with ‘remapping’ of the location of amputated limb into the mouth and chin areas. For these patients stimulation of the mouth or ipsilateral face can cause sensations, including pain, that seem be originating from the phantom limb. <span style=""> </span>Central sensitization from preexisting chronic limb pain as well as ectopic discharges from the stump neuroma are also implicated.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in;"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Therapy <span style=""> </span></span></b><span style=";font-family:";font-size:10;" >While both drug and non-drug therapies have been investigated, treatment of phantom limb pain remains poorly studied and is largely empiric.<span style=""> </span><i style="">Due to the complex nature of PLP and its therapies, a multi-disciplinary approach to treatment is mandatory including pain specialists, physiatrists, physical and occupational therapists, and psychologists. </i><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style=";font-family:Symbol;font-size:10;" ><span style="">·<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><u><span style=";font-family:";font-size:10;" >Drug treatment</span></u><span style=";font-family:";font-size:10;" >:<span style=""> </span>Most clinicians approach PLP as a neuropathic pain syndrome.<span style=""> </span>A few small controlled trials have shown positive results with gabapentin, ketamine, and opioids, but not with tricyclic antidepressants. Despite this, there is insufficient evidence to judge the superiority or inferiority of any drug therapy for PLP, and most clinicians empirically use the full range of adjuvant analgesics along with opioid therapy if needed in its management.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; text-indent: -9pt;"><!--[if !supportLists]--><span style=";font-family:Symbol;font-size:10;" ><span style="">·<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><u><span style=";font-family:";font-size:10;" >Non-drug treatments</span></u><span style=";font-family:";font-size:10;" >:<span style=""> </span>Non-pharmacologic therapies have also been investigated. These include myoelectrical prostheses, transelectrical nerve stimulation, and mirror therapy. In small studies, the regular use of a myoelectric prosthesis (a prosthesis with electrodes embedded in the socket which stimulate nerves in the stump), has been demonstrated to alter cortical re-organization and reduce pain. <span style=""> </span>For those patients for whom a myoelectric prosthesis is not possible, transelectrical nerve stimulation (a TENS unit) to the stump can have a similar affect.<span style=""> </span>A newly investigated approach is mirror therapy.<span style=""> </span><span style=""> </span>Mirror therapy involves the placement of mirrors to create the illusion of an intact limb (patients visually perceive that they have an intact limb where their stump is).<span style=""> </span>Patients are taught to move both the real and the illusory limb with the hypothesis that this increases control of the brain over the phantom limb and leads to a decrease in PLP. In one small controlled study 100% of patients who underwent mirror therapy had a decrease in pain. <o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >References</span></b><span style=";font-family:";font-size:10;" > <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">1.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Devor M and Seltzer Z. Pathophysiology of damaged nerves in relation to chronic pain. In: Wall PD and Melzack RA, Editors. <i>Textbook of Pain</i> (4th Ed). <st1:place st="on"><st1:city st="on">Churchill-Livingstone</st1:city>, <st1:state st="on">New York</st1:state></st1:place> (1999), pp. 128–164.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">2.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Bone M, Critchley P, Buggy D.<span style=""> </span><span style="">Gabapentin in postamputation phantom limb pain: A randomized, double-blind, placebo-controlled, cross-over study. </span><i style="">Reg Anesth Pain Med.</i> 2002; 27:481-486.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27.35pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">3.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Robinson LR, Czerniecki JM, Ehde DM, et al. Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. <i>Arch Phys Med Rehabil</i>. 2004; 85<i>:</i>1-6. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27.35pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">4.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Flor H. Phantom limb pain: characteristics, causes, treatment.<span style=""> </span><i style="">Lancet Neurol.</i><span style=""> </span>2002; 1:182-189.<o:p></o:p></span></p> <p class="MsoPlainText" style="margin-left: 27.35pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";" ><span style="">5.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span class="pages"><span style=";font-family:";" >Dworkin RH et al. Pharmacologic management of neuropathic pain: evidenced-based recommendations. <i style="">Pain</i> 2007. 132:237-251.</span></span><span style=";font-family:";" ><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 27.35pt; text-indent: -0.25in;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" ><span style="">6.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" >Chan BL, Witt R. <span style=""> </span>Mirror therapy for phantom limb pain. <i style="">N Engl J Med</i>. 2007; 357:2206-7.<o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Author Affiliations<span style=""> </span></span></b><span style=";font-family:";font-size:10;" >Northwestern <st1:place st="on"><st1:placetype st="on">University</st1:placetype> <st1:placename st="on">Feinberg</st1:placename> <st1:placetype st="on">School</st1:placetype></st1:place> of Medicine Palliative Care and Home Hospice Program.<o:p></o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></b></p>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-39734459974257206532009-02-06T10:50:00.001-06:002009-02-06T10:53:14.415-06:00#211 Guided Imagery For Anxiety<o:smarttagtype namespaceuri="urn:schemas-microsoft-com:office:smarttags" name="City"></o:smarttagtype><o:smarttagtype namespaceuri="urn:schemas-microsoft-com:office:smarttags" name="place"></o:smarttagtype><o:smarttagtype namespaceuri="urn:schemas-microsoft-com:office:smarttags" name="State"></o:smarttagtype><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:trackmoves/> <w:trackformatting/> <w:punctuationkerning/> 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Roman","serif"; mso-fareast-font-family:"Times New Roman";} a:link, span.MsoHyperlink {mso-style-unhide:no; color:blue; text-decoration:underline; text-underline:single;} a:visited, span.MsoHyperlinkFollowed {mso-style-noshow:yes; mso-style-priority:99; color:purple; mso-themecolor:followedhyperlink; text-decoration:underline; text-underline:single;} p.citation3, li.citation3, div.citation3 {mso-style-name:citation3; mso-style-unhide:no; margin:0in; margin-bottom:.0001pt; text-indent:-18.75pt; line-height:200%; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman","serif"; mso-fareast-font-family:"Times New Roman";} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:10.0pt; mso-ansi-font-size:10.0pt; mso-bidi-font-size:10.0pt;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} /* List Definitions */ @list l0 {mso-list-id:407045790; mso-list-type:hybrid; mso-list-template-ids:-1884539646 -493866866 67698713 67698715 67698703 67698713 67698715 67698703 67698713 67698715;} @list l0:level1 {mso-level-tab-stop:.5in; mso-level-number-position:left; text-indent:-.25in;} ol {margin-bottom:0in;} ul {margin-bottom:0in;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";} </style> <![endif]--> <p class="MsoNormal" style="text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >FAST FACTS AND CONCEPTS #211<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-bottom: 6pt; text-align: center;" align="center"><b style=""><span style=";font-family:";font-size:10;" >GUIDED IMAGERY FOR ANXIETY<o:p></o:p></span></b></p> <p class="MsoNormal" style="text-align: center; text-indent: 0.5in;" align="center"><b style=""><span style=";font-family:";font-size:10;" >Karen Cooper LCSW, OSW-C and Susan Stollings PhD<o:p></o:p></span></b></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Background</span></b><span style=";font-family:";font-size:10;" ><span style=""> </span>Anxiety occurs in hospitalized patients for many reasons including fear of specific procedures, worry about the future, and lack of control. Guided imagery is an intervention that can be delivered at the bedside in 10-15 minutes by a wide range of trained health care providers at a low cost (1).This <i style="">Fast Fact</i> will discuss guided imagery as an anxiety reduction technique.</span></p><p class="MsoNormal"><br /><span style=";font-family:";font-size:10;" > <o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >The Technique<span style=""> </span></span></b><span style=";font-family:";font-size:10;" >Guided imagery is a mind-body exercise based on prompting patients to formulate meaningful mental pictures to achieve relaxation and reduce anxiety. Many guided imagery scripts include common elements such as asking the patient to sit or lie in a comfortable position, quieting the mind, removing negative thoughts and images, and calling to mind a vivid image or scenario that is calming and relaxing (a ‘safe place’). The content of a guided imagery script can include quiet and peaceful music with focus on a “safe place” where one feels secure and relaxed or it may involve more active, physical sensations such as playing and winning a tennis match. <span style=""> </span>It can be performed by trained professionals or with the use of audio recordings, and can be performed daily or as needed by the patient. An example of language used in a guided imagery exercise is:<span style=""> </span><i style="">“Position yourself as comfortably as you can, shifting your weight so that you’re allowing your body to be fully supported by your chair or couch….