#224 Responding to Emotions in Family Meetings

FAST FACTS AND CONCEPTS #224

Responding TO EMOTION IN FAMILY MEETINGS

David E Weissman MD, Timothy E Quill MD, and Robert M Arnold MD

Background Family meetings are stressful events, often provoking strong emotional reactions. Fast Fact #29 presents a general outline on the topic of how clinicians can respond to emotions. The Fast Fact will provide a more detailed approach to emotions that arise during family meetings.

Consider your role. It is important to reflect on the role of clinicians in responding to patient/family emotions at the time life-altering information is shared. The goal is not to prevent a patient/family from having those emotions. Sadness, fear, anger, and loss are normal responses to unwelcome news. 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. Recognize that most families find clinicians’ expressions of empathy tremendously supportive and these are associated with family satisfaction.

Acknowledge that emotion is being expressed. If you have a good sense of what the emotion is, then it is useful to name it. If not, using more general language is preferable.

• I can see this is really affecting you.

• This information is very upsetting.

Legitimize the appropriateness and normalcy of the reaction. 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.

• Anyone receiving this news would feel devastated.

• It is completely expected to be very distressed by this kind of news.

Explore more about what is underneath the emotion. It is tempting to try to limit the emotion, and be prematurely reassuring. 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.

• Tell me what is the scariest (most difficult) part for you.

• Tell me more about that…. (Keep the exploration going until it is fully expressed and understood.)

Empathize (if you genuinely feel it). Empathy means being able to emotionally imagine what the patient is going through. Clinicians can initiate the prior responses (acknowledge, legitimize, explore) without having a clear feeling for the patient’s experience. These responses can be adequate in themselves. 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.

• This seems really unfair.

• I can imagine that you might feel very disappointed.

Explore strengths/coping strategies. This may occur at this phase of the interview, or it may be postponed to a later phase when planning for next steps begins.

• In past circumstances, what has helped?

• How have you adapted to difficult circumstances in the past?

• What are you hoping for now?

References

1. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009.

2. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997; 277:678-682.

3. Hardee JT. An overview of empathy. The Permanente Journal. 2003; 7(online). Available at: http://xnet.kp.org/permanentejournal/fall03/cpc.html. Accessed August 5, 2009.

Author Affiliations: Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).

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).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE, Quill TE, Arnold RM. Responding to Emotions in Family Meetings. Fast Facts and Concepts. January 2010; 224. Available at: http://www.eperc.mcw.edu/fastfact/ff_224.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts 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.

#223 The Family Meeting: Starting the Conversation

FAST FACTS AND CONCEPTS #223

THE FAMILY MEETING: Starting the conversation

David E Weissman MD, Timothy Quill MD, and Robert M Arnold MD

Background Fast Fact #16 gives a concise overview of running a family meeting. Fast Fact #222 provides a list of preparatory steps in planning for a family meeting to discuss end-of-life goals; this Fast Fact reviews the early steps of the actual meeting.

1. Introductions & setting goals for the meeting

• 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.
• The meeting leader should summarize the meeting goals (e.g. We are here to discuss next steps in the care of Mr. Jones) and ask the family to confirm these goals and/or add other agenda items.
• Note: if you do not know the patient or family well, take a moment to build relationship. Ask a non-medical question such as 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. Can you tell us about the things you liked to do before you got sick? Similarly, if the patient is not able to participate in the meeting, ask family to describe the patient prior to his becoming ill: As we get started, can you describe what Mr. Jones was like before he became ill?

2. Determine what the patient/family already knows This step is essential as it guides you in providing a synthesis of the medical information (see below). Always invite the patient and all family members to provide their understanding of the medical information. Examples of opening lines:

• Tell me what the doctors have told you about your condition?
• Can you describe for me your sense of how things are going?
• For patients who have been declining from a chronic illness, you can ask: Tell me about the past 3-6 months: what types of changes have you noted? The patient or family will typically describe changes in terms of function (physical or cognitive) and quality of life.

3. The Medical Review 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. The clinician most closely aligned with the patient’s ongoing treatment should begin this discussion, supplemented with information from consulting services if relevant. Do not provide information using medical jargon or in an organ system approach (e.g. The creatinine is improving, but there is a new pleural effusion and the heart rate has become irregular). 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. Give a ‘bottom-line’ statement: ‘getting worse,’ ‘not going to improve,’ ‘dying and time is likely very short.’

• The worsening weakness and pain you describe is from the cancer which is growing despite the chemotherapy.
• 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.
• Despite our best efforts, your wife’s brain injury from the car crash is getting worse. She can no longer stay awake or move her arms/legs.

