Barton Bobb

Dexmedetomidine: exploring its potential role and dosing guideline for its use in intractable pain in the palliative care setting.

ABSTRACT Intractable pain continues to pose problems for patients with life-limiting disease. The authors review the potential role of dexmedetomidine (Precedex), an α2-adrenergic agonist, as a bridge to obtaining effective analgesia. The authors offer criteria to consider in utilizing this medication within the context of palliative care.

Oral Ketamine for Sickle Cell Crisis Pain Refractory to Opioids

ABSTRACT There is literature demonstrating that the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine has analgesic properties that can be used as an adjuvant to opiates for pain relief in multiple various conditions and pain states. However, there is a lack of published information on ketamine used in persons with sickle cell disease in acute pain crises. The Virginia Commonwealth University Palliative Care team was consulted on a 38-year-old African American female with sickle cell thalassemia in severe acute pain crisis overlying chronic pain related to her disease. Pain control was unable to be achieved with escalating doses of opiates and other adjuvant medications. The patient responded well to an intravenous test dose of ketamine and was subsequently placed on an oral regimen of ketamine in addition to opiates. In the 24-hour period following ketamine initiation, the patients pain was able to be controlled on decreased amounts of opiates. She was eventually transitioned to an oral opiate and ketamine regimen, which allowed her to be discharged home with pain levels close to her baseline and the ability to function and perform all activities of daily living.

Organ Donation after Cardiac Death from Withdrawal of Life Support in Patients with Amyotrophic Lateral Sclerosis

OBJECTIVE Donation after cardiac death (DCD) or donation of organs after removal of life support is an accepted means of organ retrieval that usually occurs in the setting of sudden illness but has not been described in people with progressive neurologic illness. We report DCD in two people with progressive amyotrophic lateral sclerosis (ALS). METHODS Case series at an academic medical center of two men with progressive ALS who underwent withdrawal of artificial life support, rapid cardiac death, and subsequent organ donation. The primary outcome was donation of organs in concordance with patient and family wishes. RESULTS Both patients underwent peaceful withdrawal of life support in the presence of family, and multiple organs were donated. CONCLUSIONS Patients may legally and ethically refuse life-sustaining care. These patients considered their lives to be more burdensome than beneficial near the end of their lives, both carefully planned the time and circumstance of their deaths, and both fulfilled a long-standing desire to donate their organs. This study describes a potential opportunity for patients with progressive neurologic illness.

Managing Pain with Algorithms: An Opportunity for Improvement? Or: The Development and Utilization of Algorithms to Manage Acute Pain

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committees efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

The "PSOST": Providers' Signout for Scope of Treatment.

Palliative care provides open and honest communication, medically appropriate goal setting, and meticulous attention to symptom assessment and control. The Physicians Orders for Life Sustaining Treatment (POLST) is a growing movement to allow health care providers to indicate, with their patients, what they want done in specific situations, such as feeding tubes, mechanical ventilation, or transfer to an intensive care unit. We have developed an internal signout tool used by palliative medicine fellows in our institution to specify similar interventions-or not-with seriously ill palliative care patients, the Providers Signout for Scope of Treatment (PSOST). We have found that this situation-specific tool enables smooth transitions of care on nights and weekends, especially when the patient is near death, and may help prevent both overescalation of care and underuse of life saving treatments such as resuscitation. The PSOST differs from other signout tools in that it gives clear direction regarding the patients medical goals and desire for escalation of care, or not. We present it here for open access and use anywhere. This tool has also assisted in building team communication with the nursing shifts, especially nights and weekends, as all team members are able to deliver a consistent message, while meeting the goals of care for patients and families. We believe this tool could be useful with a broader patient population, outside of Palliative Medicine, to provide clearer direction for hospitalized or nursing home patients whose care is often directed by multiple providers. It could also be used as a template for signouts on other inpatient services, as care goals are important for all patients.

Guiding Patients Facing Decisions about "Futile" Chemotherapy

Ms. G is a 71-year-old woman with metastatic gastric adenocarcinoma recently diagnosed after an extensive surgical resection for a small bowel obstruction (SBO). She was admitted from the surgery clinic with intractable nausea and vomiting. An abdominal computerized tomographic (CT) scan revealed a partial SBO and peritoneal carcinomatosis. Given her recent surgery, the extent of her disease, and high likelihood of recurrent SBO, the surgical team decided that Ms. G was no longer a surgical candidate. When her symptoms did not improve with conservative measures, both oncology and palliative medicine were consulted to assist with symptom management and goals of care. The oncology team stated that Ms. G was still a chemotherapy candidate and suggested that she attend her new patient evaluation in oncology clinic the following week. The palliative medicine team then met with the patient to discuss management options and her preferences for care. The palliative care team explained ways to control her nausea and vomiting without using a nasogastric tube, and the patient agreed to transfer to their service for symptom management. The palliative team explained that her cancer was incurable but that chemotherapy options existed to help control her disease and possibly prolong her life. They also explained that the chemotherapy has side effects and that the patient would need to decide if she wanted to undergo treatment and accept potential side effects for the possibility of prolonging her life by weeks to months and improving her symptoms. As an alternative, she was told that she could focus solely on symptom control with medications and allow her disease to take its natural course. Ms. G was asked to think about how she wanted to spend the time she had left. Prior to discharge, as her symptoms improved, Ms. G was evaluated by another oncologist, who, after consulting the expert gastrointestinal cancer team, explained to her that the current chemotherapy options available for metastatic gastric cancer were rarely, if ever, successful at reversing malignant obstruction. With this information, the patient decided to be discharged home with hospice and spend time with her family. She died peacefully at her home approximately two weeks later.

Epidural Screening Before Intrathecal Analgesia

To the Editor: Presently, from10 to 20% of patients with moderate to severe pain require analgesic techniques other than the simple three-step approach described in the World Health Organization analgesic ladder.1 One such technique is intrathecal analgesic administration. This route typically offers effective analgesia for individuals who experience intractable pain or side effects from opioids.2,3 Intrathecal administration is not suitable for all patients, but there is no broad consensus on the role of screening to explore the benefits of intrathecal therapy. Advantages of epidural and intrathecal trials are several. These include determining optimal dose and drug requirements and the ultimate benefit of improved physical and mental condition, hence, improved quality of life.4 The goal of any such trial is to decrease pain by at least 50% and/or decrease symptoms by the same percentage. Some clinicians attempt such therapy using a single intrathecal dose of long-acting morphine (Duramorph) formulated for the epidural route. But this may be misleading because many patients with pain require high-dose intrathecal opioids or combinations of other analgesic or adjunctive agents, such as baclofen, local anesthetics, and clonidine.