By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Break bad news and discuss prognosis
  • Demonstrate compassion, empathy and respect for patients and their families through verbal and nonverbal means
  • Inform patients of the diagnosis of life-threatening or life-limiting illness or change in trajectory of chronic illness
    
  • Inform patients of progression of disease and complications
    

Bad News

Key Feature 1: When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality.
Skill: Patient Centered, Communication
Phase: Treatment

Key Feature 2: Give bad news:

• In an empathic, compassionate manner
• Allowing enough time
• Providing translation, as necessary

Skill: Communication 
Phase: Treatment

Key Feature 3: Obtain patient consent before involving the family.
Skill: Patient Centered, Professionalism
Phase: Treatment

Key Feature 4: After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding.
Skill: Patient Centered, Communication
Phase: Follow-up

Learning (Patients)

Key Feature 5a: To maximize the patient’s understanding and management of their condition: Determine their willingness to receive information.
Skill: Patient Centered, Communication
Phase: Diagnosis, History

Key Feature 5b: To maximize the patient’s understanding and management of their condition: Match the complexity and amount of information provided with the patient’s ability to understand.
Skill: Communication, Patient Centered
Phase: Treatment

Throughout my residency training, I have seen physicians break bad news in wildly different ways. This week, I spent time with a urologist who barged into a room where a patient and his wife appeared to be anxiously awaiting to find out whether or not the data on his prostate suggested an increased risk of prostate cancer. Before even sitting down, he said "Yup, your prostate looks suspicious for cancer." And then as he propped himself into the chair casually he said, "We're gonna need to get a biopsy of it. Just make your way to the front desk and the receptionist will help you with the forms." And out he zipped. He literally spent less then 1 minute in the room. I looked with despair at the patient sitting with his eyes wide open, while his wife's mouth gaped open. As I followed my preceptor out of the room, I watched as the wife turned to her husband and explained what the urologist said but this time in Cantonese. By the time the patient understood what was even said, the urologist was long gone. What the HECK was that.

Yes, surgeons are notorious for having poor bedside manners, but earlier this year I witnessed a general surgery resident breaking bad news in the most caring and compassionate way I have ever seen. He explained to the patient what the circumstances were without jargon, he confirmed that the patient understood, and he provided space for questioning. He gave time to ensure comfort of the patient, and obtained legitimate informed consent, something that is not often done well in the hustle and bustle of day-to-day medicine, let alone for the ultra fast pace of surgical medicine. 

To contrast the two cases, the urologist was a man who I believe is almost ready to retire, while the surgeon-in-training is of a generation being trained to provide patient-centered care. Although there are many exemplary experienced physicians who break bad news with utmost compassion, and many young MDs who lack life experience and the empathy this endows, new physicians are graduating being expected to demonstrate the competency of breaking bad news in a patient centered way. It is an important modifiable factor in creating or curbing harm that can result from devastating news. Certain rules of thumb are pervasive in medicine and the SPIKES mnemonic is the catch-phrase all junior medical doctors are taught to break bad news compassionately and effectively.

SPIKES

• Setting the scene/listening   
• Patient's understanding of condition
• Invitation from patient to give information, and how much
• Knowledge (giving medical facts, including prognosis, which is always a best guess, and confirming understanding)
• Explore emotions
• Strategize and Summarize

There are many ways the individual physician can mesh these points with their own practice style to have an authentic approach to breaking bad news. Certainly the urologist didn't, and certainly the general surgery resident went above and beyond. As a physician-in-training, I work with many stellar and occasionally not-so-stellar role models, learning how to provide good care and also witnessing where care falls short, or in this case with the urologist, how it may be the exact opposite of what I am taught to do. While I sometimes cringe at the impact this has on the patients in front of me, it will at least hopefully serve to provide me with reinforcement of the importance of holding high standards of care and not becoming so familiar with disease processes that the impact they have on a patient's lived experience is forgotten.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and alter medication therapy that is most likely to cause adverse drug events in an older individual
• Outline the pharmacokinetic changes that commonly occur with aging and demonstrate the ability to modify drug regimens accordingly
• Describe the usual anatomical and physiological changes seen with aging and understand the concept of frailty
• Describe advance planning directives (including the roles of physicians and substitute decision-makers) dealing with personal and financial decision-making emphasizing a “goals of care” approach
• Identify patients who might benefit from a palliative approach and identify this early in the disease trajectory
  • Identify opportunities for advance care planning discussions, whether or not a patient has a life-threatening or life-limiting illness
  • Initiate a palliative care approach early in the illness trajectory
  • Identify the patients stage of illness using appropriate tools
• Communicate with patient, families and care team about palliative and end of life options and care.
  

