Pain Control and Non palliative Docs

[oldpro]

During my years as a Hospice RN I found that if the primary Doc was not into Palliative care they tend to not allow pain meds to "titrate to Pain" orders. They would say, when they care to, they were afraid it was too much drug ordered and that the FDA would come after them. I would try to tell them the Hospice admission would protect them from this along with the documentation for such treatment. Now that I'm about through Basic Science I have found that Medical school is piss poor in teaching anything about palliative care.

In pharm we are worried about normal doses when a dose for a hospice patient was brought up by me in class Laughter and the professor looks were enough, like I was killing the patient. We need to push more opened mindedness in this I think, until then the patients people like us do not take care of will continue to suffer.

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[ntubebate]

Firstly, The FDA doesn't regulate prescribing controlled substances. The DEA does. (Not trying to make you look stupid, just wanted to correct you for future reference).

Now, as a Family Physician who does quite a bit of Hospice/Palliative Care Medicine I will say that I ALWAYS use "Titrate To Comfort Orders".

My reasoning is as follows:

1. I'm not the one with the patient at all hours. The RN's there KNOW when the patient is in pain and the analgesia isn't cutting it.
2. I can sleep just a little bit.
3. Opioids and benzos are reversible. The RN's have orders for the appropriate drugs to complete a reversal should it be medically indicated.
4. I can sleep at night knowing that someone isn't suffering.
5. I think of all things we do as physicians, letting someone experience a comfortable death probably is and should be one of our greatest accomplishments.

ntubebate

 

[RuralMedicine]

Firstly, The FDA doesn't regulate prescribing controlled substances. The DEA does. (Not trying to make you look stupid, just wanted to correct you for future reference).

Now, as a Family Physician who does quite a bit of Hospice/Palliative Care Medicine I will say that I ALWAYS use "Titrate To Comfort Orders".

My reasoning is as follows:

1. I'm not the one with the patient at all hours. The RN's there KNOW when the patient is in pain and the analgesia isn't cutting it.
2. I can sleep at night without the phone ringing off the hook.
3. Opioids and benzos are reversible. The RN's have orders for the appropriate drugs to complete a reversal should it be medically indicated.
4. I can sleep at night knowing that someone isn't suffering.
5. I think of all things we do as physicians, letting someone experience a comfortable death probably is and should be one of our greatest accomplishments.

ntubebate

How I write my pain orders with hospice is determined by the clinical situation and the hospice RN/team involved. I'm not for or against titrate to comfort overall. In many cases I'll write them with a caveat to contact me after certain degrees of escalation. This allows me to ensure that we have actually solved the problem (there are other interventions in addition to opiate pain medicine that are sometimes overlooked but important---to much of our local hospice provider's credit they have been receptive to this and some are even recommending this in assessments on patients I don't manage they tell me) and that there aren't other issues cropping up. (I will make home visits for my hospice patients if they can't get to my office or can't get to my office without significant difficulty/trauma) Occasionally I see hospice teams focus on managing pain that doesn't exist. I recently had a patient who denied pain, her family didn't feel she was in pain, and had no objective or subjective evidence of pain. I ended up writing a low dose of Lortab elixir prn more to pacify the Hospice RN (and then received calls that patient was refusing pain medicine--"Yes she can do that.") I'm a big believer in managing pain appropriately, I realize the effects of tolerance, and metabolism on dosing.

Reversing benzos with Romazicon is probably a bad idea since it doesn't improve the respiratory depression issue and has a tendency to potentiate seizures. Reversing opiates is possible but it's much more compassionate to avoid putting patients in a situation where that is necessary. I've reversed opiates in other patients with chronic use in emergent situations and it was not fun for the patient.

 

[oldpro]

Firstly, The FDA doesn't regulate prescribing controlled substances. The DEA does. (Not trying to make you look stupid, just wanted to correct you for future reference).

Now, as a Family Physician who does quite a bit of Hospice/Palliative Care Medicine I will say that I ALWAYS use "Titrate To Comfort Orders".