<span style=""> </span>Take a deep, full, cleansing breath…inhaling as fully as you can…breathing deep into the belly if you can…and breathing all the way out…. Imagine a place where you feel safe and peaceful and easy…a place either make-believe or real….”<span style=""> </span></i><span style=""> </span>See reference (2) for an example of a full script.<span style=""> </span>Information about further training in the use of guided imagery can be found at <a href="http://academyforguidedimagery.com/">http://academyforguidedimagery.com</a>.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" ><br /></span></b></p><p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Research Outcomes</span></b><span style=";font-family:";font-size:10;" ><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" >Guided imagery has been shown to reduce anxiety and use of anxiolytics, and to improve patient satisfaction in a variety of medical settings (1, 3, 7). In separate studies it was shown to significantly reduce anxiety and worry among patients facing abdominal surgery or cardiac catheterization compared to usual care (3, 4).<span style=""> </span>In a group of patients who had been hospitalized for more than two days, use of anxiolytic medication and heart rate were lower in the guided imagery group than in a control group (5). A combination of diaphragmatic breathing and guided imagery was used with a group of breast and gynecological cancer brachytherapy patients using 10 minutes of face to face training and a follow-up taped script via audiocassette. Patients in the intervention group had significantly less anxiety at follow-up several weeks later than those in the control group (6).<span style=""> </span>Clinical experience and expert opinion support its helpfulness for advanced cancer patients, although there is little research yet in this population (8). <span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" ><br /></span></b></p><p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >Limits and Cautions<span style=""> </span><o:p></o:p></span></b></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" >While a safe technique, guided imagery can rarely elicit negative emotional reactions, as well as create situations of patient vulnerability and susceptibility.<span style=""> </span>Due to this, guided imagery should be initiated in health care settings by a clinician who is trained in its proper use, who is comfortable with professional therapeutic boundaries, and who can respond appropriately to negative emotional reactions.<span style=""> </span>In particular, guided imagery may trigger flashbacks in patients with post-traumatic stress disorder, and it is relatively contraindicated in these patients. <span style=""> </span>It is also contraindicated in patients who have hallucinations or delusions, delirium, or severe obsessive compulsive disorder. As with any intervention, there are some patients who do not benefit from this technique or who are unable to call to mind a relaxing image.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style=";font-family:";font-size:10;" ><o:p> </o:p></span></p> <p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" ><br /></span></b></p><p class="MsoNormal"><b style=""><span style=";font-family:";font-size:10;" >References</span></b><span style=";font-family:";font-size:10;" ><o:p></o:p></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" lang="EN"><span style="">1.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Miller R. Nurses at community hospital welcome guided imagery tool. <i style="">Dimensions Crit Care Nursing</i>.<span style=""> </span>2003; 22(5):225-226.<o:p></o:p></span></p> <ol style="margin-top: 0in;" start="2" type="1"><li class="MsoNormal" style=""><span style=";font-family:";font-size:10;" >Naparstek B. <i style="">Staying Well with Guided Imagery. </i><st1:place st="on"><st1:state st="on">New York</st1:state></st1:place>: Warner Books. 1994: pp. 76-79.<o:p></o:p></span></li></ol> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;color:black;" lang="EN"><span style="">3.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Tusek D, Church JM, Fazio V W. Guided imagery as a coping strategy for perioperative patients. <i style="">AORN Journal.</i> 1997;<i style=""> 66(4</i>):644-649.<span style="color:black;"><o:p></o:p></span></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" lang="EN"><span style="">4.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">McCaffrey R, Taylor N. Effective anxiety treatment prior to diagnostic cardiac catheterization. <i style="">Holistic Nursing Practice. </i>2005;<i style=""> 19(2)</i>:70-73.<o:p></o:p></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" lang="EN"><span style="">5.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Toth M, Wolsko PM, Foreman J, Davis RB, Delbanco T, Phillips RS. A pilot study for a randomized, controlled trial on the effects of guided imagery in hospitalized medical patients. <i style="">Journal of Alternative and Complementary Medicine. </i>2007; 13(2):194-197.<o:p></o:p></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;color:black;" lang="EN"><span style="">6.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Leon-Pizarro C, Gich I, Barthe E, et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality of life indices for gynecologic and breast brachytherapy patients.<span style=""> </span><i style="">Psycho-Oncology. </i>2007;<i style=""> </i>16:971-979. <span style="color:black;"><o:p></o:p></span></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" lang="EN"><span style="">7.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Halpin LS, Speir AM, CapoBianco P, Barnett SD. Guided imagery in cardiac surgery. <i style="">Outcomes Management</i>. 2002; 6(3):132-137.<o:p></o:p></span></p> <p class="citation3" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style=";font-family:";font-size:10;" lang="EN"><span style="">8.<span style=";font-family:";font-size:7;" > </span></span></span><!--[endif]--><span style=";font-family:";font-size:10;" lang="EN">Foley KM, Back A, Bruera E, et al. (Eds). <i style="">When the Focus is on Care: Palliative Care and Cancer</i>. <st1:place st="on"><st1:city st="on">Atlanta</st1:city></st1:place>: American Cancer Society. 2005: p. 176.<o:p></o:p></span></p> <p class="citation3" style="text-indent: 0in; line-height: normal;"><span style=";font-family:";font-size:10;" lang="EN"><o:p> </o:p></span></p> <b style=""><span style=";font-family:";font-size:10;" lang="EN">Author Affiliations:<span style=""> </span></span></b><span style=";font-family:";font-size:10;" lang="EN">University of Pittsburgh Medical Center, Pittsburgh, PA.<br /><br />The original version of this <span style="font-style: italic;">Fast Fact</span> is available at <a href="http://www.eperc.mcw.edu">EPERC</a>.<br /></span>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-31278243310057916922008-12-03T09:27:00.002-06:002008-12-03T09:33:34.658-06:00210: Suicide Attempts in the Terminally Ill<div style="text-align: center;">FAST FACTS AND CONCEPTS #210<br />SUICIDE ATTEMPTS IN THE TERMINALLY ILL<br />Sean Marks MD and Drew Rosielle MD<br /><br /></div><span style="font-weight: bold;">Background</span> Chronic or advanced medical illness is a significant risk factor for suicidality (1). This Fast Fact discusses evaluating and responding to suicidality in patients with life-limiting diseases. Note: this Fast Fact does not address cases of ‘physician assisted suicide’ which have occurred after a deliberative process including psychiatric screening such as in Oregon in the US (2). <br /><br /><span style="font-weight: bold;">Ethics </span><br />• <span style="font-style: italic;">Core Principles:</span> It is a core obligation of physicians to prevent a patient from initiating suicide and to intervene medically to prevent a patient from dying after a suicide attempt (3). This obligation can include detaining and restraining patients against their will and the use of invasive medical interventions such as mechanical ventilation if needed, although such restrictions to a patient’s liberty should be kept to the minimum necessary. Most suicidal patients are considered impaired by depression or other mental illnesses and their actions are not considered autonomous, thus justifying detaining patients and providing medical interventions against their will (4). Such interventions can create further opportunities to treat the patient’s psychiatric condition, and only 20% of people who are prevented from committing suicide subsequently complete another attempt. <br /><br />• <span style="font-style: italic;">Exceptions at life’s end</span>: The above logic is less compelling in terminally ill patients who have attempted suicide, particularly with short prognoses (e.g. less than 1 month). In these patients most medical interventions are unlikely to restore health or significantly alter the dying process in a way that would materially benefit the patient. Clinicians may opt to forgo certain interventions (e.g. mechanical ventilation), particularly if family/proxy decision makers consider such interventions inappropriate in their dying loved ones. In these situations clinicians are advised to 1) verify the certainty of the very short prognosis, utilizing consultants liberally, 2) discuss with proxy decision makers all possible treatment plans including, when feasible, less-invasive supportive care options with treatment limitations (e.g. ICU monitoring, gastric lavage and charcoal administration for an overdose, but establishing a do-not-resuscitate/do-not-intubate order even if the patient deteriorates), and 3) seek ethics consultation. <br /><br />• <span style="font-style: italic;">Advance Directives:</span> Advance directives such as living wills stating a patient’s wish to not be mechanically ventilated are not binding in the setting of a suicide attempt. However, they should be honored in patients with short prognoses per the discussion above. Advanced directives specifying treatment limitations should be re-evaluated if it is suspected those statements were made during a period of undetected depression (5,6).