Disability

Key Feature 2: Screen elderly patients for disability risks (ex: falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Elderly

Key Feature 1: In the elderly patient taking multiple medications, avoid polypharmacy by:

• Monitoring side effects
• Periodically reviewing medication (ex: is the medication still indicated, is the dosage appropriate)
• Monitoring for interactions

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

Key Feature 3: In the elderly patient, screen for modifiable risk factors (ex: visual disturbance, impaired hearing) to promote safety and prolong independence.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Key Feature 4: In the elderly patient, assess functional status to:

• Anticipate and discuss the eventual need for changes in the living environment
• Ensure that social support is adequate

Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, History

Tomorrow I start my first day caring for elderly patients in a residential care home, which I will continue to do intermittently throughout the year as part of my program requirements and vocational interests. One of the most important skills in geriatric medicine is appropriate prescribing practices; frail elderly patients can be at significantly more risk of harm compared to the general fit patient with negligent prescribing. While it is always important to prescribe thoughtfully (as indicated, where benefits outweigh the harm for the individual patient, with thought given to potential drug interactions, and with monitoring for side effects), the frail elderly patient has less reserve to cope with complications from errors with medication prescribing. As well, decreased kidney and liver functioning become much more common with age, so if the body is unable to clear the medications from the system as effectively, we need to consider the effect that the drug may have if it lingers for longer or builds up to higher levels than it otherwise would. Depending on the drug, and the patient's  kidney and liver function profile, doses may need to be reduced in quantity or frequency.

UpToDate provides a table that summarizes an approach to performing a geriatric medication review:

Medication review in the frail elderly should be part of all routine comprehensive medical care, just like screening is done as part of a periodic health examination. Specific screening interventions that may be particularly indicated in elderly patients include vision screening, hearing screening, and screening for osteoporosis. Impaired vision and hearing increase risk of functional limitation, falls, and if there is comorbid osteoporosis, increase the risk that a patient may sustain a significant fracture such as of the hip, associated with significant increase in morbidity and mortality. 

A defining feature of the frail elderly patient is having limitations on functional abilities. It is also something that occurs along a continuum, with different supports indicated depending on the degree of functional limitation. It is important to incorporate monitoring frailty severity into routine clinical practice of all elderly patients. The Clinical Frailty Scale is one tool that is validated and easy to use clinically.

A comprehensive assessment of a patients overall functional status but also specific functional needs is important to be able to offer beneficial targeted interventions and supports. This also involves considering what supports the patient currently has, their personal values and goals (including Advance Care Planning), and the supports available in their community. An interdisciplinary approach to supporting the frail elderly patient is standard of care, including involving family members or other loved ones as valued and active members of the care team, as the patient wishes, and referring patients for a comprehensive geriatric assessment may be the best place to initiate an assimilation of key members for an individualized support team. In a patient who has chronic mobility or disease that is not reversible, and who is having quality-of-life reducing symptoms on a regular basis, it's never too early to consider palliative care interventions, which are not just for those who are facing life-threatening illness. For those who are approaching end of life or who have symptoms affecting quality of life that can no longer be cured, palliative care interventions are necessary. Having frequent discussions with the patient and all members of the care team helps to keep people on the same page, to optimize care and to anticipate how care can best be optimised as symptoms progress. The Palliative Performance Scale is a tool used by many palliative care physicians to help in the conversation and understanding of the trajectory of palliative care needs.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess function and symptoms using palliative care tools (ex: ESAS, PPS) and manage symptoms by multiple modalities

Key Feature 3b: In patients approaching the end of life: Attempt to address the issues identified as important to the patient. 
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment
​
In a recent post I reviewed the domains (physical, emotional, social, and spiritual) from which concerns arise in patients who are approaching end of life. In this post I will provide an overview  of the management of some of the more common issues that arise out of these domains in the patient receiving palliative care. There are many potential options to treat these common problems, but here I will list some preferred first-line choices.