My reasoning is as follows:

1. I'm not the one with the patient at all hours. The RN's there KNOW when the patient is in pain and the analgesia isn't cutting it.
2. I can sleep at night without the phone ringing off the hook.
3. Opioids and benzos are reversible. The RN's have orders for the appropriate drugs to complete a reversal should it be medically indicated.
4. I can sleep at night knowing that someone isn't suffering.
5. I think of all things we do as physicians, letting someone experience a comfortable death probably is and should be one of our greatest accomplishments.

ntubebate

You are so right MY BAD! Being out of the field during Basic Sci has just worn me out! And I meant DEA. I just wanted to put this out there after all my years experience and start a conversation on this.

I know I'm not always right but can't imagine getting into trouble for providing comfort to a terminal Patient. There is supposed to be no ceiling to Morphine and we also have used methadone too for control of pain. So I really have not changed my mind on this and know most of the Hospice RN's know how to titrate the pain meds right. Of course I still will need the reports weekly of how the patient is doing and what dose ect......

I"m so glad to see a post from someone who thinks this too.

 

[oldpro]

How I write my pain orders with hospice is determined by the clinical situation and the hospice RN/team involved. I'm not for or against titrate to comfort overall. In many cases I'll write them with a caveat to contact me after certain degrees of escalation. This allows me to ensure that we have actually solved the problem (there are other interventions in addition to opiate pain medicine that are sometimes overlooked but important---to much of our local hospice provider's credit they have been receptive to this and some are even recommending this in assessments on patients I don't manage they tell me) and that there aren't other issues cropping up. (I will make home visits for my hospice patients if they can't get to my office or can't get to my office without significant difficulty/trauma) Occasionally I see hospice teams focus on managing pain that doesn't exist. I recently had a patient who denied pain, her family didn't feel she was in pain, and had no objective or subjective evidence of pain. I ended up writing a low dose of Lortab elixir prn more to pacify the Hospice RN (and then received calls that patient was refusing pain medicine--"Yes she can do that.") I'm a big believer in managing pain appropriately, I realize the effects of tolerance, and metabolism on dosing.

Reversing benzos with Romazicon is probably a bad idea since it doesn't improve the respiratory depression issue and has a tendency to potentiate seizures. Reversing opiates is possible but it's much more compassionate to avoid putting patients in a situation where that is necessary. I've reversed opiates in other patients with chronic use in emergent situations and it was not fun for the patient.

Yes this happens at times and depends on the Nurses, I have worked with nurses who loved to make sure the patient was out of ALL PAIN. Some of it is emotional pain, being out of all PAIN may not be possible, Comfort does not always mean Pain Free.

That said you seem very caring, I like how you really think about the patient's need, I stressed a balance of medications when I practiced as a Hopsice RN before Medschool, "less is More" I always strived to try to have less drugs but basic pain meds and symptom control, essentials so the patient was comfortable, most times they did not really have any pain, most times anxiety was addressed by prn doses of Ativan and that did it. Sleep was big factor, get people to have some sleep and wow the pain is less and so is anxiety. It seemed to go hand in hand.

I still love Hospice cause I find it challenging but RURAL FP is my new field I plan to work with hospice again too!

 

[ntubebate]

I guess I should have explained my orders a little better. Rural Medicine hits the nail right on the head and basically sums up how I practice palliative care medicine.

While I do write "titrate to comfort" orders there are also orders, for instance, that if the patient needs more than three Dilaudid increases in a set period of time, I am to be notified.

I also give some freedom to the Hospice RNs to bring in some advance practice skills where they have options of using more than just opioids and benzo's. You'd be shocked at how a Hospice RN can take a conventional medicine and use it in 100 different uncoventional ways. They do this day in and day out and in general know far more than your average doc (Pain Mgmt is my forte so I like to think I'm excluded).