Using the ‘D word’ if relevant: 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 dying in the conversation. Both patients and surrogates find that saying the word dying, if done compassionately, is helpful in clearing what is often a confusing and frightening situation. I’m afraid we have run out of options to shrink the cancer. Based on your declining function, I believe you are dying.

4. Silence Whether or not you use the word dying, 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. 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). This silence can be uncomfortable; resist the urge to fill it with more facts as they will not be heard. Not all patients/families express emotions at this point and instead respond practically (Well, what happens next then?). This is fine, but you need to wait, silently, to see what response the patient/family demonstrates. In addition, even practical questions have underlying emotions (Are you sure? Or – There must be something you can do?). It is important to respond to both the factual aspect of the question (Yes I am sure. Or – There are no more effective treatments available.), as well as the emotional level (I wish I had better news for you. Or – I wish our treatments worked better than they do.).

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: How long? What will happen? Will there be suffering? What do we do now? Your response at this point should be to address prognosis in terms of time, function, and symptoms, as best you can (see Fast Facts #13,141,143,149,150). This will answer the first two questions; the last questions will require more discussion of patient-centered goals (see Fast Fact #227).

References

1. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009.

2. Quill TE, Townsend P. Bad news: delivery, dialogue and dilemmas. Arch Intern Med. 1991; 151:463-468.

3. 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. Crit Care Med. 2001; 29(2 Suppl):N26-33.

4. Lautrette A, Ciroldi M, Ksibi H, Azoulay E. End-of-life family conferences: rooted in the evidence. Crit Care Med. 2006; 34(11):S364-S372.

5. King DA, Quill T. Working with families in palliative care: one size does not fit all. J Pall Med. 2006; 9:704-715.

6. Quill TE, Arnold RM, Platt FW. "I wish things were different": Expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001; 135:551-555.

Author Affiliations: Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).

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).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE, Quill TE, Arnold RM. The Family Meeting: Starting the Conversation. Fast Facts and Concepts. December 2009; 223. Available at: http://www.eperc.mcw.edu/fastfact/ff_223.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts 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.

#222 Preparing for the Family Meeting

FAST FACTS AND CONCEPTS #222

PREPARing FOR THE FAMILY MEETING

David E Weissman MD, Timothy E Quill MD, and Robert M Arnold MD

Background 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. As with any procedure, preparation is essential to ensure the best outcome. This Fast Fact reviews how to prepare for a Family Meeting. See also Fast Fact #16 for a concise overview of family meetings, as well as Fast Facts 223-227 for discussion of additional aspects of family conferences.

Data Review

· 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).

· Review all current treatments (e.g. renal dialysis, artificial nutrition, antibiotics) and any positive and/or negative treatment effects.

· Review all treatment options being proposed.

· 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).

· 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. 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.

· 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’).

· Seek out patient/family psychosocial data. Focus on psychological issues and family dynamics (e.g. anger, guilt, fear) potentially impacting decision making. These issues may be long-standing, or due to the current illness. Note: 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.

o Review what transpired in prior family meetings.

o Learn about particular cultural/religious values and/or or social/financial issues that may impact decision making.

Information Synthesis 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).

Meeting Leadership Leading a family meeting requires considerable flexibility to ensure that all relevant participants have the opportunity to have their points of view expressed. 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. These skills include:

· Group facilitation skills.

· Counseling skills.

· Knowledge of medical and prognostic information.

· Willingness to provide leadership/guidance in decision making.

Invitations 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. The medical care team should likewise decide who they want to participate. Note: 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. If the patient has a long-time treating physician whom he/she trusts, this person should ideally be present.

Setting 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. 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.

The Pre-Meeting Meeting 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.

References

1. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009.

2. 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. Crit Care Med. 2001; 29(2 Suppl):N26-33.
3. Lautrette A, Ciroldi M, Ksibi H, Azoulay E. End-of-life family conferences: rooted in the evidence. Crit Care Med. 2006; 34(11):S364-S372.
4. King DA, Quill T. Working with families in palliative care: one size does not fit all. J Pall Med. 2006; 9:704-715.
5. Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Pall Med. 2006; 9:451-463.

6. Weissman DE. Decision making at a time of crisis near the end of life. JAMA. 2004; 292:1738-1743.

Author Affiliations: Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).

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).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE, Quill TE, Arnold RM. Preparing for the Family Meeting. Fast Facts and Concepts. December 2009; 222. Available at: http://www.eperc.mcw.edu/fastfact/ff_222.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts 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.