PHYSICAL HEALTH

• Pain​ (see my last post!)
• Constipation
  • This is a very common problem with a multitude of possible etiologies. It is always useful to try to figure out the underlying reason(s), as these may be readily reversible. However, in the patient nearing end of life, various factors may collide to produce this problem, and it may be impossible or impractical to really sort this out. In the patient who is palliative, searching for a source may also directly contradict their goals of care, but treating the problem is nevertheless indicated for symptomatic relief. Some first-line options for treating constipation in the patient receiving palliative care include:
    • Polyethylene glycol (an osmotic laxative): Providing a ton of possible benefit with next to no risk of harm, this is the favourite child in the laxative family. Otherwise known as PEG, this is an almost tasteless powder that can be mixed into any drink or semisoft food and generally takes between 1-3 days to provide relief. 
    • Senna (a stimulant laxative): Stimulant laxatives work by stimulating nerves in the gut to increase peristalsis, thereby increasing bowel motility. The only laxative that occasionally steals a bit of PEG's spotlight, it is the first-line recommendation when it comes to suspected opioid-induced constipation (which occurs due to activity at the mu opioid receptors in the gut, neurologically inhibiting bowel motility). In fact, opioids are so notorious for causing constipation, the proverb goes, "The hand that prescribes the opioid prescribes the laxative," or something to that effect. Basically, when prescribing an opioid, you just assume the patient will get constipated without a laxative on board and you prescribe one prophylactically, preferably a stimulant one. However, aside from opioid or other neurologically mediated causes of constipation, which are very common in the palliative patient, polyethylene glycol is first line. In the setting of opioid-induced constipation, PEG may be combined with senna for added benefit.
    • Prokinetics (ex: domperidone, metoclopramide): Prokinetics work similarly to stimulant laxatives in that they act on receptors to neurologically stimulate bowel motility. Unlike stimulant laxatives, however, they also have the added benefit of being an antiemetic, but this comes with the risk of increased side effects as well. Domperidone is generally a more ideal medication than metoclopramide because it has less chance of causing extrapyramidal symptoms along with a host of over side effects, particularly if using for a period longer than 3 months, but it is also more expensive, and it should not be used in patients with increased risk of a prolonged QT interval. So, in short courses and in low doses, metoclopramide may in fact be the preferred choice.
    • Enemas: When a laxative is ineffective, perhaps because things are just so "backed up," the less comfortable option of using an enema becomes more indicated. There are various enema compositions, but the one that is perhaps the most frequent and easiest to do is the sodium phosphate enema. It generally provides a rapid response with too much hassle, although if used frequently or in patients with renal insufficiency it can lead to electrolyte disturbances. If a sodium phosphate enema cannot be used, or if a number of enemas are expected to be needed, then it is best to use an alternative type of enema, such as a mineral +/- saline enema. These also work well, with minimal risk of harm, but are less convenient to administer. 
    • Methylnaltrexone: As mentioned above, opioids are stubborn constipators. The mechanism by which they cause constipation is the same as the mechanism by which they provide analgesia: mu opioid receptor agonism. Methylnaltrexone is neat in that it is a selective mu opioid antagonist for peripheral receptors, as are found in the gut, but not for central receptors, as are found in the brain. This means it continues to allow for opioid analgesia while preventing the associated constipation it would otherwise create. The downside of this medication is that it is very expensive, so in the setting of opioid-induced constipation, it is generally tried only after other laxative options have failed.
• Nausea
  • Nausea is also a common concern in patients receiving palliative care. In fact, many of these patients report that it is more distressing than their experience of pain. There are various reasons for why nausea is common in patients approaching end of life, and like constipation, it may not always be possible or practical to reverse the underlying etiology(ies). That being said, there are lots of tools in the toolbox to address this burdensome symptom. 
  • There are 4 pathways by which nausea occurs, with all causes resulting in stimulation of the vomiting centre, the ultimate part of the brain that communicates the sensation of nausea. It can sometimes help to have an idea of the most likely etiologies contributing to the sensation of nausea, because some antiemetics target some but not other nausea pathways; knowing which pathways are most likely involved can enhance your ability to choose a helpful antiemetic. That being said, some antiemetics work directly at the level of the vomiting centre, and can improve nausea regardless of the etiology.
    • The 4 different parts of the central nervous system that send signals to the vomiting centre include
      • The vestibular nuclei: Responsible for nausea associated with motion sickness
      • The chemoreceptor trigger zone: Responsible for nausea associated with toxins, medications, and metabolic factors in the blood and cerebrospinal fluid
      • Vagal and sympathetic afferents from the abdominal organs: Responsible for nausea associated with constipation, gastric irritation, bowel obstruction, etc.
      • The cortex: Responsible for nausea associated with pain, emotions, and raised intracranial pressure
  • Commonly selected first-line antiemetics in palliative care patients include:
    • Dimenhydrinate
      • Acts at vestibular nuclei, cortex, and vomiting centre
      • A commonly used mild antiemetic, in a patient with significant nausea, this may not be strong enough. The most common bothersome side effect tends to be drowsiness, so if this is not a major concern then it may be worth a try as there is minimal risk of harm.
    • Methotrimeprazine
      • Acts at the level of all 4 pathways as well as the vomiting centre
      • This antiemetic is exceptional in its ability to target all pathways along with the vomiting centre, and so it really targets nausea from any source. It also has the added benefit of providing analgesia and sedation, which can be useful in the palliative patients with pain and who may also be agitated.
      • Given its sedating properties, the medication can also cause drowsiness, which may be undesirable. Like the prokinetics, it also has a risk of causing extrapyramidal symptoms, and it is recommended to be used for no longer than 30 days.
    • Prokinetics
      • Act at chemoreceptor trigger zone and on vagal and sympathetic afferents (metoclopramide also acts at the vomiting centre, when given in high doses)
      • As discussed above, these agents have the added benefit of providing relief from constipation.
    • Ondansetron
      • Acts at chemoreceptor trigger zone, on vagal and sympathetic afferents, and at the vomiting centre.
      • An expensive medication that can also have QT prolonging effects and that increases the risk of serotonin syndrome, it tends to work well, particularly with respect to nausea from chemotherapy, radiation, and post-operatively. Generally tried after failure of other more affordable medications.
• Dyspnea
  • In the patient who is being managed palliatively for dyspnea (aka for symptomatic benefit, without treatment directed toward curing the underlying reason(s)), the two types of interventions include supplemental oxygen and medications
    • Supplemental oxygen is provided if patients are hypoxic. If patients are dyspneic but not hypoxic, a fan or humidified air can be trialed for benefit. Use of a fan blowing cool air across the face is purported to stimulate the trigeminal nerve and alleviate the sensation of breathlessness. If this is not helpful, a trial of humidified air or oxygen administered by nasal prong can be provided and continued if providing symptomatic benefit.
    • The mainstay of palliative treatment of dyspnea is opioids. They work symptomatically by decreasing the sensation of breathlessness, but also by decreasing the body's consumption of oxygen and efforts to ventilate. They alleviate suffering associated with the sensation of dyspnea. See my last blog post on palliative pain management for a rundown of the opioid medications used for pain that are the same as those used in the context of palliative dyspnea.
    • In the setting of excess upper airway secretions, glycopyrrolate is often given in palliative care patients. This is more so for symptomatic relief for loved ones at the patient's bedside, as this tends to suppress the excess secretions the patient can no longer handle that lead to the "death rattle" that occurs in the hours approaching death.