<br /><br /><span style="font-weight: bold;">Epidemiology and Risk Factors</span> The actual rate of suicide attempts in terminally ill patients is unknown, and there has been limited research into specifically ‘terminally ill’ populations. What is clear is that advancing age and psychiatric comorbidity are risk factors for suicide (along with male sex, AIDS diagnosis, a family history of suicide, and uncontrolled pain) (7,8). Cancer patients have nearly twice the incidence of suicide than the general population (rate of 31.4/100,000 vs. 16.7/100,000 patient-years) (6). Lung, stomach, and head and neck cancers have the highest suicide rates among all cancer types (9). Up to 8.5% of terminally ill cancer patients express a sustained and pervasive wish for an early death, and in one survey of terminally ill patients, 10% of patients reported “seriously pursuing” physician assisted suicide (10,11). Rates of actual suicide attempts are presumably lower.<br /><br /><span style="font-weight: bold;">Assessment</span> All patients with life-limiting illnesses should be routinely assessed for depression and mood disorders (see Fast Facts #7, 43); depressed patients should be screened for suicidal thoughts. Patients who admit to suicidal thoughts or a desire for hastened death should be asked about specific plans for self-harm, past history of suicide attempts, access to firearms or other lethal means to carry out a suicidal act, and level of support/supervision available in the home (e.g. family caregivers). Although some clinicians may be concerned that exploring suicidal thoughts may make suicide more likely, there is no evidence that this occurs. Many ill patients who express a desire for death are simply communicating unresolved emotional and existential concerns about dying: see Fast Facts #156 & 159.<br /><br /><br /><span style="font-weight: bold;">Responding to Suicidal Intent</span> All patients who are seriously threatening self-harm, or who have pervasive thoughts of ending their life, should be evaluated urgently by a psychiatrist (12). Immediate resources depend on local availability and can include prompt evaluation by an established psychiatrist, medical or psychiatric urgent care clinics or emergency departments, or even voluntary hospital admission. Options include voluntary psychiatric treatment, arranging 24 hour safety monitoring from the patient’s family and friends, introducing home hospice or home nursing support, removing means to carry out a suicidal act, and imposing emergency detention. For disabled patients close to death, removing the means of self-harm (e.g. limit access to pain medications as long as a reliable family member can administer them) and providing close supervision through, for instance, hospice services are often sufficient and minimally restrictive.<br /><br /><span style="font-weight: bold;">References</span><br />1. Hendin H. Suicide, assisted suicide and medical illness. J of Clin Psychiatry. 1999; 60 Suppl 2:46-50.<br />2. Death With Dignity Act Report 2007. State of Oregon Department of Human Services. Available at: http://www.oregon.gov/DHS/ph/pas/index.shtml. Accessed November 10, 2008.<br />3. Lo B. Resolving ethical dilemmas: a guide for clinicians – 3rd Edition. Lippincott Williams & Wilkins, 2005: 256-9.<br />4. Miller RD. Need-for-treatment criteria for involuntary civil commitment: impact in practice. Am J Psychiatry. 1992; 149:1380-4.<br />5. Ganzini L, Lee MA, Heinz RT, et al. The effect of depression treatment on elderly patients’ preferences for life sustaining medical therapy. Am J of Psychiatry. 1994; 151:1631-6.<br />6. Sontheimer D. Suicide by advance directive. J Med Ethics. 2008; 34:e4; doi:10.1136/jme.2008.025619.<br />7. Farberow NL, Banzler S, Cutter F, Reynolds D. An eight-year survey of hospital suicides. Suicide and Life-Threatening Behavior. 1971; 1:184-201.<br />8. Rabins PV. Prevention of mental disorder in the elderly: current perspectives and future prospects. J Am Geriatric Soc. 1992; 40:727-33.<br />9. Misono S, Weiss NS, Fann JR, Redman M, Yueh B. Incidence of suicide in persons with cancer. J Clin Oncol. 2008; 26:4731-4738.<br />10. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, et al. Desire for death in the terminally ill. Am J Psychiatry. 1995; 152:1185-91.<br />11. Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA. 2000; 284:2460-2468.<br />12. Block SD. Chapter 6: Assessing and managing depression in the terminally ill patient. Physician’s Guide to End of Life Care. Snyder, Lois ACP Press, 2001.<br /><br /><span style="font-weight: bold;">Author Affiliations: </span> Medical College of Wisconsin, Milwaukee, Wisconsin.<br /><br /><br />The original version of this Fast Fact can be found at <a href="http://www.eperc.mcw.edu">EPERC</a>.Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-83368867367305059472008-10-27T15:49:00.001-05:002008-10-27T15:51:06.967-05:00#209: Malignant Pericardial Effusions<p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family: Arial">MALIGNANT PERICARDIAL EFFUSIONS<o:p></o:p></span></b></p> <p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family: Arial">Vincent Thai MD<o:p></o:p></span></b></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial">Introduction</span></b><span style="font-size:10.0pt;font-family:Arial"><span style="mso-spacerun:yes"> </span>Malignant pericardial effusions (MPEs) are a rare complication of advanced cancer, but are associated with high morbidity and mortality.<span style="mso-spacerun:yes"> </span>This <i style="mso-bidi-font-style:normal">Fast Fact</i> discusses the diagnosis and management of MPEs.<b style="mso-bidi-font-weight: normal"><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-top:12.0pt"><b style="mso-bidi-font-weight: normal"><span style="font-size:10.0pt;font-family:Arial">Epidemiology and Prognosis<span style="mso-spacerun:yes"> </span></span></b><span style="font-size:10.0pt;font-family:Arial">Approximately 10% of patients with cancer develop cardiac metastases, with ~75% of these affecting the epicardium (1, 2).<span style="mso-spacerun:yes"> </span>Only a third of these, however, will develop clinically significant MPEs (1). <span style="mso-spacerun:yes"> </span>Lung and breast cancers are the most common causes.<span style="mso-spacerun:yes"> </span>MPEs are associated with a poor prognosis.<span style="mso-spacerun:yes"> </span>Studies suggest a <i style="mso-bidi-font-style:normal">median</i> survival of 2-3 months after a MPE is diagnosed, with a <i style="mso-bidi-font-style:normal">mean</i> survival of 5 months for solid tumors and 20 months for hematologic malignancies (3, 4).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial"><span style="mso-spacerun:yes"> </span><b style="mso-bidi-font-weight:normal"><o:p></o:p></b></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial">Physiology and Symptoms</span></b><span style="font-size:10.0pt;font-family:Arial"> <span style="mso-spacerun:yes"> </span>The pericardial space is normally filled with less than 50 ml of serous fluid. As this volume increases due to epicardial or pericardial metastases or lymphatic obstruction, both right and left ventricular failure can occur due to inadequate filling.<span style="mso-spacerun:yes"> </span>Signs and symptoms include peripheral and pulmonary edema, chest discomfort, cough, shortness of breath, and orthopnea.<span style="mso-spacerun:yes"> </span>Severity of symptoms depends on the volume of the MPE as well as the rapidity of its accumulation; severe cases can present with cardiac tamponade and shock.<span style="mso-spacerun:yes"> </span>An echocardiogram is indicated whenever a MPE is suspected.<span style="mso-spacerun:yes"> </span>Not only does it confirm the presence of an effusion, but its findings can dictate whether or not urgent treatment is indicated (e.g. if signs of tamponade are evident).<span style="mso-spacerun:yes"> </span>A diagnostic pericardiocentesis or pericardial biopsy is sometimes needed to confirm the cause of the effusion.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial">Treatment Options</span></b><span style="font-size:10.0pt;font-family:Arial"><span style="mso-spacerun:yes"> </span><span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><i style="mso-bidi-font-style:normal"><span style="font-size:10.0pt;font-family:Arial">Systemic chemotherapy or radiotherapy </span></i><span style="font-size:10.0pt;font-family:Arial">are effective for chemo- or radio-sensitive tumors such as previously untreated breast cancer and many lymphomas. Reaccumulation rates for both modalities are about 1/3 overall, depending on the patient’s overall course and response to therapy (5).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><i style="mso-bidi-font-style:normal"><span style="font-size:10.0pt;font-family:Arial">Pericardiocentesis</span></i><span style="font-size:10.0pt;font-family:Arial"> results in immediate symptom relief in most patients, however the effusion may rapidly re-accumulate in many patients, needing repeat pericardiocentesis (within 1-2 weeks in some series) (6).<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><i style="mso-bidi-font-style:normal"><span style="font-size:10.0pt;font-family:Arial">Pericardial sclerosis</span></i><span style="font-size:10.0pt;font-family:Arial"> involves instilling a sclerosing agent with the intention of scarring the pericardium to the epicardium, preventing reaccumulation of the MPE (similar to pleural effusions – see <i style="mso-bidi-font-style:normal">Fast Fact</i> #157).<span style="mso-spacerun:yes"> </span>Multiple agents have been studied including doxyclycline, minocycline, and bleomycin.<span style="mso-spacerun:yes"> </span>Success rates (no reaccumulation at 30 days) are about 70-90% (7, 8).<span style="mso-spacerun:yes"> </span>Longer term success rates have not been defined due to the poor survival of study patients. The major side effect is chest pain (50-70%), cardiac arrhythmias, and fever (8, 9, 10).<span style="mso-spacerun:yes"> </span>In head to head comparisons with doxycycline, bleomycin has been shown to have fewer side effects and to lead to shorter hospitalizations (10, 11, 12). <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><i style="mso-bidi-font-style:normal"><span style="font-size:10.0pt;font-family:Arial">Surgical decompression </span></i><span style="font-size:10.0pt;font-family:Arial">therapies range from less invasive (balloon pericardiotomy, subxiphoid or thorascopic pericardiostomy) to more extensive (open thoracotomy with pericardial stripping).