One thing I do have printed on right on my preprinted order sheet in bold letters right at the bottom is that if at any time they feel uncomfortable carrying out any order, be it a standing order, a titrate to comfort order or what have you, CALL MY A$$! I honestly rarely sleep and I chose this profession because taking care of people the best I know how is what gets me up out of the bed in the mornings. Ask any Nurse, CNA, MD, NP, PA, ect that's ever worked with me and they'll tell you I enjoy nothing more than being able to teach you the answer to your question and doing it in a way that makes it possible for you to understand it. That holds true no matter when you call me.

ntubebate

 

[ntubebate]

Also, just to touch on the issues of reversals.

In what is now going on ten years of Family Medicine/Ob-GYN practice I have NEVER had a hospice RN need to reverse a patient from opioids or benzos.

That said, I feel comfortable using titrate to comfort orders because I feel comfortable that our Hospice RN's know the difference between titrating to comfort and titrating to respiratory arrest. Our hospice nurses generally know what a particular patient can or cannot handle and when they don't they've very conservative until they reach that point.

I have, however, had to reverse some opioids with Narcan in my time and in a patient habituated to opiates they've all told me that they just wish I'd let'em die. It's NOT a pleasant experience and I think it should be avoided if at all medically possible.

ntubebate

 

[oldpro]

Also, just to touch on the issues of reversals.

In what is now going on ten years of Family Medicine/Ob-GYN practice I have NEVER had a hospice RN need to reverse a patient from opioids or benzos.

....................................
ntubebate

Yes in my 9 years as a Hospice RN that had never happened to me either, but I can tell you opioid abuse among the terminal is common, more than we would like to admit. It is up the the Hospice nurses to evaluate abuse and with the MD come up with plans to lessen it and help the person, we do not care about addiction just comfort and to avoid side effects, I really do not understand the post about reversing so much? If that is happing too much then it's time for training IMO. If there was abuse of the drugs it was always by the Patients not Me.

Oh and I know not all terminal patients are admitted to Hospice but they should be, anyone with a Disease at end stage where the changes of any longevity are just so small with the current Treatment should be admitted, Hospice is not perfect but its a system that can best take care of the comfort needs 24hours a day, better than I could once a FP I'm confident of that.

Think of it this way, your mother has a disease that is painful and has a 20% chance of extension of a year or so with this treatment and the rules say no Hospice cause you want to take that small chance. I think it's BS and wrong, cause I have known many to take that chance and out of the Hospice system and they had so much difficulties with comfort. The ones in Hospice go to the Hospital less, suffer comfort issues less and have more contact with Health professions ( ie: Nurses, Aids, Consolers and Social Workers). They should be admitted to Hospice with the treatment period. This is my opinion.

 

[RuralMedicine]

Also, just to touch on the issues of reversals.

In what is now going on ten years of Family Medicine/Ob-GYN practice I have NEVER had a hospice RN need to reverse a patient from opioids or benzos.

That said, I feel comfortable using titrate to comfort orders because I feel comfortable that our Hospice RN's know the difference between titrating to comfort and titrating to respiratory arrest. Our hospice nurses generally know what a particular patient can or cannot handle and when they don't they've very conservative until they reach that point.

I have, however, had to reverse some opioids with Narcan in my time and in a patient habituated to opiates they've all told me that they just wish I'd let'em die. It's NOT a pleasant experience and I think it should be avoided if at all medically possible.