EMOTIONAL HEALTH

• Anxiety and/or depression
  • Many patients approaching end of life may experience anxiety and/or depression that can seriously decrease quality of life. It is important to explore why the patient is experiencing these emotions, and even if seen as a reasonable response to their circumstance, their quality of life can be enhanced with appropriate therapy consisting of  psychological and/or pharmacological treatments. 
    • Psychological treatments
      • The same therapies as for patients who are not palliative apply here, including empathic listening, psychological counselling, relaxation strategies, art and music therapy, etc.
    • Pharmacological treatments
      • When selecting medications, it is important to recognize that some psychiatric medications may take weeks to have a significant effect. Depending on prognosis, a patient may benefit from treatment with the same medications as recommended in the non-palliative population (ex: SSRI, SNRI), but also may not. When there is less time, psychostimulants have been used by some clinicians to enhance mood, but evidence for this intervention is lacking. Although benzodiazepines in the setting of acute anxiety have rapid onset, they do carry a risk of respiratory depression, and are associated with increased risk of falling and of exacerbating delirium. Generally their use ought to be limited to the setting of acute panic attack or specific treatment-related phobia. Buspirone, which is not as powerful of an anxiolytic as benzodiazepines are, is indicated for patients suffering from generalised anxiety disorder and could be given a trial in the palliative care patient (but may take a few weeks to reach a dose with clinical benefit). Buspirone is preferable to benzodiazepines as it is not sedating and does not not impact cognition. In the acutely agitated patient, consider a trial of methotrimeprazine or other antipsychotic before resorting to using a benzodiazepine.

​
SOCIAL HEALTH

• Guardianship, wills, and financial planning
  • The details vary from province to province, so it is important to be familiar with the guidelines and legislation in the region in which you are practicing. The province of BC has provided a document that outlines the details of these issues as it pertains to resident of the province of BC. The national Speak Up website on advance care planning also provides links to each of the provincial/territorial advance care planning webpages, which is how I found the document pertaining to the province of BC.

SPIRITUAL HEALTH

• As described in "Palliative Medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald, "Spiritual care involves fundamental spiritual and existential issues of belief, connection, wholeness, meaning, and purpose. (...) Spiritual pain has been described as the experience of an individual who has become disconnected and alienated from the deepest and most fundamental aspects of him- or herself." 
• To address spiritual pain and provide spiritual therapy, it is mostly about one's approach as a care provider than the provision of specific treatment options. To quote more from Oneschuk et al., who explain how to promote spiritual wellbeing much more eloquently than I can,
  • "The nonjudgmental and empathetic intervention of actively listening are unquestionably therapeutic. In being present to the patient, more subtle qualities of compassion and empathy are more readily available to the healthcare professional. A study of patients with advanced cancer found that their greatest spiritual needs were to overcome fears (51%), to find hope (42%), to discover meaning in life (40%), and to talk to someone about several specific issues, notably finding peace (43%), meaning in life (28%), and death and dying (25%). ‘Being with’ people at the end of life requires healthcare professionals to be vulnerable as they venture into an aspect of the human experience that is as much an art as a science."
  • "One study asked patients and family caregivers to identify those individuals whom they felt were most involved in patients’ spiritual care. This resulted in a total of 237 individuals being identified, namely family and friends (41%), clergy (17%), and clinicians (29%). During interviews with these clinicians in which they were asked about the core elements of their spiritual care delivery, three themes emerged, namely being present, recognition of the shared humanity of practitioner and patient, and a process termed co-creating, whereby aspects of patients’ spirituality are incorporated into their care plan. Thus, although spiritual care specifically addresses spiritual and existential issues that are essential to human meaning, it also extends across care domains, influencing the way in which care is delivered."
  • "Spirituality is difficult to define, but an equally challenging issue is to determine the healthcare professions’ role in spiritual care delivery. The professional standards of various healthcare disciplines subsume spiritual care within their scopes of practice, although ease with this and competencies vary from one clinician to another. Spiritual care professionals or professional chaplains possess advanced training in multi-faith spiritual care, are Masters prepared, and are accredited by their professional organizations. Whereas the professional chaplain possesses expert knowledge, the issue of role overlap within an interprofessional team seems to be particularly challenging, as it relates to spiritual care which arguably falls within the ambit of all healthcare professionals. A wide range of healthcare providers may be capable of providing spiritual care, with individuals who seem to be most effective being those who are actively cultivating their own spirituality."