<span style="mso-spacerun:yes"> </span>A pericardial ‘window’ (which allows ongoing drainage of fluid externally or internally such as into the pleural cavity) is often created.<span style="mso-spacerun:yes"> </span>Case series have suggested reaccumulation rates with surgical therapies are low (less than 15% up to 10 months out) (13, 14, 15).<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial">Decision-Making<span style="mso-spacerun:yes"> </span></span></b><span style="font-size:10.0pt; font-family:Arial">The treatment of MPEs depends on how urgently treatment is needed, the likelihood of the tumor responding to anti-neoplastic treatments, and the anticipated survival of the patient. <span style="mso-spacerun:yes"> </span>A multidisciplinary approach to decision-making, involving input from medical and radiation oncology, cardiology, and thoracic surgery is recommended. Simple pericardiocentesis may be appropriate for patients with short prognoses (less than 1 month), particularly if their MPE is not expected to re-accumulate in their remaining life-span.<span style="mso-spacerun:yes"> </span>A symptomatic patient with no signs of tamponade and a chemotherapy-sensitive tumor such as untreated breast cancer may receive a durable response from a pericardiocentesis for symptom relief, followed by chemotherapy.<span style="mso-spacerun:yes"> </span>Patients with longer prognoses (>1 month) who are expected to re-accumulate their MPEs will likely benefit most from sclerosis or surgical decompression; there is no clear evidence currently suggesting one strategy is superior to the other.<span style="mso-spacerun:yes"> </span>Symptom directed care without specific intervention for the MPE is an appropriate option for patients with very short prognoses and for those who decline more invasive treatments.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial">References<o:p></o:p></span></b></p> <ol style="margin-top:0in" start="1" type="1"> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Klatt EC, Heitz DR. Cardiac metastases. <i style="mso-bidi-font-style:normal">Cancer.</i> 1990; 65(6):1456-59.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Abraham KP, Reddy V, Gattuso P. Neoplasms metastatic to the heart: review of 3314 consecutive autopsies. <i style="mso-bidi-font-style:normal">Am.J.Cardiovasc.Pathol</i>. 1990; 3:195-198..<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Moores, D.W, Allen K.B, Faber L.P, Dziuban S.W, Gillman D.J, Warren W.H., Ilves R, Lininger L, Subxiphoid pericardial drainage for pericardial tamponade, <i style="mso-bidi-font-style:normal">The Journal of Thoracic and Cardiovascular Surgery 1995, </i>109 (3), 546-552<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span lang="FR" style="font-size:10.0pt;font-family:Arial;mso-ansi-language:FR">Dosios T, Theaskos,N, Angouras D, et al. </span><span style="font-size:10.0pt; font-family:Arial">Risk factors affecting the survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. <i style="mso-bidi-font-style:normal">Chest</i>. 2003; 124:242<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Lamont E, Hoffman PC. Oncologic Emergencies (chapter). In: <i style="mso-bidi-font-style:normal">Principles of Critical Care. </i>3<sup>rd</sup> Edition. McGraw Hill; <st1:place st="on"><st1:state st="on">New York</st1:state></st1:place>: 2005.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span lang="NO-BOK" style="font-size:10.0pt;font-family:Arial;mso-ansi-language: NO-BOK">Laham RJ, Cohen DJ, Kuntz RE et al. </span><span style="font-size: 10.0pt;font-family:Arial">Pericardial effusion in patients with cancer: outcome with contemporary management strategies. <i style="mso-bidi-font-style: normal">HEART.</i> 1996; 75(1):67-71.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Lashevsky I, Ben Yosef R, Rinkevich D, Reisner S, Markiewicz W. Intrapericardial minocycline sclerosis for malignant pericardial effusion. <i style="mso-bidi-font-style: normal">Chest.</i> 1996;109(6):1452-54.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Maher EA, Shepherd FA, Todd TJR. Pericardial sclerosis as the primary management of malignant pericardial effusion and cardiac tamponade. <i style="mso-bidi-font-style: normal">J Thoracic Cardiovascular Surg. </i>1996; 112(3):637-643.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span class="hlite"><span style="font-size:10.0pt;font-family:Arial">Ben Yosef</span></span><span style="font-size:10.0pt;font-family:Arial">,R.; Phefer,R.; Ge,A.; Catane,R. Management of malignant pericardial effusion Harefuah, <span class="hlite">1988</span>, 115, 5-6, 138-141, ISRAEL<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Liu G, Crump M, Goss PE, Dancey J, Shepherd FA. Prospective comparison of the sclerosing agents doxycycline and bleomycin for the primary management of malignant pericardial effusion and cardiac tamponade. <i style="mso-bidi-font-style:normal">J Clin.Oncol</i>. 1996; 14(12):3141-47.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span lang="FR" style="font-size:10.0pt;font-family:Arial;mso-ansi-language:FR">Yano T, Yokoyama H, Inoue T, et al. </span><span style="font-size:10.0pt; font-family:Arial">A simple technique to manage malignant pericardial effusion with a local instillation of bleomycin in non-small cell carcinoma of the lung. <i style="mso-bidi-font-style:normal">Oncology.</i> 1994;51:507-509.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">van Belle SJ, Volckaert A, Taeymans Y, Spapen H, Block P. Treatment of malignant pericardial tamponade with sclerosis induced by instillation of bleomycin. <i style="mso-bidi-font-style:normal">Int.J.Cardiol</i>. 1987; 16(2):155-160.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Galli M, Politi A, Pedretti F, Castiglioni B, Zerboni S. Percutaneous balloon pericardiotomy for malignant pericardial tamponade. <i style="mso-bidi-font-style:normal">Chest.</i> 1995; 108(6):1499-1501.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. <i style="mso-bidi-font-style:normal">Cathet.Cardiovasc.Diagn</i>. 199; 22(4):244-49.<o:p></o:p></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in"><span style="font-size:10.0pt;font-family:Arial">Ziskind AA, Pearce AC, Lemmon CC, et al. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. <i style="mso-bidi-font-style: normal">J.Am.Coll.Cardiol</i>. 1993; 21(1):1-5.<o:p></o:p></span></li></ol><div><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"><br /></span></div><div><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">The original version of this <span class="Apple-style-span" style="font-style: italic;">Fast Fact</span> is on the <a href="http://www.eperc.mcw.edu">EPERC website</a>. </span></div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-33085872615370625942008-10-10T09:21:00.001-05:002008-10-10T09:23:32.027-05:00#208: Clinical care following withdrawal of dialysis<h3 align="center" style="margin-top:0in;margin-right:41.75pt;margin-bottom:0in; margin-left:13.7pt;margin-bottom:.0001pt;text-align:center"><span style="font-size:10.0pt;">FAST FACTS AND CONCEPTS #208<o:p></o:p></span></h3> <h3 align="center" style="margin-top:0in;margin-right:41.75pt;margin-bottom:6.0pt; margin-left:13.7pt;text-align:center"><span style="font-size:10.0pt;">CLINICAL CARE FOLLOWING WITHDRAWAL OF DIALYSIS<o:p></o:p></span></h3> <p class="MsoNormal" align="center" style="text-align:center"><b style="mso-bidi-font-weight: normal"><span style="mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Sara N Davison MD and Drew A Rosielle MD<o:p></o:p></span></b></p> <p class="MsoNormal" align="center" style="text-align:center"><b style="mso-bidi-font-weight: normal"><span style="mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Background</span></b><span style="mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;"> <span style="mso-spacerun:yes"> </span></span><i style="mso-bidi-font-style:normal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">Fast Fact</span></i><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;"> #207 discussed decision-making around dialysis discontinuation; this <i style="mso-bidi-font-style: normal">Fast Fact</i> addresses care of the patient around the time of discontinuation.</span><span lang="EN-CA" style="font-family: Arial;mso-fareast-Arial Unicode MS"font-family:";font-size:10.0pt;"><o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">Communication and care-planning at the time of dialysis cessation<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Counsel about what to expect: mean survival following dialysis withdrawal is 8-10 days (although rarely can be many weeks).<span style="mso-spacerun:yes"> </span>Address the likelihood of progressive encephalopathy.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Counsel about symptoms (see below).<span style="mso-spacerun:yes"> </span>Reassure patients/families that these can be adequately treated, although drugs with sedating side effects may be necessary to ensure comfort. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Recommend continuing fluid restriction (< style="mso-spacerun:yes"> </span>Discuss diet: a liberal, pleasure-based diet is appropriate for many patients although they should be cautioned it could worsen symptoms from edema.<o:p></o:p></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Address potential care sites for the final days of life.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Review other medical treatments the patient is receiving and discontinue those that will not improve their quality of life while dying; clarify treatment limitations including resuscitation (code) status.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l0 level1 lfo1; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Provide emotional/psychological, spiritual, social work, and bereavement support services.