ntubebate

I've also never reversed opiates in the hospice/palliative care arena. As I mentioned I have done it in other patients with chronic opiate use (addicts and chronic pain patients) and it is from my experiences that I wrote my initial post. Just because we have Narcan doesn't mean we can be careless and sloppy with opiate dosing. In all but three of my narcotic reversal experiences the initial opiate delivery occurred outside of the hospital. In the other three things probably could have been done differently (although in the third scenario I'm not sure I would have done things much differently myself):
1.) 40 YO male with ESLD and hepatorenal syndrome who a surgery intern placed on a continuous infusion of dilaudid ?why he couldn't explain later. I was the unfortunate resident on call when the patient was noted to be unresponsive with sats in the 70s. He reversed somewhat but I still ended up having to intubate. CXR showed new infiltrates likely aspiration, admitted to MICU messy vent course with ARDS but ultimately extubated and subsequently transplanted. There is an upside I suppose.
2.) 38 YO male with chronic pain admitted to Psych (pain was so bad he was suicidal) started on Methadone with the Psychiatry team was managing and titrating he was found down and pulseless when his wife came to visit. Arriving at the code, CPR started, I established peripheral access and we gave naloxone and then slow dripped him in the unit overnight. It wasn't a pleasant experience but he survived. Psych took him back afterward and reportedly he did really well with remeron, his pain ?vanished and life was good. *This is part of the reason I advocate only playing with Methadone if you really understand it's pharmacodynamics Ntubate (not saying you don't).
3.) 69 YO male admitted with pneumonia given 2mg IV Morphine by my intern for severe rib pain from coughing not relieved by tylenol. He was unresponsive, bradypneic, and hypoxic about 15 minutes after this. The intern paged me in a panic and at the bedside we reversed but O2 sats were marginal and ABG worse so I intubated [My poor intern was too busy berating himself in the hallway--In retrospect I suppose that his underlying lung issue with played a significant role in his response to the Morphine. However, had the nurse called me instead of the intern I would have likely done the same thing (the exception being that I tend to start with 1mg increments of Morphine in the elderly although he was a big guy so perhaps I would have been braver. You can always give more is my motto), which I told him. The patient actually weaned from the ventilator well and was extubated by ICU day #3. He was home for Christmas with the grandchildren (who brought the whole team christmas cookies )

*One thing I've done a few times in chronic use patients who have misused their pain medicine and gotten into trouble has been to semi-reverse. I think if I was ever in a need to reverse situation with a hospice patient I would approach it this way. My medicine team inherited a patient who had somehow managed to get large amounts of oxycontin from several different providers. She overdosed and got admitted to our team, the ED physician who saw her documented that she had a gag reflex and would arouse they got busy with a trauma called me to admit after and when I saw the patient five minutes after their call, she was not arousable and had aspirated. (I guess all her oxycontin finally kicked in.) So I intubated and we weaned her off the vent and discharged her after psych stated she was not a danger to herself and she refused rehab five days later. She returned on our next call. This time I saw her a little earlier in the process and started a low dose Naloxone drip we avoided intubating, strongly recommended rehab, learned that we couldn't actually take away her remaining Oxycontin stash, reconsulted psych and discharged after they again assured us she was safe. Again she returned on our next call (2 days after discharge). We repeated the process. She returned the next night the resident on call paged me to ask me if I could explain how to "titrate to gag" (as my intern had written in d/c summary that patient was maintained on a naloxone drip which was titrated to gag).

 

[bigeyedfish]

During my years as a Hospice RN I found that if the primary Doc was not into Palliative care they tend to not allow pain meds to "titrate to Pain" orders. They would say, when they care to, they were afraid it was too much drug ordered and that the FDA would come after them. I would try to tell them the Hospice admission would protect them from this along with the documentation for such treatment. Now that I'm about through Basic Science I have found that Medical school is piss poor in teaching anything about palliative care.

In pharm we are worried about normal doses when a dose for a hospice patient was brought up by me in class Laughter and the professor looks were enough, like I was killing the patient. We need to push more opened mindedness in this I think, until then the patients people like us do not take care of will continue to suffer.

Good for you for thinking about these issues, but you have to take what the pharmD's say with a grain of salt. There is a lot you can learn from them, but it's going to be up to you to decide how to apply it. I was paged yesterday by the pharmacy for going up on a patient's vanc with a trough of 12. The pharmacist was literally flabergasted, "I can't figure out why you would do this." When I told him that the patient has mrsa osteomyelitis and what troughs we were shooting for he said that was not in his book and he didn't recommend it.