Assessing and treating each symptom that arises is important in its own right. It's also important to have a sense of the global health status of each patient in allowing for conversations that guide care moving forward. The Palliative Performance Scale (PPS) is a tool used by many palliative care physicians to anticipate and communicate with the care team to be able to optimize palliative care for the whole person. 

Key Feature 3a: In patients with chronic disease: Actively inquire about pain.
Skill: Clinical Reasoning
Phase: History

Key Feature 3b: In patients with chronic disease: Treat appropriately by:

• Titrating medication to the patient's pain
  
• Taking into account other treatments and conditions
  (ex: watching for interactions)
  
• Considering non-pharmacologic treatment and
  adjuvant therapies
  

Skill: Clinical Reasoning
Phase: Treatment, Hypothesis generation

Palliative Care

Key Feature 4: In patients with pain, manage it (ex: adjust dosages, change analgesics) proactively through frequent reassessments and monitoring of drug side effects (ex: nausea, constipation, cognitive impairment). 
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

The standard general approach to pain control is based on the World Health Organization's Pain Ladder, with the diagram and information below coming from "Palliative medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. The "ladder" was designed with cancer pain in mind, but it tends to provide the framework for pain management for people with all sorts of acute and chronic sources of pain. The basic idea is that for mild pain you start with non-opioid medications, with specific choice depending on the type of pain and patient characteristics. It is important to actively inquire not just about the presence of pain, but also about the quality of the pain in patients in order to treat it most effectively. Not illustrated as part of the pain ladder but equally important are also nonpharmacological interventions that can be useful in alleviating pain. As pain increases in severity, the choice of pain medication and/or dose ought to increase accordingly. Adjuvants (medications originally developed for reasons other than to improve pain, but that can also alleviate pain as a secondary effect, depending on the type of pain) can also be very useful when indicated. Poor pain control can have a significant negative impact on quality of life, and we have lots of tools in the box to work to mitigate this source of distress. It is important to continue to reassess patients experiencing pain or receiving therapy for it, to ensure that pain is in fact controlled, as well as to monitor for side and adverse effects.

Nonpharmacological therapies to consider starting, in the context of mild pain and patients who are motivated to try them, or to consider adding on to pharmacological treatments for added pain relief, could include:

• Application of heat or cold
• Exercise
• Massage
• Relaxation therapies (including meditation, guided imagery, music and art therapy, animal therapy)
• Acupuncture

There are of course many others beyond this brief list. In the setting of cancer, for example, radiation therapy may be an option (although much less benign) to improve pain control.

Common non-opioid medications for mild pain include acetaminophen and NSAIDs (ex: naproxen, ibuprofen, diclofenac, ketorolac). 

• Acetaminophen works on the perception of pain at the level of the brain. It tends to be used first line as it is has minimal risk of harm. It is, however, metabolised by the liver, so it should not be used in patients with impaired liver function or who consume excess alcohol (3 or more drinks daily). It is available in oral and rectal preparations, and can be taken as needed or around the clock.
• NSAIDs work by inhibiting prostaglandin synthesis, acting peripherally to decrease the release of inflammatory mediators and associated pain signals. When pain is secondary to an inflammatory process, they may theoretically be preferred over acetaminophen. They are generally safe to use short-term in the otherwise healthy person, but carry certain risks if they are taken for a prolonged period of time in a dose-dependent fashion. The main risks are gastrointestinal bleeding (which is why any patient who is going to take an NSAID regularly for more than 1 week should also be on a gastroprotective agent), renal impairment (patients with compromised renal function or who are at increased risk of this, such as patients with diabetes mellitus or the elderly, should avoid the use of NSAIDs), and abnormal hemostasis (predisposing patients to more significant bleeding should they have a reason for a bleed). NSAIDs can generally be found in any type of preparation depending on the specific agent selected. For inflammatory musculoskeletal pain, diclofenac gel can be prescribed without risk of the above adverse consequences.

For pain that is sufficiently severe and that cannot otherwise be controlled (with non-opioids, adjuncts, and nonpharmacological modalities), treatment with an opioid may be indicated. Opioids exert their analgesic effect mostly by agonising mu opioid receptors in the brain. Commonly prescribed weak opioids include codeine and tramadol, and commonly prescribed strong opioids include morphine, hydromorphone, oxycodone, fentanyl, and methadone.

