Skip to main content

Blogs to Boards: Question 5


This is the fifth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  

Question 5

In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice?”

Which one of the following is not a potential scenario to use octreotide? Choose the best answer.

a) A 37 year old male with end stage alcoholic hepatitis who starts vomiting blood 
b) A 90 year old with a severe diarrhea with a history of a rectal tumor and radiation burns to the perineal area 
c) A 42 year old female with a tense distended abdomen leaking a small amount from a previous paracentesis site. 
d) A 27 year old male with a malignant wound with copious drainage 
e) A 31 year old female with abdominal pain from opioid-induced constipation 


Discussion:

Comments

Bruce Scott MD said…
I think I accidentally submitted a previous comment before completing it.

I certainly said something incorrect in that comment (claiming that the 2nd Edition of Twycross HPCFUSA didn't have info on octreotide--don't know why I misremembered this).

HPCF has a section on octreotide. The reference to octreotide use in tumor anti-secretory effects is Harvey M and Dunlop R (1996) Octreotide and the secretory effects of advanced cancer. Palliative Medicine. 10: 346-347

This use is new to me. I would have gotten the question wrong if it weren't for choice E, which was pretty clear.

We did have one case where we used depot octreotide successfully in a palliative patient with intractable diarrhea. Most of his bowel was resected, but he did not want to pursue a surgical solution (absolutely would not consider any intervention that would lead to an ostomy). Brought him in to the unit to test the effect of subcutaneous octreotide (as well as adjust his analgesia). When he responded to the octreotide, we got pharmacy approval to use the depot version. he came in to the hospital for his monthly shots then.

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …