Hospice eNews

What the Media Said about End-of-Life Care This Week

Week of July 4, 2005

…a service of Florida Hospices and Palliative Care

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NEW SOCIAL WORK EOL WEBSITE LAUNCHED

The Social Work Leadership Development Awards (SWLDA) Program of the Project on Death in America recently held its second Social Work Summit on End-of-Life and Palliative Care in Washington, DC. The group identified key priority initiatives in the areas of policy/advocacy, research, education and practice. The group developed action plans for each priority and established work groups in all four areas. A steering committee and a board of consultants will oversee the next steps and foster development of a network composed of the participating organizations.

The group’s website, at www.swlda.org, announces the emerging network and points viewers to the old archives of the SWLDA. Another link points to the new network’s website, which indicates that the organization expects it “will become a usable website for social workers and colleagues to learn more about what is happening in this emerging network of social work in end-of-life and palliative care.” Current information includes recent press releases and announcements, as well information on upcoming events and deadlines for abstracts. (SWLDA Website)

EXPERT OFFERS TIPS ON EOL PAIN TREATMENT

Speaking at the annual meeting of the American College of Physicians, Boston pain specialist Dr. Janet L. Abrahm called opioids the “mainstay” of treating end-of-life pain. Abrahm, who is codirector of the pain and palliative care program at Dana-Farber Cancer Institute, offered “pearls” for meeting the challenges involved.

* Patients in chronic, severe pain don’t necessarily have any “objective, observable signs,” and caregivers must watch for behavioral indicators such as guarding a painful body part or abnormal sleeping, eating or interactions.

* Nonpharmacologic therapies such as heat, cold and massage can help. Cold works well for neuropathic pain and heat for muscle spasms. Acupuncture and cognitive-behavioral therapy are also effective.

* Peak methadone levels do not occur until 3-4 days after treatment is initiated. Starting doses that are too high will result in a very sleepy patient by the third day.

* Demerol, due to its short half-life, is useless for chronic, severe pain. Patients will begin to show signs of opioid toxicity after a couple of days.

* Spontaneous brief jerks, hypervigilance and hyperalgesia are all signs of opioid neurotoxicity. Families should be reassured that jerks, such as a patient pulling away when touched by a family member, are reflexes, not signs of familial rejection.

* If opioid toxicity results in myoclonic jerks, a liter or two of fluids will “flush out some of the drug and its metabolites.” Patients should then be switched to other analgesics.

* Another symptom of opioid toxicity is bad dreams. Patients should be asked if they’re having nightmares or hallucinations.

* Preventive laxatives should be prescribed when using any opioid, even oxycodone. Abrahm says that people in pain “don’t think about whether they’ve had a bowel movement” and can even become delirious if their bowels are impacted.

* Fiber-based laxatives should not be used for patients on opioids, because “fiber turns to cement in your gut when you’re on opioids.” Polyethylene glycol is preferable to lactulose or sorbitol since it does not produce bloating or gas.

* Transmucosal fentanyl can be as quick as IV administration for quick pain relief. Oralet “lollipops” next to the gum are dissolved by saliva, but should not be swallowed because most of the drug would be metabolized.

* Fentanyl patches only work well if patients have subcutaneous fat reservoirs. In elderly, malnourished patients, a fentanyl patch is “a very expensive Band-Aid.”

* Moaning in delirious patients can be mistaken for pain. If increasing opioids increases the moaning, it may be caused by delirium, not pain. If unsure, “rotate the opioid and treat the delirium simultaneously.” Haldol works best, but Zyprexa also is effective. Don’t use benzodiazepines, says Abrahm, because even low doses can cause delirium in older people.

Abrahm also offered suggestions for “dealing with dosage questions.”

* When switching from one opioid to another, use published equivalence charts but reduce the calculated dose by a third. Incomplete cross-tolerance is common because different opioids “bind slightly differently to receptors.”

* When converting from morphine to methadone, it matters whether the patient is on a low dose or a high dose. If morphine is being given in low doses (30 mg. per day or less), 4 mg. of morphine is equivalent to 1 mg. of methadone. At high doses (1000 mg. per day), 20 mg. of morphine is equivalent to 1 mg. of methadone.

* Increase the dose by a factor of five when switching patients from IV to oral Dilaudid because the liver metabolizes 80% of the oral Dilaudid “on its first pass.” If you only double the dose when switching to oral administration, you’ve just convinced the patient “that only the shots work,” Abrahm said.

* When converting a patient from oral to IV morphine, include the rescue doses in the calculation. Include the calculations on the chart so the hospital staff won’t question the dosage as being too high.

Abrahm has acknowledged that she serves as a consultant or speaker for several pharmaceutical companies that manufacture pain medications. (Family Practice News, 2005;35(11):63)

PAIN AND MEDICAL MARIJUANA NOTES

* According to a new study, emergency room physicians, “seldom see eye to eye” with patients wanting to be treated for chronic pain. Dr. Scott M. Fishman, professor of anesthesiology at the University of California, Davis, says that the result is frustrated physicians and patients without the help they need. Patients were less likely than physicians to believe that chronic pain would improve, “strongly disagreed that they were addicted to their pain medications,” and feared opioid dependence more than the physicians. (Family Practice News, 2005:35(11):63)

* A review of the research around the three commonly used pain rating scales – the Visual Analogue Scale, the Verbal Rating Scale and the Numerical Rating Scale – found all three “valid, reliable and appropriate for use in clinical practice.” The Visual Analogue Scale was found to have “more practical difficulties” than the others. The Numerical Rating Scale has “good sensitivity” and the data can be statistically analyzed. While patients prefer the Verbal Rating Scale, “it lacks sensitivity and the data it produces can be misunderstood.” (Journal of Clinical Nursing, 2005:14(7):798)