General principles of opioid initiation and titration include having a regular dosing schedule (initially starting with a short-acting preparation until the baseline pain is controlled) with a prescribed breakthrough dose for pain to be taken as needed for acute exacerbations (generally prescribed to be taken as much as every 1 hour, or in the setting of opioids with a very rapid half life, up to every 30 minutes or so). The degree of pain control as reported by the patient along with the number of needed breakthrough doses in a given 24 hour period indicates whether or not there is a need to adjust the baseline opioid dose. As a general rule of thumb, if greater than 3 breakthrough doses in a 24 hour period are needed, unless this is attributed to being incident pain (aggravated by a specific event such as movement that would not otherwise be present at baseline), then an increase in the baseline opioid dose is warranted. The amount to up-titrate can be calculated by adding up the total quantity of opioid needed in the last 24 hour period (baseline and amount of breakthrough used), calculating the conversion to the new choice of opioid based on number of morphine equivalents, and dividing this quantity so that it is given over the next 24 hour period as the scheduled dose. And then a new quantity of breakthrough pain medication is prescribed, and a rule of thumb for this is dosing it at about 10% of the total daily scheduled amount of opioid to be given over the next 24 hour period. 

On the flip side, when patients report good pain control, with minimal to no use of doses required for breakthrough pain, the patient can be gradually weaned down as tolerated. 

Side effects of all opioids are generally the same (though they may occur to different degrees depending on the formulation, dose, and patient factors), and they most commonly include transient nausea, transient drowsiness, and constipation that is not transient and that lasts as long as the opioid is being taken. If they are given in a high dose too quickly, they can cause respiratory depression, but when prescribed responsibly in small doses with gradual up-titration, this concern is mitigated. For the nausea, an antiemetic can be prescribed either to be taken routinely or as needed, and for the constipation the patient will likely need to be on a regular dose of laxative medication. See my next post for more detail on these options.

Besides the above side effects that can occur when any opioid is used, there is also the phenomenon of opioid neurotoxicity that can occur. Briefly, this is a situation in which patients can develop altered mental status (ex: delirium, agitation, somnolence), vivid or unpleasant dreams, delusions/hallucinations (usually visual), and increased pain perception (ex: allodynia or hyperalgesia). Myoclonic jerks and seizures can also occur. In the setting of suspected opioid neurotoxicity, rotating to a different opioid is warranted (other options include simply changing the route by which the current opioid is delivered, decreasing the dose of the current opioid and adding an adjuvant, or just treating the toxic symptoms themselves; rotating the opioid is generally the preferred option). This is done by adding up the total number of morphine equivalents a patient has on board in a given 24 hour period, calculating the equivalent dose in the opioid to which the patient is being rotated to, reducing this dose by 25%, and dividing the dose to be scheduled throughout the day as the half-life of the new opioid indicates.

​Opioid options include:

• Codeine
  • Codeine is a pro-drug, which means it needs to be converted to its active form once ingested in order to have an analgesic effect. However, up to 10% of people do not have make the enzyme needed to do this, so the analgesic effect of this medication can be limited to that of a placebo effect in some people. 
• Tramadol 
  • Tramadol produces analgesia by its mu-agonist activity, but it also reduces pain through its dual action of preventing serotonin and norepinephrine reuptake as well. This means it must be used with caution in patients who are taking medications that also reduce the reuptake of serotonin (as is common with many antidepressants) as there is an increased risk of serotonin syndrome. It must also be used with caution in patients who have an increased risk of seizure. A major downside of this medication is expensive and not covered by most provincial drug plans. Although my preference is not to use codeine because it may be ineffective in some people, I would trial codeine for moderately severe pain in the outpatient population if the cost of tramadol is prohibitive for the patient in front of me.
• Morphine
  • The prototypical medical opioid, morphine is a strong opioid analgesic as it has strong affinity to the opioid mu receptor. It is a derivative of the naturally occurring opium  from the poppy plant. 90% of it is metabolised by the liver, and its metabolites (some active, some causing neurotoxic side effects) are excreted really. For patients with renal insufficiency it must be used very cautiously, or more ideally an alternative opioid should be selected. It is available in short-acting versions given every 4 hours or every 1 hour for breakthrough pain. It is also available in long-acting versions that can be given every 12 hours or once every 24 hours in its even longer-acting form.
• Hydromorphone
  • Morphine 2.0, this is a semisynthetic morphine derivative that is about 5 times more potent than morphine. It may have less neurotoxic metabolites, with a reduced risk for the associated side effects. This is my go to strong short-acting opioid. It has pretty well the same formulations available as its sister morphine.
• Oxycodone
  • Also a highly-potent semisynthetic compound, this opioid is approx 1.5-2 times as potent as morphine. Some of its activity is secondary to some of its active metabolites, and similar to codeine, this requires liver enzymes that approximately 5-10% of the population do not possess for genetic reasons. It is only available by mouth in Canada, which also limits its utility.
• Fentanyl
  • Infamous for its deadly impact on the streets in the unprecedented and ongoing Fentanyl Crisis, this opioid is undeniably helpful to the clinician who is helping patients cope with severe pain. It is approximately 100 times more potent than morphine! It has a quick onset of action, but also a short-half life, at least when it is prescribed parenterally (including through the sublingual route). While this can be beneficial for acute breakthrough pain control that is short lasting, it's permanent home in the palliative toolkit is mostly for its role in providing long-acting pain control through its transdermal application (aka the fentanyl patch). The only opioid that is administered this way, this is an excellent way of providing pain relief to patients who have stable pain control and who are unable to tolerate other forms of opioid administration (ex: if they cannot tolerate medications by mouth, this provides a pain- and hassle-free way to provide pain relief compared to repeated injection as the other alternative). The patch lasts 72 hours, and so only needs to be replaced every 3 days. It also seems to have less neurotoxic side effects than the strong opioids listed above, and so renal insufficiency is not as significant of a concern. Because the short-acting version is so very short, once a patient has stable pain control on a fentanyl patch, typically they will have one of the other strong opioids on board in a short-acting formulation for breakthrough pain. 
• Methadone
  • A synthetic opioid most known for its use in the context opioid addiction, it provides approximately 10 times the analgesic effect as morphine. The actually conversion depends on the dose being used; the relationship is not linear due to its lipophylicity and subsequent storage in the body's fatty tissues. This factor also gives it a somewhat unpredictable half-life, and can only be prescribed by physicians with special training in its use. Generally, it is prescribed to be given every 8-12 hours. It is affordable, and it is unique in that while it agonizes the mu opioid receptor, it also seemingly provides neuropathic pain relief through its activity as an NMDA (glutamate) receptor antagonist. It has no known active metabolites, so is a good choice in a patient with renal failure, and due the unique way it is stored in the body's fat, it is a good choice for the patient who receives hemodialysis. It is metabolised by the liver, so in the setting of hepatic disease, the dose ought to be adjusted cautiously.