Also I wouldn't expect to learn much about palliative care in basic science. Do a rotation in heme/onc inpatient.

 

[RuralMedicine]

Good for you for thinking about these issues, but you have to take what the pharmD's say with a grain of salt. There is a lot you can learn from them, but it's going to be up to you to decide how to apply it. I was paged yesterday by the pharmacy for going up on a patient's vanc with a trough of 12. The pharmacist was literally flabergasted, "I can't figure out why you would do this." When I told him that the patient has mrsa osteomyelitis and what troughs we were shooting for he said that was not in his book and he didn't recommend it.

Also I wouldn't expect to learn much about palliative care in basic science. Do a rotation in heme/onc inpatient.

Totally off the original topic but I'm curious what trough were you shooting for? It would also matter what your peak was but I'd guess with a trough of 12 unless you were dosing very frequently you're probably hitting an adequate peak. PharmD's often get very territorial about drug levels although if you work with them and give them the clinical picture they can be helpful. Often if I can tell them what I'm shooting for peak/trough wise they can use their computer to spit out a dose that actually yields very close to what I wanted. It's helpful for the tricky patients/clinical scenarios. With a lot of patients I can hit the target too with very little math (and I usually don't bother to run those patients by them which sometimes I suppose hurts their feelings).

 

[bigeyedfish]

Totally off the original topic but I'm curious what trough were you shooting for? It would also matter what your peak was but I'd guess with a trough of 12 unless you were dosing very frequently you're probably hitting an adequate peak. PharmD's often get very territorial about drug levels although if you work with them and give them the clinical picture they can be helpful. Often if I can tell them what I'm shooting for peak/trough wise they can use their computer to spit out a dose that actually yields very close to what I wanted. It's helpful for the tricky patients/clinical scenarios. With a lot of patients I can hit the target too with very little math (and I usually don't bother to run those patients by them which sometimes I suppose hurts their feelings).

A trough of as low as possible that will help the patient, in this case we wanted to go above 15. At my institution we're starting to see mrsa with a higher minimum inhibitory concentration. So, if the bug is only susceptible to vanc, and the patient is not getting better, you've got to go up. This is documented in the literature. That gets some people's panties in a wad, not just pharmacists, but vanc is not nearly as nephrotoxic as it used to be, if renal function is good to start with and the patient is not on other nephrotoxic drugs. When it first came out it was mixed with some nephrotoxic carrier so it developed a reputation. Also levels aren't usually as variable as with gent, for example, which has rightfully earned it's reputation for toxicity, and it's metabolism varies more from person to person.

A few of the nephrologists I've worked with at my institution on the general medicine wards don't even check vanc levels. They just base it on clinical response. I don't know how comfortable I am with that, and the ID docs don't like it.

 

[RuralMedicine]

A trough of as low as possible that will help the patient, in this case we wanted to go above 15. At my institution we're starting to see mrsa with a higher minimum inhibitory concentration. So, if the bug is only susceptible to vanc, and the patient is not getting better, you've got to go up. This is documented in the literature. That gets some people's panties in a wad, not just pharmacists, but vanc is not nearly as nephrotoxic as it used to be, if renal function is good to start with and the patient is not on other nephrotoxic drugs. When it first came out it was mixed with some nephrotoxic carrier so it developed a reputation. Also levels aren't usually as variable as with gent, for example, which has rightfully earned it's reputation for toxicity, and it's metabolism varies more from person to person.

A few of the nephrologists I've worked with at my institution on the general medicine wards don't even check vanc levels. They just base it on clinical response. I don't know how comfortable I am with that, and the ID docs don't like it.

Yeah your MIC should be part of your calculations, and yeah MRSA is a problem. We have so much community aquired MRSA here and it's a real problem. Shooting for a trough at or just above 15 isn't unreasonable in some clinical situations although it may make people question. Actually if I'm using Vancomycin in someone with very poor renal function I check random levels and redose when my level gets to 15 or below (so I'm essentially using troughs of 15) and it works well. If you're pushing Vancomycin doses you may actually have more ototoxicity concerns than nephrotoxicity concerns.

