CONTACTS
Course director: Jose Mendoza, MD
josamend@utmb.edu
Cell (512) 779-8761
If you are going to miss any of this rotation, Dr. Mendoza will need an email from your chief resident/fellowship coordinator at the above email in advance. Thank you.
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Where to meet: Day 1 please report to John Sealy 4.160 at 9AM
This curriculum requires about 30 minutes of preparatory reading prior to each day. Required readings are required; please complete BEFORE the next day. Additional readings and other material are supplied for days when clinical load allows for additional learning, or for additional preparation for life, love, and the pursuit of excellent medicine.
Day 1: Introduction to Palliative Care, the Palliative Care Consult, with historical perspective.
Palliative Care is defined as the interdisciplinary care of a patient and his/her caregivers that focuses on quality of life and symptom management. It is provided in conjunction with other medical treatments for patients with life-limiting illness, chronic illness, curable illness, or patients in the last phase of life.
Topic 1: Intro to Hospice and Palliative Medicine
Objectives:
1. Introduce the history of the hospice and palliative movement.
2. Discuss the components of a palliative care consult (expand home tab for example).
3. Review the expectations of the Palliative rotation.
a. Required readings
b. Schedule
c. Consult Etiquette
· Required Reading: None
· Recommended Reading:
- New Yorker article by Atul Guwande, “Letting Go.” http://www.newyorker.com/magazine/2010/08/02/letting-go-2
- NEJM editorial by Kelly and Meier, “Palliative Care- A Shifting Paradigm.” http://www.nejm.org/doi/full/10.1056/NEJMe1004139
Topic 2: Opioids- Pain and Dyspnea
Opiates are commonly used in palliative medicine for advanced pain control and shortness of breath. Using opiates responsibly requires comprehensive understanding of their pharmacology, side effects, and risks. Opiate naive patients and opiate tolerant patients must be treated very differently. We will discuss how to start patients on opiates and different formulations. One size fits all is never the answer with opioids!
Objectives:
1. Learn the basics of opioids’ mechanism of action and side effects.
2. Discuss opioid conversion, the principle of incomplete cross tolerance, and “MEDD!”
3. Do some case studies utilizing the above highlighting palliative patients with pain and dyspnea.
Required Reading:
- Please create or recall a case of difficult opiate conversion/utilization that we can review.
- "Once-Daily Opioids for Chronic Dyspnea: A Dose Increment and Pharmacovigilance Study." Currow DC et al. JPSM, 2011.
Recommended Reading:
- “Opioids in Cancer Pain: Common Dosing Errors.” http://www.cancernetwork.com/palliative-and-supportive-care/opioids-cancer-pain-common-dosing-errors2)
Topic 3: Delirium
Clinicians fail to recognize delirium in more than 70% of cases. As a future attending physician, you will have to identify, treat, and counsel patients and families about this distressing condition. We can reverse delirium half of the time, but unfortunately for the other half, delirium can be a warning sign that end of life is near (terminal delirium). Untreated delirium will certainly lead to calls by nursing in the middle of the night. If you want to get rest on call, pay attention to this topic!
Objectives:
1. Review tools to screen for delirium
2. Discuss possible etiologies of delirium
3. Review non-pharmacologic and pharmacologic management of delirium
4. Briefly review hospital safety (fall risks, restraints, catheters) and its possible implications in delirium
Required Reading:
· Review the Memorial Delirium Assessment Scale (MDAS), available at http://www.delirant.info/DreamHC/Download/MDAS.pdf
· “Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial” JAMA Intern Med. 2017 Jan 1;177(1):34-42.
Topic 4: Communication and Difficult Conversations
Hospice and Palliative Care is all about communication. In this online lecture, a Palliative care Nurse Practitioner discusses some communication basics. We suggest that each of you have a little tiny notes application or pad where you write down ways to say things that you want to remember during her talk and during your weeks here.
Lecture location: Ms. Robin Rome’s lecture on Communicating bad news, available at: https://youtu.be/hHIoFVvBt0w
Objectives:
1. Breaking Bad News: Review the SPIKES protocol (expand home tab for link)
2. Open discussion, Showing Empathy, using love as a communication tool
3. How to discuss end of life, when hope is all the family wants to hear…
Required Reading:
· SPIKES Protocol (expand Home tab in top right corner of page)
· Chose Option 1 or 2 below.
Option 1 “I love apps:”
This week, please upload the VITALTALK app to your smartphone and try it out. You can use it prior to a difficult conversation or to debrief after one. You can use it in a real-time situation or recalling a conversation that you may have had with a patient. Spend at least 20 min with it. This app was created by a team including James Tulsky and Bob Arnold of OncoTalk fame. We will go over the SPIKES protocol together.
Option 2 “I hate apps/have no smartphone”
Please check out Bob Arnold’s 28 minute plenary at https://www.youtube.com/watch?v=pdkKPbYfCoc. You may start at minute 2:55. He shows videos from VitalTalk.org.