#221Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction

FAST FACTS AND CONCEPTS #221

Treatment of Pain in Patients Taking Buprenorphine for OPIOID ADDICTION

Julie W Childers MD and Robert Arnold MD

Background This Fast Fact discusses treating pain in patients using buprenorphine for opioid addiction. Buprenorphine is a mixed opioid agonist/antagonist, available in the United States in the sublingual form as ‘Subutex,’ and formulated with naloxone as ‘Suboxone.’ It is approved for treatment of opioid addiction in the US; such use is restricted to qualified physicians who have received training and a waiver to practice medication-assisted opioid addiction therapy. 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. Note: buprenorphine is also used as an analgesic, particularly in Europe, where a transdermal system is available. Currently it is uncommonly used in the US as an analgesic. Naloxone has minimal sublingual bioavailability and is included only to prevent abuse by intravenous injection; in this Fast Fact ‘buprenorphine’ refers to both sublingual products.

Pharmacology Buprenorphine binds to mu-opioid receptors tightly but with low intrinsic activity, providing some analgesic effects but effectively preventing other opioids from binding. This ‘blocks’ the analgesic and euphoric effects of other opioids, leading to its effectiveness in opioid addiction therapy. Buprenorphine’s effect at the mu-opioid receptor lasts 24 to 60 hours, and can lengthen even further with increasing doses. 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.

Pain Management Strategies 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). As with all patients with pain, non-pharmacologic therapies and non-opioid analgesics should be used when safe and likely to work. The following strategies should be chosen and implemented in close collaboration with the physician treating the patient’s opioid addiction.

• 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.
• 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. 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. The patient should be monitored carefully in the initial period to titrate the opioid agonist dose downward as its effect becomes greater. Before restarting buprenorphine, the patient should be opioid-free for 12-24 hours to avoid precipitating withdrawal. This process should be overseen by an approved buprenorphine provider.
• For patients with mild to moderate acute pain, consider treating the pain with buprenorphine alone. 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.
• Another option is to continue buprenorphine and use short-acting opioid agonists at high enough doses to overcome buprenorphine’s partial agonism. 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.
• In a patient who is expected to have an ongoing need for pain management, consider replacing buprenorphine with methadone therapy for opioid addiction. 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.
• Patients who have life-limiting illnesses that are expected to cause significant pain are not good candidates for buprenorphine therapy for addiction. 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.

Author Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA.

References

1. Alford DP, et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006; 144:127-134.
2. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. Available at http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf. Accessed June 25, 2009.
3. Heit HA, Gourlay DL. Buprenorphine: new tricks with an old molecule for pain management. Clin J Pain. 2008; 24:93-97.
4. Helm S, et al. Opioid antagonists, partial agonists, and agonists/antagonists: the role of office-based detoxification. Pain Physician. 2008; 11:225-235.
5. Johnson RE, Fudula PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005; 29(3):297-326.
6. Kögel B, Christoph T, Strassburger W, Friderichs E. Interaction of mu-opioid receptor agonists and antagonists with the analgesic effect of buprenorphine in mice. Eur J Pain. 2005; 9(5):599-611.
7. Mark, TL, Kassed CA, Vandivort-Warren R, et al. Alcohol and opioid dependence medications: prescription trends, overall and by physician specialty. Drug Alcohol Depend. 2009; 99:345-349.
8. Mercadante S, Villari P, Ferrera P, et al. Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine. J Pain Symptom Manage. 2006; 32(2):175-9.
9. Schumacher MA, Basbaum AI, Way WL. Opioid analgesics and antagonists. In: Katzung BG, ed. Basic and clinical pharmacology. New York, NY: McGraw-Hill; 2007.

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: www.eperc.mcw.edu. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Childers JW, Arnold R. Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction. Fast Facts and Concepts. November 2009; 221. Available at: http://www.eperc.mcw.edu/fastfact/ff_221.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts 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.

#220 Hypodermoclysis

FAST FACTS AND CONCEPTS #220

HYPODERMOCLYSIS

Arif H Kamal MD and Eduardo Bruera MD

Background This Fast Fact discusses subcutaneous fluid infusions, also known as hypodermoclysis (HDC). The use of parenteral hydration in dying patients is controversial and is discussed in Fast Fact #133. While this Fast Fact discusses subcutaneous fluid infusions for purposes of hydration, similar techniques can also be used to deliver medications (see Fast Fact #28).

Historical and Current Practice 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. Due to its ease of use, and subsequent research demonstrating its safety and efficacy, HDC has become more widely used. In the US, HDC is mostly used in geriatric and palliative care settings, although it is used more widely elsewhere in the world.