And now back to our regularly scheduled topic

 

[sdn1977]

Totally off the original topic but I'm curious what trough were you shooting for? It would also matter what your peak was but I'd guess with a trough of 12 unless you were dosing very frequently you're probably hitting an adequate peak. PharmD's often get very territorial about drug levels although if you work with them and give them the clinical picture they can be helpful. Often if I can tell them what I'm shooting for peak/trough wise they can use their computer to spit out a dose that actually yields very close to what I wanted. It's helpful for the tricky patients/clinical scenarios. With a lot of patients I can hit the target too with very little math (and I usually don't bother to run those patients by them which sometimes I suppose hurts their feelings).

Thanks for the kind thoughts, but no....our feelings don't get hurt.

We just need to document because these "outliers" get noted on audits & we get by JCAHO (the apparent universal evil god) that can make our lives miserable if they don't feel we have taken time for a second look. They are also very antiquated in what they look for - renal failure, which the previous poster suggested was often related to either contaminants or concomittant renal toxic drugs. So...if the pt ever, in the course of his/her hospitalization, suffered a decrease in renal function & had a high dose of any potentially nephrotoxic drug & we didn't note that we had looked & had a justification for its use &/or dose - even if it was unrelated to the drug itself.....we get dinged.

In my institution & those that have enough pharmacists....we don't bother with a call to you. I just look at the progress notes....see what your intent its....make the right notations in my records & try to let you know when the levels get beyond what your stated goals are (or, more importantly...less than what your stated goals are). The big issue within pharmacy & vancomycin is not so much monitoring for renal failure but monitoring for dosing above the MIC for the bacteria. Evidence suggests that our tx failures are not due so much to resistance, but to tx staph which shows genetic polymorphism which requires dosing higher than what would normally be suggested & we underdose so we get a poor outcome. So...we prefer to not have tx failures - thus we monitor (with hopes the lab can & will do a rapid MIC on the culture) & we can get the dose high enough to have a positive outcome.

But...back to the topic of narcotics.....unfortunately, it is true, in some states.....authorities are very hard on prescribers who do not fall within the "accepted" specialties of prescribing high dose narcotics - oncology, pain management, PM&R. The DEA & state boards can make these folks lives difficult (Texas is a good example of this). So...many FP's & IM's who will & can tx a hospice pt are reluctant to go high on narcotics because of burecratic (sp?) backlash.

bigeyedfish....I don't think oldpro was referring to pharm as in pharmacists, rather the course she/he took. We, as pharmacists, are not at all concerned about escalating narcotic doses in hospice pts - it is our drug abusers who bother us. But...perhaps I misread.

 

[RuralMedicine]

Thanks for the kind thoughts, but no....our feelings don't get hurt.

Unfortunately some pharmacists feelings do get hurt (I was told this by one of our pharmacists earlier this week when I wrote for my own Vancomycin in a "uncomplicated" scenario).

The big issue within pharmacy & vancomycin is not so much monitoring for renal failure but monitoring for dosing above the MIC for the bacteria. Evidence suggests that our tx failures are not due so much to resistance, but to tx staph which shows genetic polymorphism which requires dosing higher than what would normally be suggested & we underdose so we get a poor outcome. So...we prefer to not have tx failures - thus we monitor (with hopes the lab can & will do a rapid MIC on the culture) & we can get the dose high enough to have a positive outcome.

Very good point--one I've seen colleagues forget at times unfortunately.

But...back to the topic of narcotics.....unfortunately, it is true, in some states.....authorities are very hard on prescribers who do not fall within the "accepted" specialties of prescribing high dose narcotics - oncology, pain management, PM&R. The DEA & state boards can make these folks lives difficult (Texas is a good example of this). So...many FP's & IM's who will & can tx a hospice pt are reluctant to go high on narcotics because of burecratic (sp?) backlash.

