Compassionate Pain Management for Patients with Advanced Illness

Supported by evidence-based data, this webinar will help physicians and healthcare
professionals gain greater understanding of the multifaceted applications of pain management
in the context of palliative hospice care. Attendees will explore the different types of pain, the
assessment of pain, the holistic concept of total pain, and the numerous opioid, non-opioid, and
non-pharmacologic treatment modalities used in pain management near the end of life.

1. Compassionate Pain Management for Patients with Advanced Illness 1 Lauren Loftis MD, FAAHPM | Regional Medical Director [email protected] Frank Puglisi | Pharm D, VITAS Pharmacy

2. Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS ® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 Credit TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity . CME Provider Information

3. VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:   VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.  VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioners. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2024–06/06/2027.  Social workers completing this course receive 1.0 continuing education credit(s). VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois. CE Provider Information

4. Describe the pathophysiology of pain at the end of life Review both pharmacological and nonpharmacological measures of pain management in the dying patient Identify the signs of pain and discomfort and provide effective treatment Identify some interprofessional strategies to improve pain management at the end of life Objectives

5. Case Study of Mr. "Bob Jones" 5 Patient Mr. Jones, 65 y/o male with stage IV colon cancer, extensive metastases to the bone, liver, and brain. Lives with wife as primary caretaker, estranged son in another state who is not accepting of dad’s terminal diagnosis. Medical History D isease has progressed despite surgery, chemo and radiation. PPS 60%. Symptoms Severe fatigue, significant pain. Currently hospitalized after presenting to ED in severe pain. Treatments Dilaudid 4mg IV q 2 hours prn, oxycodone/acetaminophen 5/325 1 PO q 6 hours

6. The Concept of “Total Pain” Control Ong, C. K., & Forbes, D. (2005). Embracing Cicely Saunders's concept of total pain. BMJ (Clinical research ed.) , 331 (7516), 576. https:// doi.org /10.1136/bmj.331.7516.576-d Pain and discomfort at the end of life are frequently under-recognized and undertreated.  New modalities help prolong life, but there is a constant risk of prolonged suffering.  Physicians need a holistic approach targeting pain at the end of life. 6

7. The Initial Visit What questions to ask? 7 How severe is the pain? Where is the pain located? What are you taking for the pain? How is that working for you?

8. Types of Pain Pain at the end of life is most commonly associated with the pathology causing the disease and ultimately leading to death. Acute pain is usually associated with an intervention like surgical interventions, repositioning, or suctioning. Chronic pain is usually a complex interplay between several organ systems. 8

9. Anxiety as a Component of “Total Pain” Anxiety and depression frequently accompany pain, and addressing this is pivotal to alleviating “total pain.” - Organic causes of anxiety - Medications can cause anxiety Failure to address pre-existing anxiety can lead to significant distress at the end of life. 9

10. Other Components of “Total Pain” Apart from physical noxious stimuli, other factors that can affect individuals at the end of life, as elucidated by the concept of “total pain”: E motional discomfort I nterpersonal conflicts N onacceptance of one’s own death 10

11. The Four Dimensions of “Total Pain” 11 Conflict Fear Pain Despair Emotional Physical

12. Portenoy’s Model of “Total Pain” 12 Somatic or Visceral Nociceptive Neuropathic Mechanisms Psychosocial - Influences Psychological State & Traits Loss of Work Physical Disabilities Social/Family - Functioning Financial Concerns Fear of Death

13. What Else D o I Discover D uring M y Initial E ncounter With Mr. Jones? Mr. Jones is a Vietnam veteran and has signs of undiagnosed PTSD and significant existential distress about his diagnosis. Mr. Jones always wanted to take his wife to Hawaii and now “it’s never going to happen.” Mr. Jones hasn’t had a BM in 10 days. Mr. Jones just wants to get home with his wife and their dogs and “sleep in his own bed.” Mr. Jones’ son is adamant he does not want his father taking morphine. 13

14. Optimize patient comfort Enhance Functional ability Physical well-being Psychological well-being Spiritual well-being Minimize side effects Enhance quality of life 14 Pain Management Goals

15. Important Reminder 15 Pain management is based on the needs and expectations of the patient and family, not our own.

16. Take a careful history Establish the patient’s goals of care and build rapport and trust Take a careful look at your patient Nonverbal signs of pain, i.e., dry eyes, nose, mouth, wounds, GU, dental, extremities/MSK, IV sites/devices Assessment of hygiene and well-being focused on maintaining the patient's dignity at the end of life is essential 16 History and Physical

17. Reluctant to report pain Won’t be believed Will be viewed as a “complainer” Think this will impede care Reluctant to give in to pain Giving in equates to defeat Reluctant to take opioids Increasing pain means death is imminent Think that morphine hastens death 17 Patient and Family Barriers

18. Talk with Mr. Jones’ son about his hesitation to giving his father pain medication. Ask open-ended questions. Explore where hesitancy is originating from: Belief system? Anticipatory grief? Misconceptions about hospice? Is there a true allergy? Create a calm environment and thoughtful approach. Hospice team members available to support transition to being open to hospice and empowered to be involved in dad’s care. 18 What Do We Do Next?

