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Potpourri from Clinical Work III

Interesting issues and questions from my recent stint on the inpatient hospice and palliative care service.

  1. Hospices are not supposed to discriminate against patients based on code status.  Yet I think in practice some do. Some do not take patients who are DNR.  Others ask them to sign a DNR form on enrollment.   Other people's experiences with this?  Is anyone concerned?
  2. We cared for a patient with Complex Regional Pain Syndrome (former name Reflex Sympathetic Dystrophy).  This patient has a chronic painful condition but no terminal illness, and pushes on the boundaries of what constitutes a "palliative care" patient.  In some sense all hospitalized patients can benefit from palliative care.  The question is, how far do our boundaries extend in caring for these patients?  Sure we can help everyone, at least a little bit.  But at some point the costs outweigh the benefits.  Where is that line, and how much should be determined on a local basis versus a national  mission and vision for palliative care?  AAHPM says palliative medicine providers should care for patients with "serious" conditions.  Is CRPS serious?  How about sickle cell crisis?  Chronic back pain?  Late life disability?
  3. We had a patient who was told he had a prognosis of weeks to months.  He said he didn't believe it; he thought his prognosis was years.  The medicine attending recommended we reiterate that his prognosis was weeks to months until he "got it."  What do you think about this?  On the one hand, this seems like battery of some sort.  On the other hand, while we didn't reiterate his prognosis on a daily basis, we did point out the multitude of ways his body was failing.  He eventually accepted his prognosis and transitioned to hospice. 
  4. When treating opioid related nausea that is not well treated with the initial dose of an anti-emetic, do you generally push the dose of one medication or add another agent until you achieve satisfactory effect?  I usually start with metoclopramide (5mg TID scheduled before meals) because of it's anti-dopaminergic and promotility properties, and push the dose before switching to another agent.  Curious what others have done.
  5. Now that ondansetron (Zofran) is generic, people are prescribing it like water.  The teaching when I trained was that it was first line for nausea due to chemotherapy, radiation, and anesthesia.  I don't actually think it has been studied and found effective for other causes of nausea.  What are other people's clinical experience?  I recommended against routine use when lecturing to a bunch of Emergency Medicine residents and was absolutely slammed - "but it works better!"  Trying to keep an open mind here...maybe it does work better?
by: Alex Smith


David Tribble said…
1. You are correct that hospices are not allowed to discriminate on the basis of code status with regard to Medicare patients. On the other hand, we are not obliged to provide resuscitation, either. Typically we attempt to coax the patient/family to a clearer understanding, but should not be twisting anyone's arm to sign a DNR

2. In its purest sense, palliative medicine addresses suffering without regard to prognosis. The extent to which palliative care practitioners become chronic disease managers is driven by the resources available to them, more than anything else.

3. You are correct that we do not attempt to browbeat a patient with his prognosis. Your approach of reflecting his status to him and allowing him to observe his own prognosis seems a very rational approach

4. You are also correct about Zofran. There are no controlled studies that find it superior in general nausea. It is a bit cleaner in terms of side effects, however.
Anonymous said…
Against nausea...try P-6, Nei-Guan point. It can work. I use also Domperidone as you use Metoclopramida. I don´t have any good comparison with Zofran

Jose A. Tous, medico general
Helen Chen said…
Re: nausea. Was just doing AAHPM board review questions. The clear answer to a question about opiate-related nausea was "needs an antiemetic" but the only available choice on the MCQ was ondansetron. Interesting given the lack of evidence.

Re: reiterating the prognosis until he "got it". So often, the consult question is "please help us with EOL communication and decision making" but the actual agenda is "please make sure the pt chooses hospice" or "please make sure the pt does what we recommend". It's often a challenge, isn't it? I thought your approach was very reasonable and I'm going to borrow it.
Jeanne Lahaie, GCNS-BC said…
2. CRPS can be relieved very well with subanesthetic ketamine. Lots of literature out there on its use in chronic pain, particularly those on high doses of opioids. Ask the Clinical Nurse Specialist for pain at SFVA or Palo Alto VA for more info or feel free to email me at Some are using it with PCA for this purpose, but Board of Registered Nursing and other regulatory bodies may have restrictions on where and when it can be used.
Alex, a lively post.

CRPS: it's serious, it's not life-limiting. I think the answer really depends on individual clinicians and teams and what they are adequately trained for and prepared for. I also have to propose that many/most of us who do palliative care work are the most knowledgable/comfortable clinicians with opioids, especially the chronic use of 'high dose' opioids. This is a good thing, but doesn't mean many of us individually and team-wise are ready to step into roles in which we take over management of these not-dying-very complex patients. To me the question is not 'is this a palliative medicine' patient (I don't really know what that means) but is this someone I/my team have the resources/knowledge to help in both the short and long term.

Re: prognosis. Leave them alone (about that), but keep showing up nonetheless. Accepting that you're dying takes time; we can't be brow beating our patients with this; talk about it, continue offering to talk about it, and keep on showing up no matter where the patient is. It usually works as it did it seems with your patients. We should not play the role of the Bad News Hit Men.

Ondansetron: Scant data head to head with D2 blockers for nausea - really none that I know about that mean anything. Copious data that it's highly effective (and, when tested, more effective than D2 blockers) for chemotx and postop nausea. While absolutely this is a generalization, I see no reason to think that we should doubt its efficacy compared to D2 blockers for opioid related nausea. If it's better than D2 blockers for chemo nausea, who are we to think it's worse for opioid related nausea. I think there used to be a pharmacoeconomic argument to reserve it for clinical situations in which its superiority was PROVEN; that is less and less the case however and I think we should admit to ourselves we didn't use it b/c of cost. In addition, it's not like we're swimming in data proving the efficacy of D2 blockers for opioid induced nausea. Frankly - if you had opioid induced nausea would you rather try 8mg of ondansetron ODT or Reglan? Having lived through akathesia myself, I'm going for the ondansetron.

Along the lines, I remain very curious as to if practice is going to change dramatically w/r/t anticoagulation at EOL if LMWH ever becomes cheap.
Monique said…
Zofran is absolutely first line in the ER now. What I like about it is that I don't have to fear the akathisia of the zines. Compazine would regularly have me having to practically restrain a patient since their urge to flee would be so strong. I would say the general rule in our practice is to repeat the zofran once and then move on. This being said, I think there is evidence that it might be wise to move on to another agent right away if the initial dose doesn't work. Now that it's cheap at Kaiser, we put it in the water.

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