Some adjuvants that may be useful in pain management, particularly in the palliative care setting:

• Dexamethasone is a corticosteroid that helps to reduce inflammation, particularly useful in reducing pain associated with peritumoural edema (commonly used in the setting of headache secondary to brain metastases) as well as bone pain (for which bisphosphonates are also a mainstay)
• Tricyclic antidepressants (ex: nortriptyline), rarely prescribed as antidepressants now given the superiority of newer options, they still have much utility in treating neuropathic pain, particularly that which is characterised as constant.
• Gabapentin, originally developed as an anticonvulsant, is also a mainstay in the treatment of neuropathic pain, and it may be particularly indicated in the neuropathic pain characterised as intermittent and sharp/shooting.
• Ketamine is a big gun drug that's been around the block and that has fallen out of but now back in favour with many physicians today. It is a medication often used for induction in anesthesia with associated strong analgesic properties and dissociative side effects. Typically this medication is prescribed in consultation with an anesthesiologist or other pain specialist. 
• Hyoscine for colicky bowel or genitourinary pain. Not to be used if there is suspicion of complete obstruction. 
• Methotrimeprazine is an antipsychotic with analgesic properties that can be a useful adjuvant in the setting of pain complicated by agitation or delirium

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate knowledge of pediatric palliative care issues
• Establish and advocate for the patient’s goals of care, and needs (spiritual, emotional and psychosocial).
  • Identify situations that may benefit from a family meeting and facilitate these meetings.
    
  • Support patients and families coping with loss and bereavement, grief (including anticipatory grief), risk factors for atypical grief and develop an awareness of local resources to assist families through this process
    

Key Feature 3a: In patients approaching the end of life: Identify the individual issues important to the patient, including physical issues (ex: dyspnea, pain, constipation, nausea), emotional issues, social issues (ex: guardianship, wills, finances), and spiritual issues. 
Skills: Patient Centered, Clinical Reasoning
Phase: History

As expressed in my previous post, palliative care aims to alleviate total suffering, including sources of physical pain or discomfort, along with emotional, social, and spiritual concerns. In patients who are approaching end of life, it is important to explicitly screen for concerns in these various domains, as some patients may not be as forthcoming about certain types of distress. Common physical issues that affect patients approaching the end of their life include pain, dyspnea, constipation, and nausea, and these are so common they are worth screening for specifically. Asking how a patient is feeling emotionally can open up a conversation about mood and anxious distress, and gathering  a good social history can provide a framework for exploring social issues and revealing the extent to which advance care planning has been explored. Spiritual issues can often distress patients, consciously or unconsciously, as many patients are faced with difficult existential issues as they approach end of life. Taking a spiritual history is not something clinicians are trained to do very often, but it is essential in providing care that truly seeks to alleviate all sources of suffering. The approach I've adopted to taking a spiritual history comes from "Palliative Medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. It is summarised by the acronym "FICA" and is demonstrated in the following table as published in the book:

It's worth mentioning that the overall approach to pediatric palliative care is much the same, considering many of the same issues as for the adult patient. However, according to UpToDate, "Although the goals of palliative care in children are the same as those in adults, implementation of care is different because of the need for age-based care, differences in the underlying illnesses, the emotional and psychological issues in dealing with a poor outcome in a child, and the necessity of dealing with the child, parents, and in some families, siblings." The need for a strong team-based strategy with pediatric expertise cannot be stressed enough, and meetings that include the family are important to put together the most understanding and resources to maximize care. It's also important to consider how the patient's family and other loved ones may be impacted by anticipatory grief and eventually loss and bereavement of their loved one. Ensuring these support people are themselves supported promotes the capacity for the patient to be better cared for, and can help promote healthy adaption to life after loss. It helps to know the resources available within your community, as well as resources online or in print. These principles of integrating and caring for a family network are also esteemed for the care of adult palliative care patients.