<o:p></o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;"><o:p> </o:p></span></b></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">Symptom Management <span style="mso-spacerun:yes"> </span></span></b><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">In one cohort of hospitalized patients who stopped dialysis confusion/agitation was reported to affect 70% of patients, followed by pain (55%), dyspnea (48%), nausea (36%), twitching/seizures (27%), anxiety/psychological distress (27%), pruritis (24%), and peripheral edema (21%). <span style="mso-spacerun:yes"> </span>Because of a paucity of clinical research, the following recommendations are largely based on clinical experience and pharmacologic common sense. Many drugs which were previously cleared by dialysis may need to be dose-adjusted or discontinued.<span style="mso-spacerun:yes"> </span>Treatment plans should be frequently re-evaluated, with particular attention to the use of scheduled medications.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Pain management</span></u><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">:<span style="mso-spacerun:yes"> </span>Acetaminophen is the agent of choice for mild pain.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">Fast Fact</i> #161 addresses opioid use in renal failure.<span style="mso-spacerun:yes"> </span>Fentanyl and methadone are considered safest after dialysis discontinuation, although methadone should only be initiated by clinicians familiar with its use.<span style="mso-spacerun:yes"> </span>Toxic hydromorphone metabolites, previously cleared by dialysis, can accumulate rapidly once dialysis is stopped and it should be used with caution and close monitoring of side effects.<span style="mso-spacerun:yes"> </span>Gabapentin and pregabalin quickly accumulate once dialysis is stopped and should be discontinued or severely dose-reduced (see <i style="mso-bidi-font-style:normal">Fast Fact</i> #49).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Shortness of breath</span></u><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">:<span style="mso-spacerun:yes"> </span>Oxygen, positioning, and opioids are the mainstays of therapy (see Fast Fact #27). Ultrafiltration is not recommended as it can be distressing for patients/family to see the patient back on a therapy which appears similar to hemodialysis. For the occasional patient who has a residual urine output of >100ml/day, high dose diuretics can be used.<span style="mso-spacerun:yes"> </span><span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Anxiety/agitation/restlessness</span></u><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">:<span style="mso-spacerun:yes"> </span>Assure pain and psychosocial issues are addressed.<span style="mso-spacerun:yes"> </span>Haloperidol or benzodiazepines are effective.<span style="mso-spacerun:yes"> </span>Haloperidol may lower the seizure threshold and the metabolites are excreted in the urine and feces so it is recommended to dose at half the typical starting dose following dialysis withdrawal. While benzodiazepines do not accumulate in chronic kidney disease, clinical experience supports starting with very low doses in this population.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Restless legs</span></u><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">:<span style="mso-spacerun:yes"> </span>Clonazepam is particularly useful for the restless legs associated with uremia (0.5 – 2.0 mg bid). Clonidine (0.1-0.2 mg bid) can also be used. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Muscle cramps</span></u><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">: Dialysis patients are often treated with quinine sulphate which accumulates rapidly once dialysis is stopped and should be discontinued.<span style="mso-spacerun:yes"> </span>Clonazepam and other benzodiazepines are better in this setting.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Nausea</span></u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">: <span style="mso-spacerun:yes"> </span>Reduced doses of metoclopromide (starting at 5mg bid) are effective for gastroparesis.<span style="mso-spacerun:yes"> </span>Uremia-induced nausea often responds well to dopamine antagonists such as haloperidol and prochloperazine which are often sedating in the context of uremia.<span style="mso-spacerun:yes"> </span>Ondansetron has some advantages as it is less sedating and does not accumulate in kidney failure.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l2 level1 lfo3; tab-stops:list .25in"><span lang="EN-CA" style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;font-size:10.0pt;"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">Pruritus</span></u><span lang="EN-CA" style=" ;font-family:Arial;font-size:10.0pt;">: Emollients such as hydrourea cream, ondansetron, and antihistamines may be beneficial.<span style="mso-spacerun:yes"> </span>Gabapentin, while effective, is too toxic in this population to initiate its use.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span lang="EN-CA" style="font-family:Arial;font-size:10.0pt;">References<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">1.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Germain MJ, Cohen LM, Davison SN. Withholding and Withdrawing from Dialysis: What We Know About How Our Patients Die.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">Seminars in Dialysis</i>. 2007; 20:200-204.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">2.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Murtagh FEM, Addington-Hall JM, Donohoe P, Higginson IJ.<span style="mso-spacerun:yes"> </span>Symptom Management in Patients With Established Renal Failure Managed Without Dialysis.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">EDTNA ERCA J</i>. 2006; 32:93-98.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">3.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Chambers EJ, Germain M, Brown E (Eds.).<span style="mso-spacerun:yes"> </span>Supportive Care for the Renal Patient (1st Edition). <st1:city st="on">Oxford</st1:city>: <st1:place st="on"><st1:placename st="on">Oxford</st1:placename> <st1:placetype st="on">University</st1:placetype></st1:place> Press; 2004.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">4.<span style="font:7.0pt "Times New Roman""> </span></span></span><span lang="DE" style=" font-family:Arial;mso-fareast-Arial Unicode MS";mso-ansi-language: DEfont-family:";font-size:10.0pt;">Cohen LM, Germain MJ, Poppel DM.<span style="mso-spacerun:yes"> </span></span><span lang="EN-CA" style="font-family:Arial;mso-fareast-Arial Unicode MS"font-family:";font-size:10.0pt;">Practical considerations in dialysis withdrawal.<span style="mso-spacerun:yes"> </span>“To have that option is a blessing.”<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">JAMA</i>. 2003; 289:2113-2119.</span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">5.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Murtagh FE, Chai MO, Donohoe P, Edmonds PM, Higginson IJ.<span style="mso-spacerun:yes"> </span>The use of opioid analgesia in end-stage renal disease patients managed without dialysis: recommendations for practice.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style: normal">J Pain Palliat Care Pharmacother. </i>2007; 21:5-16.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-list:l1 level1 lfo2; tab-stops:list .25in"><span style=" font-family:Arial;mso-fareast-mso-ansi-language:EN-USfont-family:Arial;font-size:10.0pt;"><span style="mso-list:Ignore">6.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Lugon JR.<span style="mso-spacerun:yes"> </span>Uremic pruritus: a review.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">Hemodialysis Intl.</i> 2005; 9:180-88.<o:p></o:p></span></p> <p class="MsoNormal"><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;color:navy;"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;">Author Affiliations:<span style="mso-spacerun:yes"> </span></span></b><st1:placetype st="on"><span style="mso-ansi-language: EN-US;font-family:Arial;font-size:10.0pt;">University</span></st1:placetype><span style=" mso-ansi-language:EN-US;font-family:Arial;font-size:10.0pt;"> of <st1:placename st="on">Alberta</st1:placename>, <st1:city st="on">Edmonton</st1:city>, <st1:state st="on">Alberta</st1:state> (SND), and the Medical <st1:placetype st="on">College</st1:placetype> of <st1:placename st="on">Wisconsin</st1:placename>, <st1:place st="on"><st1:city st="on">Milwaukee</st1:city>, <st1:state st="on">Wisconsin</st1:state></st1:place> (DAR).<o:p></o:p></span></p> <p class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial; font-size: 48px;"><br /></span></p><p class="MsoNormal"><span style="mso-ansi-language: EN-US;font-family:Arial;font-size:10.0pt;"><o:p><a href="http://www.eperc.mcw.edu">This Fast Fact is also available at EPERC</a>. </o:p></span></p><p class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial; font-size: 48px;"><br /></span></p>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-19535972937994142572008-09-15T09:36:00.003-05:002008-09-15T09:37:54.350-05:00#207: Withdrawal of dialysis: decision-making<h3 align="center" style="margin-top:0in;margin-right:41.75pt;margin-bottom:0in; margin-left:13.7pt;margin-bottom:.0001pt;text-align:center"><span class="Apple-style-span" style="font-family: Arial; font-size: 13px; ">FAST FACTS AND CONCEPTS #207</span><br /></h3><p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family: Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">WITHDRAWAL OF DIALYSIS: DECISION-MAKING<o:p></o:p></span></b></p> <p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family: Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">Sara N Davison MD and Drew A Rosielle MD<o:p></o:p></span></b></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Background<span style="mso-spacerun:yes"> </span></span></b><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Historically, stopping dialysis was considered by many to be a form of suicide.<span style="mso-spacerun:yes"> </span>However, it is now a widely accepted practice in most countries, with broad ethical and legal consensus that dialysis can be stopped when it is no longer achieving a meaningful goal for the patient. In fact, ~25% of deaths of dialysis patients in <st1:place st="on">North America</st1:place> occur after its cessation. <span style="mso-spacerun:yes"> </span></span><span style="font-size:10.0pt; font-family:Arial;mso-ansi-language:EN-US">This <i style="mso-bidi-font-style: normal">Fast Fact</i> reviews key issues pertaining to the decision to stop chronic dialysis; <i style="mso-bidi-font-style:normal">Fast Fact</i> #208 will discuss the care of patients after it is stopped.