* Ines Berger, associate professor of anesthesiology at the Medical College of Georgia, says there aren’t a lot of controlled research studies on medical marijuana, “so it’s very limiting to have discussion or be an advocate for it.” One of the issues which needs to be addressed is “standardized delivery,” since “the ideal amount, type of cannabis and delivery method that should be used are not clear.” (The Augusta Chronicle, 6/14)

* The Rhode Island Legislature passed a bill legalizing medical marijuana (33 to 1 in the Senate and 52 to 10 in the House), but Governor Donald L. Carcieri (R) is likely to veto it. Supporters believe they have enough votes to override. (The New York Times, 6/29)

END-OF-LIFE NOTES

* “MIA doctors” disappear when their patients are about to die, says an article in The Seattle Times. Dr. Anthony Back, a cancer specialist who teaches communication skills to young doctors, say that physicians can go missing in action even when they’ve known the patient for years. Back’s article on teaching doctors how to say goodbye originally appeared in the April issue of the Annals of Internal Medicine. (Detroit Free Press, 6/28)

* The American Medical Student Association (AMSA) recently announced the third annual AMSA Foundation End of Life Education Fellowship, which introduces 18 medical students to “EOL care and its role in health services delivery.” This year’s program is held in Chicago and Miami. The press release is online at www.amsa.org/news. (AMSA Website, 6/20)

A new project at the University of Edinburgh is designed to “help terminally ill Sikh and Muslim patients have a ‘good death’ sensitive to their cultural and religious beliefs.” The goal of the research is to “identify ways in which health professionals can better understand the palliative care needs of minorities and give patients the opportunity to die with dignity.” (University of Edinburgh Press Release, 6/26)

* Delegates to the recent British Medical Association conference dropped the Association’s stance against physician-assisted suicide and euthanasia, saying, “The question of criminal law in relation to assisted dying was ‘primarily a matter for society and for Parliament.’” One approved motion stated, “The BMA should not oppose legislation which alters the criminal law but should press for robust safeguards both for patients and for doctors who do not wish to be involved in such procedures.” (BBC News, 6/30)

* Since nearly a quarter of the members of the New York Assembly were absent on the last day of the session, lawmakers postponed a vote on a bill that would establish a procedure determining the care an incapacitated person should receive. Supporters were apparently concerned that there would be insufficient votes to pass it. The Senate also did not act on the bill. (The Democrat & Chronicle, 6/28)

OTHER NOTES

* Researchers at M. D. Anderson Cancer Center in Houston are researching a drug called Anvirzel, which is derived from oleanders. Dr. Robert Newman says that Anvirzel is “highly effective against human tumor cells in tissue cultures.” Newman is developing an oral formulation of the drug and will seek FDA approval for it. He hopes to be in clinical trials to determine safety by next spring, followed by trials for anti-tumor activity in two to three years. The CEO of the company that produces it, Phoenix Biotechnology, says that Anvirzel “fits into ‘a new paradigm’ of cancer therapy that treats the disease as a chronic ailment rather than an acute condition.” (The Houston Chronicle, 7/3)

* California’s “three-strikes” law is increasing the number of older inmates in the state’s prisons, creating “staggering medical costs.” Senator Gloria Romero (D) says, “We are locking up the elderly at the expense of building schools for students and keeping university fees down, and we can’t pretend that’s not happening.” Experts say that compassionate release of older prisoners and more flexible sentencing guidelines would shift the cost to other agencies, reducing the burden on prison budgets. (Los Angeles Times, 6/26)

* Dr. Bernadine Healy says the state of Texas “bigfooted” the custody rights of Katie Wernecke’s parents when the Department of Child Protective Services took her in order to insure that the she got follow-up radiation after chemotherapy for her cancer. The parents opposed it because of the long-term toxic effects. Healy says, “The state mistakenly believed that the immediate radiation ordered by her doctor was a government-sanctioned and required treatment,” but that “most pediatric oncologists would beg to differ.” Katie’s doctor removed himself from the case and Katie is now being treated at M. D. Anderson Cancer Center, where doctors promise to “consider all options.” (US News & World Report, 6/27)

* A recent US Reuters Health poll of 957 adults who have never been diagnosed with cancer found that the most common misperception is that surgically removing a cancer causes it to spread. The second most common misperception is that “a cure for cancer already exists but it is being withheld from the public in order to increase profits.” The original article appeared in the medical journal Cancer. (Medline Plus, 6/27)

* President Bush signed the Patient Navigator bill, which authorizes DHHS to establish a competitive grant program, through fiscal year 2010, that will help patients access health care services. The bill is online at thomas.loc.gov, where you can search on “patient navigator,” without the quotes. (White House Press Release, 6/29)

* An article in the Journal of Nursing Scholarship extends “the original need-driven-dementia-composed behavior (NDB) model by explaining the consequences of behavioral symptoms for the person with dementia.” Researchers found that people with significant dementia communicate their needs by non-normative behavior and that it is difficult for caregivers to recognize the presence and extent of their needs. “Cascading effects occur in which not meeting the original need results in new needs and behavioral symptoms.” (Journal of Nursing Scholarship, 2005;37(2):134)

* The new Medicare Expedited Appeals Process allows a hospice patient, no longer certified as terminal by the physician, to formally request that services continue. The changes to the rules can be found in the Claims Processing Manual, available from the CMS website at www.cms.hhs.gov/manuals/pm_trans/R594CP.pdf. (CMS, NHPCO Newsbriefs, 6/30)