19. 19 Pharmacologic Management of Pain Somatic Visceral Neuropathic Non-physical Acetaminophen Acetaminophen Anticonvulsants SSRIs/SNRI NSAIDs NSAIDs Gabapentin Stimulants Corticosteroids Corticosteroids Pregabalin NMDA receptor antagonists +/- oral opioids +/- oral opioids Benzodiazepines Antispasmodics

20. 20 Opiates and Opioid Selection Medication Factors Patient Factors Hospice Considerations Onset and duration of action Routes of administration Dosage forms Metabolism and elimination Pain assessment History of opioid use Co-morbidities Other medications Drug allergies or adverse reactions Patient- and family- specific goals Other symptoms Caregiver burden Prognosis

21. 21 Opiates Long Acting Morphine ER Large tablets Oxycontin Fentanyl Methadone Short Acting Oxycodone >> Hydrocodone >> Hydromorphone >> Morphine Both Morphine and Hydromorphone metabolites are neuro-excitatory (neurotoxic)

22. Overcome fears and preconceived ideas by: Maintaining a good knowledge base of effective pain management Sharing knowledge with patients and families Using open-ended questions Empowering the patient to guide decision-making Acceptable quality of life 22 Empowering the Patient

23. 23 The Interdisciplinary Team Team Manager Primary RN Hospice Aide Team Physician Chaplain Social Worker Volunteer Pharm D

24. Assessment: Cancer-related pain with complicated anticipatory grief and existential distress, insomnia, constipation. Minimal control despite escalating doses of IV dilaudid and PO oxycodone Plan: What matters most (pain control, “getting outta here,” Hawaii)? What drugs would I consider and why? Long-acting opiate (methadone) Short-acting opiate (morphine) Adjuvants (steroids, NSAIDs, Tylenol, SNRI, gabapentin, ketamine) What other symptoms might be impacting his pain (constipation, PTSD, insomnia, existential distress)? 24 What Do We Do Now for Mr. Jones?

25. 25 Pain Management Is So Much More Than Opiates Alone! Mr. Jones agreed to receive hospice services at home Continuous care arranged to manage symptoms MD evaluated patient at time of admission and same-day after transport home Medications profiled and delivered to home along with HME, oxygen, and supplies HHA provided first bath in weeks; constipation addressed Pharm D assisted with methadone titration regimen and pharmacologic selection Social worker and chaplain consulted to assist family and patient As a result, Mr. Jones “felt so much better, he couldn’t believe it” and “wished he’d called us months ago.”

26. 26 Pain Management Improves Quality of Life VITAS patient JC was able to make “one last cast” on a fishing trip with his wife. Navy Veteran Jose Cepeda, pictured with his family, was honored at an Atlanta Braves game for his WWII service while on VITAS service.

27. Questions?

28. Additional Hospice Resources The VITAS mobile app includes helpful tools and information: Interactive Palliative Performance Scale (PPS) Body-Mass Index (BMI) calculator Opioid converter Disease-specific hospice eligibility guidelines Hospice care discussion guides We look forward to having you attend some of our future webinars! Scan now to download the VITAS app.

29. References Bandieri , et al. (2016). Randomized Trial of Low-Dose Morphine Versus Weak Opioids in Moderate Cancer Pain. J Clin Oncol. 34(5):436–442. Ong, C. K., & Forbes, D. (2005). Embracing Cicely Saunders's concept of total pain. BMJ (Clinical research ed.), 331(7516), 576. https:// doi.org /10.1136/bmj.331.7516.576-d Hagarty , et al. (2020). Severe pain at the end of life: a population-level observational study. BMC palliative care , 19 (1), 60. https:// doi.org /10.1186/s12904-020-00569-2 Hallenbeck , James, MD. (2009). Palliative Care Perspectives, Chapter 5: Non-Pain Symptom Management: Dyspnea. Portenoy R. (2008). Practical aspects of pain control in the patient with cancer. CA-A Journal for Clinicians. 38:332. Van den Beuken -van Everdingen , et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years. Annals of Oncology , 18 (9), 1437-1449. Welk,Thomas A. (1991). “An Educational Model for Explaining Hospice Services” The American Journal of Hospice & Palliative Care. P.14-17.