</span><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language: EN-US"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family: "Arial Unicode MS";mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Why dialysis is stopped<span style="mso-spacerun:yes"> </span></span></b><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language: EN-US">The goal of dialysis is not only to prolong life by providing renal replacement therapy, but to maintain a patient’s quality of life at an acceptable level (see <i style="mso-bidi-font-style:normal">Fast Fact</i> #163).<span style="mso-spacerun:yes"> </span>Discussions to stop dialysis usually occur when:<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo2; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol; mso-ansi-language:EN-US"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial; mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">Dialysis is no longer serving to substantially prolong life or is only prolonging a patient’s death (e.g., a patient dying from advanced cancer or sepsis with multiorgan system failure).<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l0 level1 lfo2; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol; mso-ansi-language:EN-US"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial; mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">The burdens of dialysis and its complications outweigh its life-prolonging benefits to a patient (e.g., a patient with progressive frailty who is becoming bedbound, a patient with severe cognitive failure).<span style="mso-spacerun:yes"> </span>In these scenarios dialysis is likely to prolong life but is not helping to restore a patient to an acceptable level of quality of life as assessed by the patient or her/his surrogate decision maker.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family: "Arial Unicode MS";mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Demographics</span></b><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language: EN-US"><span style="mso-spacerun:yes"> </span>The demographics of dialysis withdrawal have been studied at length.<span style="mso-spacerun:yes"> </span>Patient characteristics associated with withdrawal are older age, female, white race, longer duration of dialysis, higher educational level, living alone, severe pain, and comorbidity (with chronic or progressive diseases).<span style="mso-spacerun:yes"> </span>Ethnic differences have been observed, with African Americans and Hispanics being less likely to stop dialysis than European Americans.<span style="mso-spacerun:yes"> </span>Reported prevalence levels of patient decision-making capacity at the time of withdrawal vary considerably with estimates ranging from 37% to 80%, suggesting cognitive failure drives many of these decisions. Nephrologists rate cognitive and physical functional status as the most important factors for their decision-making around stopping dialysis, and 93% of North American nephrologists report a willingness to honor a patient’s request to stop, even if </span><span style="font-size:10.0pt;font-family:Arial;mso-ansi-language: EN-US">they have a personal preference to continue</span><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">.<span style="mso-spacerun:yes"> </span>Internationally, practices vary tremendously, with much lower rates of dialysis cessation in <st1:country-region st="on">Japan</st1:country-region> compared to <st1:place st="on">North America</st1:place>, for instance.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family: "Arial Unicode MS";mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Responding to a request to stop dialysis</span></b><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US"><span style="mso-spacerun:yes"> </span>For patients who are otherwise dying, counsel about terminal care issues surrounding dialysis withdrawal (see Fast Fact #208).<span style="mso-spacerun:yes"> </span>For patients not otherwise close to death, explore reasons for withdrawal, especially for treatable factors that might contribute to the desire to withdraw dialysis.<span style="mso-spacerun:yes"> </span>For patients whose desire to stop dialysis is being driven by factors that are potentially ameliorable, clinicians should make sure that the decision to stop dialysis is fully informed, including the possibility that some concerns could be addressed.<span style="mso-spacerun:yes"> </span>These include:<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l1 level1 lfo3; tab-stops:.25in"><span style="font-size:10.0pt;font-family: Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol;mso-ansi-language: EN-US"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial; mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">Inadequately treated depression, anxiety, pain, and other physical or psychological symptoms (including spiritual and existential suffering) <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l1 level1 lfo3; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol; mso-ansi-language:EN-US"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial; mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">Dissatisfaction or difficulties with dialysis itself (e.g., modality, time commitment, or setting of treatment)<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left:.25in;text-indent:-9.0pt;mso-list:l1 level1 lfo3; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:Symbol; mso-ansi-language:EN-US"><span style="mso-list:Ignore">·<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial; mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language:EN-US">Inadequate social support, or concerns with being a burden to loved ones.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family: "Arial Unicode MS";mso-ansi-language:EN-US">Offer to evaluate and treat these concerns; consider a time-limited trial to see if a patient’s quality of life can be improved.<span style="mso-spacerun:yes"> </span>However, once a clinician feels a patient or surrogate is making a fully informed choice that is consistent with a patient’s values and goals, that decision should be honored. <span style="mso-spacerun:yes"> </span>Proactively address any concerns patients may voice about the ethics of withdrawal.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family: "Arial Unicode MS";mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US">Broaching dialysis withdrawal</span></b><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US"><span style="mso-spacerun:yes"> </span>Clinicians who are concerned continuing dialysis is no longer benefitting a patient due the reasons described above should broach discontinuation with the patient and family.<span style="mso-spacerun:yes"> </span>This discussion should occur as part of a larger goals-of-care conversation which addresses prognosis (see <i style="mso-bidi-font-style:normal">Fast Fact</i> #191), patient/family assessment of quality of life, and establishes realistic care goals.<span style="mso-spacerun:yes"> </span>Dialysis should be discussed as part of an overall medical plan and framed as how it can or cannot address the care goals.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style: normal">“Dialysis will likely make your mother live longer. <span style="mso-spacerun:yes"> </span>However – given everything that has been happening – it is not going to improve her strength, memory, or ability to take care of herself.<span style="mso-spacerun:yes"> </span>Based on what you’ve told me about your mother and what is important for her, I would recommend stopping the dialysis as it is only serving to maintain her in a state she would find unacceptable.”<span style="mso-spacerun:yes"> </span></i><o:p></o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-US"><o:p> </o:p></span></b></p> <p style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt; font-family:Arial">References<o:p></o:p></span></b></p> <p class="MsoBodyText" style="margin-top:0in;margin-right:41.4pt;margin-bottom: 0in;margin-left:.25in;margin-bottom:.0001pt;text-indent:-.25in;mso-list:l2 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:Arial"><span style="mso-list:Ignore">1.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial">Galla JH and the <em><span style="font-family:Arial">Renal Physicians Association/American Society of Nephrology Working Group. </span></em>Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">J Am Soc Nephrol</i>. 2000; 11:1340-1342.<o:p></o:p></span></p> <p class="MsoBodyText" style="margin-top:0in;margin-right:41.4pt;margin-bottom: 0in;margin-left:.25in;margin-bottom:.0001pt;text-indent:-.25in;mso-list:l2 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:Arial"><span style="mso-list:Ignore">2.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial">Murtagh F, Cohen LM, Germain MJ. Dialysis Discontinuation: Quo Vadis?<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">Advances <span style="mso-spacerun:yes"> </span>Chronic Kid Dis</i>. 2007; 14(4):379-401.<o:p></o:p></span></p> <p class="MsoBodyText" style="margin-top:0in;margin-right:41.4pt;margin-bottom: 0in;margin-left:.25in;margin-bottom:.0001pt;text-indent:-.25in;mso-list:l2 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:Arial"><span style="mso-list:Ignore">3.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial">Holley JL, Davison SN, Moss AH. Nephrologists’ Changing Practices in Reported End-of-Life Decision-Making.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">Clin J Am Soc Nephrol.</i> 2007; 2:107-111.</span><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:"Arial Unicode MS""><o:p></o:p></span></p> <p class="MsoBodyText" style="margin-top:0in;margin-right:41.4pt;margin-bottom: 0in;margin-left:.25in;margin-bottom:.0001pt;text-indent:-.25in;mso-list:l2 level1 lfo1; tab-stops:list .25in"><span style="font-size:10.0pt; font-family:Arial;mso-fareast-font-family:Arial"><span style="mso-list:Ignore">4.