Perhaps this is another reason I'm one of the few physicians in our area who will follow with hospice--which I think is unfortunate. I haven't yet gotten dinged for my narcotic use with hospice. Although honestly I have non terminal patients who demand higher doses that a lot of what we'll do in hospice. (Just because they demand doesn't mean I give them though). I don't use narcotics much for chronic non malignant pain so perhaps that spares me or perhaps our state is more reasonable I'm not sure. My motivated chronic pain patients actually get a lot better with non narcotic meds and I tend to go that route. I do have a friend/colleague who is currently facing a DEA audit (although not as a result of hospice involvement, and no he's not selling scripts which I can say much more confidently about him than one of the pain specialists I attempt to avoid refering to) and I admit if I thought taking hospice patients would lead to that I'd stop working with hospice too.

 

[3dtp]

Oh and I know not all terminal patients are admitted to Hospice but they should be, anyone with a Disease at end stage where the changes of any longevity are just so small with the current Treatment should be admitted, Hospice is not perfect but its a system that can best take care of the comfort needs 24hours a day, better than I could once a FP I'm confident of that.

Think of it this way, your mother has a disease that is painful and has a 20% chance of extension of a year or so with this treatment and the rules say no Hospice cause you want to take that small chance. I think it's BS and wrong, cause I have known many to take that chance and out of the Hospice system and they had so much difficulties with comfort. The ones in Hospice go to the Hospital less, suffer comfort issues less and have more contact with Health professions ( ie: Nurses, Aids, Consolers and Social Workers). They should be admitted to Hospice with the treatment period. This is my opinion.

This has been a very interesting discussion, but oldpro, I'm afraid I have to disagree somewhat with this, not because it isn't philosophically correct, but Hospice, as it is financially implemented in this country, would render unavailable highly effective treatments for pain management simply because hospice cannot afford them under the current financial structure.

I am a radiation oncologist, and perhaps 30-50% of radiation medicine is used for symptom management and pain management. Patients on active hospice care do not get referred to radiation, despite the fact that 10 treatments will result in dramatic relief of pain in the case of boney mets, preservation of function and thus quality of remaining half-year(s) in the case of spinal cord compressions, and preservation of lucidity and function in the case of brain mets, the cough and hemoptysis resolved when the mainstem occlusive NSCLCA tumor is irradiated and clears. There are many other examples I can give, but as hospice is practiced, some of these patients will not be appropriately referred for radiation therapy. None of these treatments will cure a metastatic disease, in fact some say all lung cancer treatment is palliative, none will prolong life and the disease will invariably progress, but these treatments will give dramatic and prompt symptom management and pain relief with few side effects of treatment.

So, using your example, if your mother who has breast cancer with spinal mets and a new onset of lower extremity weakness, and incontinence/retention of bladder, improved on dexamethasone, is in hospice care, the dexamethasone will provide symptomatic relief for a brief period before the cord compression by the tumor progresses resulting in markedly decreased quality of life in relatively short order. That same patient checking out of hospice to receive a brief 5-10 day course of radiation for palliation of the cord compression will experience permanent local relief, will be off the dexamethasone which has other side effects and if this is the primary source of the patient's pain, likely a reduced need for narcotic analgesia.

I have run across patients I have referred to hospice post-radiation with signs of chronic narcotic OD short of respiratory depression, in remote areas where "titrate to pain" was used. Backing off on the narcotic allowed a reduction in benzos. Switching to a different narcotic at intervals seems to help too.

 

[3dtp]

Unfortunately some pharmacists feelings do get hurt (I was told this by one of our pharmacists earlier this week when I wrote for my own Vancomycin in a "uncomplicated" scenario).



Very good point--one I've seen colleagues forget at times unfortunately.



