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Potpourri from Clinical Work II

I've been on the palliative care service these last two weeks. Some interesting and challenging issues came up.  I don't have time to flesh them out into individual posts.  I would love some feedback from the GeriPal commmunity.
  1. I was consulted about a 62 year old woman with an unusual form of memory disorder: she couldn't form new memories (all cases completely altered to protect patient identity).  She was stuck in a past that existed 8 years ago.  She had end stage renal disease and was on dialysis.  She knew that she needed dialysis to survive, because that was also true 8 years ago, and would agree to start each dialysis session.  Shortly after starting a dialysis run, however, she'd stand up, forgetting why she was there, and try to go for a walk.  The frequent need to re-orient her proved too much for the dialysis providers.  They refused to continue dialysis.  This case raised a number of issues.  First, if she understands the risks and benefits of dialysis, but then can't sit still for it, what is our obligation?  If we stop the dialysis she will die - and clearly if we talk to this patient about her life, which she believes is her life from 8 years ago, she doesn't want to die.  Second, the team was considering giving her sedating medications so she could make it through each dialysis run.  This form of chemical restraint might be less repugnant than phyically strapping her down, but it is still a form of restraint that doesn't seem right.  We (with the help of a formal neuropsychiatric consultation) ultimately decided she doesn't have capacity to make complex medical decisions.  I don't know how this case will end.
  2. What is up with neuroleptics for hiccups?  Specifically gapabentin.  Is this real or marketing?  I was asked about gabapentin twice in the last week.  There are a few reports (here and here) in the literature that I can find, but I want to know from the "real world" if this works.
  3. Why isn't there a lower dose of long-acting opioid?  I've had several instances of patients with chronic pain or COPD for whom very low dose opioids are effective.  But their total daily dose is typically around 8-12mg of oral morphine equivalents - too low for the lowest dose of long acting opioid.  The lowest dose fentanyl patch is 12.5mg, equianalgesic to 25mg of oral morphine; the lowest dose of MS Contin is 15mg twice a day (30mg/day);  the lowest dose of oxycontin is 10mg twice a day, again equianalgesic to 30mg of oral morphine a day.  Having to take medications multiple times a day is a drag for patients, and for those in nursing homes, burdensome on the staff.  Anyone else frustrated by this?
Looking forward to seeing some of you in Boston at the palliative care conference! 


Anonymous said…
First case is fascinating - glad I'm not the substitute decision maker! Re capacity, can someone comment on ethical/legal aspects of "executional capacity", i.e. someone may understand consequences of a decision, but not be able to execute what is required, e.g. going back to living independently ... acceptable to allow patient to put themselves at risk if unlikely they have capacity to prevent bad outcome?

Second case - re quality of evidence issue, e.g. gabapentin for hiccups, gabapentin for dialysis-induced pruritus, etc. You may have come across these articles re gabapentin marketing/trial reporting: N Engl J Med 361:1963, November 12, 2009 Special Article & N Engl J Med 360:103, January 8, 2009 Perspective. I have noticed significant variation in practice when evidence is at case report level - some centers use iv lidocaine for pain, some don't, etc. When I reflect on my own practice, I wonder how my threshold for prescribing treatments with thin evidence is actually determined.

Last point - in Canada & presumably elsewhere, once daily long-acting morphine is available in 10 mg dose - marketed as "Kadian" in Canada.

Paul McIntyre
ken covinsky said…
I don't know whether or not there is any evidence supporting the use of gabapentin for hiccups. But keep in mind that that the maker of gabapentin paid $430 million in fines to settle charges that they marketed and promoted gabapentin (neurontin) for off label purposes.

All users of Gabapentin should read Mike Steinman's article describing the promotion of gabapentin. This analysis of industry documents suggests a systematic effort to manipulate continuing medical education, word of mouth marketing, and the medical literature to build the market share of gabapentin.

I don't know if hiccups were one of the indications that were marketed in this effort. But it does seem that one needs to be very careful about gabapentin anecdotes that you have heard. One also needs to view the medical literature in this area with skepticism, thinking about the quality of the studies, and their supporters, and the possibility that negative studies have been suppressed.

The original documents that formed the basis for Mike's study are available for review at the UCSF Drug Industry Document Archive.
Helen Chen said…
Re: execution capacity. Interesting concept--I think we do try to assess this at least on some basic levels, e.g. KELS, assessing ability to do basic self-discharge planning/tasks etc. However, unfortunately, sometimes we are left dealing with the aftermath of a practically predictable poor outcome because an individual with capacity insists on exercising poor judgment and embarking on a course of action that is likely to fail.

Re: the case. Really challenging--glad I'm not the decision maker either! However, is one of the elephants in the room the issue of administrative resource allocation (we don't have the personnel to sit with/reorient her?) I am aware of a similar case that wasn't viewed as a problem...until the family became unable to provider sitter coverage.
Ori Tzvieli said…
1) regarding second point acupuncture can be very helpful for hiccups if you can get it - better than any med I have seen

2) regarding third point - how about splittin up a 5mg methadone tab into half or quarter...very variable dose response as you know but might be worth a try.
Dan Matlock said…

First, good luck with your presentation this week.

1) First case: wow! Nephrology has come a long way in being able to say to patients that dialysis offers no benefit. Here, there denial feels really unethical. Helen Chen makes a great point about the sitter.

2) Hiccups: I don't know the data but anecdotally, I had amazing luck with hiccups using low dose haldol in one patient in hospice.

3) I actually perscribed 2.5 mgs of methadone in clinic last friday for a 92 yo with narcotic intolerance (nausea) and bad OA - we'll see.
Mike said…
As to the first case, I may have a different approach than to say this patient does not have the capacity to make the complex medical decision. I would argue that her reality is acceptable to her even if it is based in 8 yrs ago actually. I would consider offering her the sedation during dialysis based on the experience that she had. If the patient understands the reason for it and agrees to the controlled sedation during dialysis, this would allow her to continue the acceptable quality of life that she believes currently exists.
As to the Neurontin for hiccups, I have had 1 or 2 patients that have responded, but they were patients with GBM so I assume it was a centrally mediated mechanism for the diaphragmatic irritability. I have not seen it effective in other settings although I admit that I have not tried it as a first line drug in those other difficult cases.
As to #3, I agree that a lower dose extended release opiate would be a useful tool particularly in the elderly. I too wish we had that choice. The methadone option is something I have not used regularly in these type of cases
Alex Smith said…
Thanks to all for their comments. A few responses: executional capacity is a great term for what was lacking for this patient. I don't know of any established term in the literature, you might like to trademark that one! Helen Chen is right that the "sitter" issue was a VERY important subtext. No nursing facility would take her with a sitter, but she was too "healthy" to stay in the hospital.

RE hiccups - great idea about the accupuncture for protracted hiccups. I don't know if we have anyone who can practice accupuncture in our hospital (or if hospital regulations would allow it). My wife and I looked up accupressure points for treatment of hiccups and there seems to be one on the underside of the forarm. Something to try next time. RE gabapentin marketing, Ken makes a great point about viewing the medical literature with skepticism, given the makers of gabapentin's well documented sordid past.

RE low dose long acting opioids - Paul - I wish we had that low dose Kadian in the US! Low dose methadone is an idea, let us know how it works out for your patient Dan.

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