<span style="font:7.0pt "Times New Roman""> </span></span></span><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"">White Y, Fitzpatrick G.<span style="mso-spacerun:yes"> </span>Dialysis: prolonging life or prolonging dying? Ethical, legal and professional considerations for end of life decision making.<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">EDTNA ERCA J. </i>2006; 32:99-103.<o:p></o:p></span></p> <p class="MsoBodyText" style="margin-top:0in;margin-right:41.4pt;margin-bottom: 0in;margin-left:.25in;margin-bottom:.0001pt;text-indent:-.25in;mso-list:l2 level1 lfo1; tab-stops:list .25in"><span style="mso-list:Ignore">5.<span style="font:7.0pt "Times New Roman""> </span></span><span style="font-size:10.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"">Cohen LM, Germain MJ, Poppel DM.<span style="mso-spacerun:yes"> </span>Practical considerations in dialysis withdrawal.<span style="mso-spacerun:yes"> </span>“To have that option is a blessing.”<span style="mso-spacerun:yes"> </span><i style="mso-bidi-font-style:normal">JAMA</i>. 2003; 289:2113-2119</span><span style="mso-fareast-font-family:"Arial Unicode MS"">.<o:p></o:p></span></p> <p class="MsoBodyText" style="margin-right:41.4pt"><span style="mso-fareast-font-family: "Arial Unicode MS""><o:p> </o:p></span></p> <b style="mso-bidi-font-weight:normal"><span lang="EN-CA" style="font-size:10.0pt; mso-bidi-font-size:12.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS"; mso-ansi-language:EN-CA;mso-fareast-language:JA;mso-bidi-language:AR-SA">Author Affiliations:</span></b><span lang="EN-CA" style="font-size:10.0pt;mso-bidi-font-size: 12.0pt;font-family:Arial;mso-fareast-font-family:"Arial Unicode MS";mso-ansi-language: EN-CA;mso-fareast-language:JA;mso-bidi-language:AR-SA"><span style="mso-spacerun:yes"> </span>The <st1:placetype st="on">University</st1:placetype> of <st1:placename st="on">Alberta</st1:placename>, <st1:city st="on">Edmonton</st1:city>, <st1:state st="on">Alberta</st1:state> (SND), and the Medical <st1:placetype st="on">College</st1:placetype> of <st1:placename st="on">Wisconsin</st1:placename>, <st1:city st="on">Milwaukee</st1:city>, Wisconsin (DAR). </span><div><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"><br /></span></div><div><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"><a href="http://www.eperc.mcw.edu/ff_index.htm">This Fast Fact is also available at EPERC</a>. </span></div>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0tag:blogger.com,1999:blog-7003073374405237023.post-81305783249724533012008-09-15T09:32:00.004-05:002008-09-15T09:34:20.810-05:00#206: Genetic screening and DNA banking at the end of life<p class="MsoNormal" align="center" style="text-align:center;mso-layout-grid-align: none;text-autospace:none"><b><span style=" text-transform:uppercase;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">fast facts and concepts #206</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></b></p> <p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center; mso-layout-grid-align:none;text-autospace:none"><b><span style=" text-transform:uppercase;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Genetic Screening and DNA Banking at the End of Life</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></b></p> <p class="MsoNormal" align="center" style="margin-bottom:6.0pt;text-align:center; mso-layout-grid-align:none;text-autospace:none"><b><span style=" ;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">John M. Quillin PhD, Joann N. Bodurtha MD, and Thomas J. Smith MD</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></b></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Background</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></b><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Many dying patients voice concern for the health of surviving family members.</span><sup><span class="Apple-style-span" style="font-size: medium;">1, 2 </span></sup><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">The most common causes of death can cluster in families, and this clustering can reflect shared family genes. About 5% to 10% of cancers are strongly hereditary,</span></span><sup><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">3 </span></span></sup><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">and a family history of heart disease is well established as a risk factor for the disease.</span><sup><span class="Apple-style-span" style="font-size: medium;">4-6 </span></sup><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Family members may benefit from knowing their genetic risk, and offering testing can be a generative act for a dying patient. </span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Today’s genetic tests can identify known markers of disease for only some families, so testing is most helpful if it includes the affected patient (otherwise ‘negative’ test results are less informative). In addition, more informative genetic tests will likely be available in the future. Once patients die, however, their DNA is no longer readily available for this future testing. On the other hand, decisions about genetic testing are complex and can have profound emotional, familial, and financial impacts on those affected and should not be pursued hastily.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Arial;color:black;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Possible Genetic Conditions</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></b><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">If a patient or family member asks if survivors could be affected by the patient’s disease, consider recommending genetic testing or banking for known genetic disorders (e.g. hemochromatosis, cystic fibrosis) and in the following settings:</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Earlier-than-expected age at diagnosis (e.g. breast cancer before age 50)</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Multiple primary cancers (e.g. a history of both colon and ovarian cancer)</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">A major birth defect (e.g. spina bifida, congenital heart defect) or multiple minor physical anomalies</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Profound hearing or vision loss without an environmental explanation</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Developmental disability or autism</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Disorders of sexual development</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Unusually tall or short stature compared to relatives</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Unusual skin pigmentation, such as ≥6 café-au-lait spots, or lumps (e.g., multiple lipomas)</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Congenital myopathy or muscular dystrophy</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Cardiomyopathy or arrhythmia without clear cut cause, or at an age earlier than expected</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Suspected connective tissue disease (e.g. hyperflexibility)</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Excessive bleeding or clotting tendencies not associated with medication or comorbidity</span></span><span style=" ;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="margin-left:.35in;text-indent:-.15in;mso-list:l0 level1 lfo1; tab-stops:list .25in;mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol;"><span style="mso-list:Ignore"><span class="Apple-style-span" style="font-size: medium;">·</span><span style="font:7.0pt "Times New Roman""><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></span><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Seizures without an identifiable etiology</span></span><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><span style="mso-bidi-font-weight: bold;font-family:Arial;color:black;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">Talking to Patients and Families </span></span></b><span style="font-family:Arial;color:black;"><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">There is no consensus on who should be approached for discussion of familial risk, and to date no studies on effective communication strategies for genetic screening at the end of life are available, despite acknowledgment of a practice gap.</span><sup><span class="Apple-style-span" style="font-size: medium;">7-9 </span></sup><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">In practice, a straightforward invitation for discussion of the topic may be effective: </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">“I’d like to talk with you about your family health history. Some health conditions tend to run in families and knowing your health history and seeing if it is connected to your illness could help others in your family to stay healthy. Most diseases are not strongly genetic, but sometimes it is helpful to have a genetic test or store a blood sample for testing later.”</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></i></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><i style="mso-bidi-font-style:normal"><span style="font-family:Arial;color:black;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></i></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Genetic counselors, medical geneticists, and genetic nurses</span></span></b><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;"> can facilitate comprehensive genetics evaluation, assist in test selection, provide informed consent, and educate patients and family members about indications for and costs of testing and banking. Genetic consultation is usually covered by major insurers and Medicare, especially for patients with active disease such as cancer.</span><span style="color:black;"><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><span style="font-family:Arial;color:black;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">DNA Banking</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></b><span style=" mso-bidi-font-weight:bold;font-family:Arial;color:black;"><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Banking involves drawing blood for long-term storage at a DNA banking facility.