HDC vs. Intravenous Hydration Decisions for parenteral hydration in dying patients are complex and individual decision making is paramount. When parenteral hydration is indicated, clinicians are generally faced with a decision to use HDC or intravenous (IV) hydration (see Fast Fact #134).

• Advantages of HDC over IV: Starting and maintaining a subcutaneous infusion catheter is relatively pain-free. 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. HDC provides greater potential sites for needle placement (arm, back, abdomen, thighs), and equipment costs are generally lower than with IVs. Subcutaneous catheters can be easily disconnected from IV tubing and re-used later, allowing a patient to receive intermittent fluid treatments. Portable infusion devices are not needed with HDC. HDC infusions may also cause less agitation in patients with dementia versus IV (1).
• Disadvantages: HDC is limited by a continuous infusion rate of 1-2 ml/min or 1.5-3 L/day (2). This is adequate for most clinical situations, and additional catheters can be added if needed. Bolus infusions (up to 500 ml/hour) are possible with HDC, but often require hyaluronidase (see below). Both HDC and IV infusions have similar rates of local adverse events (e.g. erythema, cellulitis) and lifespan of infusion site (3). HDC can be technically difficult in patients with substantial peripheral edema, as well as in cachectic patients with little subcutaneous tissue. Patients and families may have pre-conceived attitudes about greater benefits with IV routes even while acknowledging increased burden (4).

Technique

• Equipment needed: Small butterfly needle (usually 22 gauge) or angiocatheter, skin preparation (alcohol or iodine), sterile occlusive dressing, solution bag (saline or saline-dextrose combination), tubing with drip chamber. 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.
• Procedure: After cleaning the local site, insert the needle bevel up into the subcutaneous tissue. Attach to fluid and tubing and cover with occlusive dressing. Select an infusion fluid and set drip rate or fluid bolus. Normal saline (NS) is typically used although half-normal saline or 2/3 D5W in 1/3 NS have been used in clinical practice. Drip rates can be set to 20-125 ml/hour with gravity (no pump required) or 1-2 ml/minute. 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). 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). No evidence exists for the frequency of site change. 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) Teflon cannulas, although expensive, can be used for a week and are helpful for patients who have trouble maintaining a catheter site (6). Local anesthetic creams may be helpful during catheter placement to reduce discomfort, especially in children.
• Recombinant human hyaluronidase: RHH is an enzyme that temporarily lyses the subcutaneous interstitial space to promote diffusion of fluid. It can be used for site discomfort or if a faster rate of absorption is desired. Previous preparations were of bovine origin and were associated with local allergic reactions, anaphylaxis, and pain, making its role controversial. RHH has shown no human allergenicity (7). Recent studies have investigated RHH versus placebo in a randomized trial with gravity-driven infusion. The RHH group showed higher obtainable fluid rates, decreased discomfort, and similar local reactions. 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).

Cautions Uncommon local reactions include edema, local pain, or erythema. Interventions include slowing the rate, changing the site, or using RHH. Rare complications include cellulitis and vascular puncture. Systemic complications such as pulmonary edema can occur with all types of parenteral hydration.

References

1. O'Keeffe ST, Lavan JN. Subcutaneous fluids in elderly hospital patients with cognitive impairment. Gerontology. 1996; 42(1):36-39.
2. Berger EY. Nutrition by hypodermoclysis. J Am Geriatr Soc. 1984; 32(3):199-203.
3. Slesak G, Schnurle JW, Kinzel E, Jakob J, Dietz PK. Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomized trial. J Am Geriatr Soc. 2003; 51(2):155-160.
4. Mercadante S, Ferrera P, Girelli D, Casuccio A. Patients' and relatives' perceptions about intravenous and subcutaneous hydration. J Pain Symptom Manage. 2005; 30(4):354-358.
5. Dalal S, Bruera E. Dehydration in cancer patients: to treat or not to treat. J Support Oncol. 2004; 2(6):467-479, 483.
6. Macmillan K, Bruera E, Kuehn N, Selmser P, Macmillan A. A prospective comparison study between a butterfly needle and a Teflon cannula for subcutaneous narcotic administration. J Pain Symptom Manage. 1994; 9(2):82-84.
7. Yocum 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. J Infus Nurs. 2007; 30(5):293-299.
8. Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. J Palliat Med. 2007; 10(6):1312-1320.

Author Affiliations: Mayo Clinic, Rochester, MN (AK) and University of Texas M.D. Anderson Cancer Center, Houston, TX (EB).

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: www.eperc.mcw.edu. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Kamal AH, Bruera E. Hypodermoclysis. Fast Facts and Concepts. October 2009; 220. Available at: http://www.eperc.mcw.edu/fastfact/ff_220.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts 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.