Once you've asked and begun exploring any sources of discomfort, it's important to be an advocate for the patient in attempting to relieve their burden. Although many patients approaching end of life exude an astonishing degree of energy and capacity for autonomy despite the circumstances, many others may be too exhausted to do so, or not be aware of the possibility that some, if not most, of their physical, social, emotional, and spiritual suffering can be alleviated. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and manage common end of life care issues (e.g. nutrition, dysphagia, code status, hospital transfer, home and LTC visits)

Key Feature 1: In all patients with terminal illnesses (ex: end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e., do not limit the use of palliative care to cancer patients). 
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment

Key Feature 2: In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e., use a team approach when necessary). 
Skill: Patient Centered
Phase: Treatment

Key Feature 5: In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (ex: wishes for treatment of infections, intubation, dying at home)
Skill: Patient Centered, Clinical Reasoning
Phase: History, Hypothesis generation

Today I began my palliative care rotation at St Paul's Hospital. I met 4 different patients on the ward all receiving palliative care for very different reasons. All patients had incurable but not unmanageable disease states, including end-stage chronic obstructive pulmonary disease, impaired postoperative wound healing in the setting of severe frailty, advanced congestive heart failure, and metastatic esophageal cancer. Although only one of these patients had a diagnosis of cancer, all of them had symptoms that warranted management according to the principles of palliative care. For a succinct overview of what palliative care entails, see the WHO Palliative Care webpage.

Central to the palliative care approach is the appreciation of an individual's total suffering, which includes sources of physical pain  but also areas of emotional, social, and spiritual pain, among other domains. The benefit of a multidisciplinary team strategy when taking a comprehensive perspective of pain cannot be understated; while the physician is certainly an expert in treating physical sources of pain with analgesia, this is but one method of alleviating pain associated with life-limiting and life-threatening illness. The book, "Palliative medicine: A case-based manual" by Oneschuk, Hagen, and MacDonald (2012) provides examples of the ways in which various health care professionals may contribute to alleviating a patient's total suffering:

• A spiritual care provider can provide counselling and support for patients and their families
• A social worker can address the family’s stress, as well as coordinating hospital discharge planning
• A psychologist can provide psychological assessment and treatments
• Physiotherapists and occupational therapists can contribute to pain management interventions (ex: acupuncture, splinting, energy conservation strategies)
• Dieticians can assist with symptoms, including anorexia–cachexia
• Professionals skilled in complementary therapies—including relaxation, meditation, massage, and distraction—can address stress and anxiety
• Trained volunteers can provide valuable support to patients and their families through companionship and activities

There are many methods of mitigating suffering, many of which may or may not be useful or desirable to a specific individual given the context of their circumstances and how it interacts with their beliefs, values, and wishes. As a treating physician, it is important to have conversations that explore these considerations, as indicated by the context. Whenever any medical decision is made, it is always important to ensure the decision is being made with informed consent. Furthermore, it may be important given certain circumstances to begin thinking about the decisions one may want for their health in anticipation of a future time when they may no longer be able to speak for themselves. This is particularly important when a patient is at greater risk of an incapacitating illness or event (although some say it is never too early to start having these conversations because you just never know). Regardless, it is always important to have these conversations with patients diagnosed with a terminal illness, and the sooner the better, when more time can be given to proper reflection. When done well in advance, this is typically the process of Advance Care Planning (ACP), and consists of reflecting on one's values and wishes for future health care decisions, along with identifying a person whom they would want to make decisions for them if/when they cannot make decisions for themselves (aka a substitute decision maker [SDM]), and communicating this verbally or as documented in writing (far preferable). This may include conversations about Goals of Care, which are more focused health care goals given a situation at hand (ex: What a patient's goals are for a given hospital admission and the scope of what they would and would not want to receive in terms of medical management. This would include but is not limited to clarification of the patient's Code Status.) The conversation does not end here of course, and each medical decision should be done with informed consent as given by the patient or the SDM if indicated. And as patients' circumstances and occasionally their beliefs, values, and wishes change, it is important to revisit ACP accordingly. If there has has been no ACP, then urgent decisions will need to be made regardless for medical decisions at hand, but research indicates that the outcomes are far more ideal for patients and care providers if these conversations are begun well in advance. The Pallium Palliative Pocketbook lists benefits of ACP as follows:

• End-of-life wishes are known and followed
• Less stress and anxiety for family members
• More satisfaction with care
• Better quality of life and quality of death
• Less use of inappropriate health resources

For more information on ACP, check out www.advancecareplanning.ca.