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">DNA banking is typically not covered by insurance; costs vary from one to a few hundred dollars. Facilities offering DNA banking vary in their informed consent requirements and documentation for ownership of samples (e.g. who is authorized to submit a sample to a laboratory for genetic testing).</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Banking can be particularly helpful considering turn-around-time for genetic test results can be long and more informative tests may become available in the future.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">In addition, given the complex and emotional decision making that can be involved in genetic testing, banking gives family members time to seek counseling and to carefully consider such decisions, without feeling pressure to pursue testing before a loved one dies.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></b></p> <p class="MsoNormal" style="mso-layout-grid-align:none;text-autospace:none"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Resources </span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></b><span style=" ;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Clinical laboratories that currently offer DNA banking can be found at </span><a href="http://www.genetests.org/"><span class="Apple-style-span" style="font-size: medium;">http://www.genetests.org</span></a><span class="Apple-style-span" style="font-size: medium;">. Providers can search for nearby genetic counselors and geneticists at </span><a href="http://www.nsgc.org/"><span class="Apple-style-span" style="font-size: medium;">http://www.nsgc.org</span></a><span class="Apple-style-span" style="font-size: medium;"> and </span><a href="http://www.acmg.net/"><span class="Apple-style-span" style="font-size: medium;">http://www.acmg.net</span></a><span class="Apple-style-span" style="font-size: medium;">. General resources for clinicians about genetic counseling and testing can be found in references 10</span><span style="color:black;"><span class="Apple-style-span" style="font-size: medium;">-13.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></span></p> <p class="MsoNormal" style="margin-top:12.0pt;mso-layout-grid-align:none; text-autospace:none"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;color:black;"><span class="Apple-style-span" style="font-size: medium;">References</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></b></p> <ol style="margin-top:0in" start="1" type="1"> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Duggleby W, Wright K. Elderly palliative care cancer patients' descriptions of hope-fostering strategies. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Int J Palliat Nurs</span></i><span class="Apple-style-span" style="font-size: medium;">. 2004;10:352-359.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Skirton H, Frazier LQ, Calvin AO, Cohen MZ. A legacy for the children--attitudes of older adults in the </span><st1:place st="on"><st1:country-region st="on"><span class="Apple-style-span" style="font-size: medium;">united kingdom</span></st1:country-region></st1:place><span class="Apple-style-span" style="font-size: medium;"> to genetic testing. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">J Clin Nurs</span></i><span class="Apple-style-span" style="font-size: medium;">. 2006;15:565-573.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Offit K. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Clinical Cancer Genetics. </span></i><st1:place st="on"><st1:state st="on"><span class="Apple-style-span" style="font-size: medium;">New York</span></st1:state></st1:place><span class="Apple-style-span" style="font-size: medium;">: Wiley-Liss, Inc.; 1998.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><st1:place st="on"><st1:city st="on"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Hunt</span></span></st1:city><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;"> </span><st1:state st="on"><span class="Apple-style-span" style="font-size: medium;">SC</span></st1:state></span></st1:place><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">, Gwinn M, Adams TD. Family history assessment: Strategies for prevention of cardiovascular disease. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Am J Prev Med</span></i><span class="Apple-style-span" style="font-size: medium;">. 2003;24:136-142.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span lang="PT" style="mso-ansi-language:PT;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Murabito JM, Pencina MJ, Nam BH, et al. </span></span><span style=" ;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Sibling cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults. </span></span><i style="mso-bidi-font-style: normal"><span lang="PT" style=" mso-ansi-language:PT;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">JAMA</span></span></i><span lang="PT" style=" mso-ansi-language:PT;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">. 2005;294:3117-3123.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Lloyd-Jones DM, Nam BH, D'Agostino RB S, et al. Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: A prospective study of parents and offspring. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">JAMA</span></i><span class="Apple-style-span" style="font-size: medium;">. 2004;291:2204-2211.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Kirk J. The family history of cancer - a common concern in palliative care. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Progress in Palliative Care</span></i><span class="Apple-style-span" style="font-size: medium;">. 2004;</span><st1:time minute="59" hour="12" st="on"><span class="Apple-style-span" style="font-size: medium;">12:59</span></st1:time><span class="Apple-style-span" style="font-size: medium;">-65.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Lillie AK. Exploring cancer genetics and care of the family: An evolving challenge for palliative care. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Int J Palliat Nurs</span></i><span class="Apple-style-span" style="font-size: medium;">. 2006;12:70-74.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Quillin JM, Bodurtha JN, Smith TJ. Genetics assessment at the end of life: Suggestions for implementation in clinic and future research. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">J Palliat Med</span></i><span class="Apple-style-span" style="font-size: medium;">. 2008;11:451-458.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Pletcher BA, Toriello HV, Noblin SJ, et al. Indications for genetic referral: A guide for healthcare providers. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">Genet Med</span></i><span class="Apple-style-span" style="font-size: medium;">. 2007;9:385-389.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">American Society of Clinical Oncology. American society of clinical oncology policy statement update: Genetic testing for cancer susceptibility. </span><i style="mso-bidi-font-style:normal"><span class="Apple-style-span" style="font-size: medium;">J Clin Oncol</span></i><span class="Apple-style-span" style="font-size: medium;">. 2003;21:2397-2406.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Genetics and Your Practice. March of Dimes.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Available at: </span><a href="http://marchofdimes.com/gyponline/index.bm2"><span class="Apple-style-span" style="font-size: medium;">http://marchofdimes.com/gyponline/index.bm2</span></a><span class="Apple-style-span" style="font-size: medium;">.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Accessed </span><st1:date year="2008" day="10" month="7" st="on"><span class="Apple-style-span" style="font-size: medium;">July 10, 2008</span></st1:date><span class="Apple-style-span" style="font-size: medium;">.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> <li class="MsoNormal" style="mso-list:l1 level1 lfo2;tab-stops:list .5in; mso-layout-grid-align:none;text-autospace:nonecolor:black;"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">National Office of Public Health Genomics.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Centers for Disease Control and Prevention.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Available at: </span><a href="http://www.cdc.gov/genomics/"><span class="Apple-style-span" style="font-size: medium;">http://www.cdc.gov/genomics/</span></a><span class="Apple-style-span" style="font-size: medium;">.</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span><span class="Apple-style-span" style="font-size: medium;">Accessed </span><st1:date year="2008" day="10" month="7" st="on"><span class="Apple-style-span" style="font-size: medium;">July 10, 2008</span></st1:date><span class="Apple-style-span" style="font-size: medium;">.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></li> </ol> <p class="MsoNormal" style="margin-left:.25in;text-indent:-.25in;mso-layout-grid-align: none;text-autospace:none"><span style=" ;font-family:Arial;color:black;"><o:p><span class="Apple-style-span" style="font-size: medium;"> </span></o:p></span></p> <p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Author Affiliations:</span><span style="mso-spacerun:yes"><span class="Apple-style-span" style="font-size: medium;"> </span></span></span></b><span style=" ;font-family:Arial;"><span class="Apple-style-span" style="font-size: medium;">Massey Cancer Center,</span><b style="mso-bidi-font-weight:normal"><span class="Apple-style-span" style="font-size: medium;"> </span></b><span class="Apple-style-span" style="font-size: medium;">Virginia Commonwealth University.</span><span class="Apple-style-span" style="font-size: medium;"><o:p></o:p></span></span></p><p class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial; "><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></p><p class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial; "><a href="http://www.eperc.mcw.edu/fastFact/ff_206.htm"><span class="Apple-style-span" style="font-size: medium;">This Fast Fact is available at EPERC</span></a><span class="Apple-style-span" style="font-size: medium;">.</span></span></p>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.com0