Perhaps this is another reason I'm one of the few physicians in our area who will follow with hospice--which I think is unfortunate. I haven't yet gotten dinged for my narcotic use with hospice. Although honestly I have non terminal patients who demand higher doses that a lot of what we'll do in hospice. (Just because they demand doesn't mean I give them though). I don't use narcotics much for chronic non malignant pain so perhaps that spares me or perhaps our state is more reasonable I'm not sure. My motivated chronic pain patients actually get a lot better with non narcotic meds and I tend to go that route. I do have a friend/colleague who is currently facing a DEA audit (although not as a result of hospice involvement, and no he's not selling scripts which I can say much more confidently about him than one of the pain specialists I attempt to avoid refering to) and I admit if I thought taking hospice patients would lead to that I'd stop working with hospice too.

Unfortunately, it is not just the DEA that is a worry here. There is a nationally recognized well respected hospice physician who had a pharmacist call the state license board because the pharmacist felt he was over-prescribing narcs. I know this guy well.

Newer practice guidelines and legislation have reduced the likelihood of this happening again, but it is still a risk and one that I am willing to take to insure appropriate pain management is done.

I do tend to use liquid forms since these have lower street value than pills and I do like Duragesic-DAW because its low abuse potential and good effect. For "low-risk" of abuse patients, whatever that means, I will write for fentanyl trans-dermal, but unfortunately, the street smart have figured out that the much more affordable generic fentanyl can be easily extracted from the matrix and there have been deaths nationwide from this, so I still tend to write for Duragesic, esp. when affordability is less of an issue.

 

[oldpro]

This has been a very interesting discussion, but oldpro, I'm afraid I have to disagree somewhat with this, not because it isn't philosophically correct, but Hospice, as it is financially implemented in this country, would render unavailable highly effective treatments for pain management simply because hospice cannot afford them under the current financial structure.

I am a radiation oncologist, and perhaps 30-50% of radiation medicine is used for symptom management and pain management. Patients on active hospice care do not get referred to radiation, despite the fact that 10 treatments will result in dramatic relief of pain in the case of boney mets, preservation of function and thus quality of remaining half-year(s) in the case of spinal cord compressions, and preservation of lucidity and function in the case of brain mets, the cough and hemoptysis resolved when the mainstem occlusive NSCLCA tumor is irradiated and clears. There are many other examples I can give, but as hospice is practiced, some of these patients will not be appropriately referred for radiation therapy. None of these treatments will cure a metastatic disease, in fact some say all lung cancer treatment is palliative, none will prolong life and the disease will invariably progress, but these treatments will give dramatic and prompt symptom management and pain relief with few side effects of treatment.

So, using your example, if your mother who has breast cancer with spinal mets and a new onset of lower extremity weakness, and incontinence/retention of bladder, improved on dexamethasone, is in hospice care, the dexamethasone will provide symptomatic relief for a brief period before the cord compression by the tumor progresses resulting in markedly decreased quality of life in relatively short order. That same patient checking out of hospice to receive a brief 5-10 day course of radiation for palliation of the cord compression will experience permanent local relief, will be off the dexamethasone which has other side effects and if this is the primary source of the patient's pain, likely a reduced need for narcotic analgesia.

I have run across patients I have referred to hospice post-radiation with signs of chronic narcotic OD short of respiratory depression, in remote areas where "titrate to pain" was used. Backing off on the narcotic allowed a reduction in benzos. Switching to a different narcotic at intervals seems to help too.

I agree with you but also there should be changes in the current delivery system, Hospice should allow such treatments, I have worked for some that did and paid for the radiation. It's not so clear cut. I think it may change to this universal but people are not accepting all the time. We will see how this goes, I think Docs need to be less scared of the DEA, if you have good documentation of Treatment then stick to it! I will, I will not let my patients suffer due to some outdated and uninformed Ideas, Pharmacists are not Docs.

In the End I will play the games to get the best treatment for my Patients so they may not be admitted into Hospice yet until the rad is done or whatever I know this. You are right.

This is my belief and yes thanks for joining in this is how we learn!