Topic 5: End of Life Care and Comfort Care Order Sets
An early needs assessment of residents revealed that end of life care is an area where more education is needed, and now. Nurses bear the brunt of care in hospitals at EOL where symptoms need to be addressed minute-to-minute and family anxiety can be very high. Symptoms arise unexpectedly at the end-of-life in most patients, and an anticipatory order set for your nurses and your patients during that time can be a life-saver, pun intended. If you have ever been present at a peaceful death you know that it can be very rewarding.
Day 5 Objectives:
1. Discuss signs of an actively dying patient.
2. Learn common, distressing symptoms presenting at the EOL. Understand how in death symptoms appear UNEXPECTEDLY.
3. Dissect a comfort care order set and its application. Review how to access the Palliative Care/CC order set in EPIC
Required Reading:
- “Use of a palliative care order set to improve resident comfort with symptom management in palliative care.” http://journals.sagepub.com/doi/pdf/10.1177/0269216308090169
- Google Fast Facts for Palliative Care at mypcnow.org. (Or download the app). Search for “Opioid Infusion Titration Order” and read it! Try the search bar for a symptom you need help on: Nausea, or Constipation, or Shortness of breath. See what happens. Use this website.
Recommended Reading:
- “A Prospective Study on the Dying Process in Terminally Ill Cancer Patients”: Am J Hosp Palliat Care Jul-Aug 1998;15(4):217-22. doi: 10.1177/104990919801500407
- "Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers." Steinhauser KE et al. JAMA, 2000.
Topic 6: Geriatric Polypharmacy
As our population ages and our medical technology advances, patients are started on more and more medications to treat their multiple comorbidities. Older adults are at increased risk for falls and confusion, especially when prescribed >5 medications. Deprescribing is the planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden or harm while improving quality of life. Palliative providers frequently make recommendations to discontinue medications no longer deemed necessary for a patient's given life expectancy.
Day 6 Objectives:
1. Review evidence for when risks >benefit for certain medications
2. Learn process for deprescribing medications
3. Discuss side effects with certain classes of medications in the elderly
4. Review the physiologic changes of aging in relation to drug metabolism including drug absorption, distribution, metabolism, and excretion.
Required reading:
· Review the deprescribing algorithms for PPIs, antihyperglycemics, antipsychotics, benzodiazepines, cholinesterase inhibitors, and memantine available at: https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
Recommended reading:
· “Polypharmacy, Adverse Drug Reactions, and Geriatric Syndromes” Shah BM, et al. Clin Geriatr Med. 2012. PMID: 22500537
Topic 7: Advance Directives
Advance directives are documents that legally express a person’s wishes about how they want to be cared for in life threatening or end-of-life situations. ADs consist of a) the naming of a health care proxy or health care next-of-kin and b) descriptive statements about the type of care a person would or would not want in a situation (such as, “ if I were permanently unconscious I would want to be artificially fed through a tube”). Physician Orders for Sustaining Treatments (POST or POLSTs) documents are something else entirely. We will discuss the definitions and the differences and when they are and are not appropriate.
Objectives:
1. Review what an advance directive is used for and in what circumstances
2. Learn state specific forms of AD
3. Discuss limitations to AD
4. Emphasize the importance of documenting GOC conversations
Required Reading:
- "When Advance Directives are Ignored": http://newoldage.blogs.nytimes.com/2014/06/24/when-advance-directives-are-ignored/?module=Search&mabReward=relbias%3Ar%2C%7B%222%22%3A%22RI%3A12%22%7D
Recommended Reading:
-“Reasons Why Physicians Do Not Have Discussions About Poor Prognosis, Why It Matters, and What Can Be Improved”: J Clin Oncol. 2012 Aug 1;30(22):2715-7. doi: 10.1200/JCO.2012.42.4564. Epub 2012 Jul 2.
Topic 8: Other Symptoms: Nausea, Vomiting, Constipation
Palliative medicine fellowship trained physicians are specially equipped to treat debilitating symptoms unresponsive to standard treatment regimens. Symptoms such as nausea, vomiting, and constipation are common in chronic diseases and warrant pro-active, methodical approaches to treatment.
Please view Dr. Burke's recorded lecture here: https://youtu.be/c5_3_nj9QY8
Objectives:
1. Review common etiologies and prevention strategies for treating nausea, vomiting, and constipation
2. Learn evidence-based approaches to treating nausea, vomiting, and constipation
3. Determine which classes of medication to use in specific disease processes
Required Reading:
· “Randomized, Double-Blind, Placebo-Controlled Trial of Oral Docusate in the Management of Constipation in Hospice Patients” J Pain Symptom Manage. 2013 Jan;45(1):2-13. doi: 10.1016/j.jpainsymman.2012.02.008. Epub 2012 Aug 11
Topic 9: Medical Ethics
Objectives:
1. Learn how to approach complex clinical ethical issues.
2. To engage participants in developing their ethical knowledge, and a deeper ethical awareness.
Recommended reading :
Clinical ethics: A practical approach to ethical decisions in clinical medicine by Albert R. Johnson