Many of us have heard the saying that emergency medicine is the best 15 minutes of every other specialty. This, is in part, due to the wide breadth of disease and knowledge one must have to take care of patients. In emergency medicine we typically focus on acute disease specific problems and life sustaining treatments, but as the population gets older we are also having to deal with chronic conditions as well. This was not an area that I was trained in residency, but certainly one that I am seeing more and more often. There was a great review article published in the Journal of Emergency Medicine in January of 2018 titled, Palliative Care Symptom Management in the Emergency Department: The ABC’s of Symptom Management for the Emergency Physician. The lead author of this paper is Mari Siegel, MD, who I had the pleasure of interviewing for this episode.
REBEL Cast Episode 54 – Hyperoxia in the Critically Ill
Mari Siegel, MD
Assistant Professor of Emergency Medicine
Difference Between Palliative Care and Hospice Care
Palliative care is the prevention and relieving of suffering while supporting quality of life both for patients and families. Hospice care falls under the umbrella of palliative care. Both focus on symptom management, but hospice care is generally the appropriate service for patients who have ≤6 months to live or no longer want curative treatment, while palliative care is more appropriate earlier in a patients disease course.
The “Surprise” Question
Would you be surprised if this patient died in the next 2 years? If the answer is no, then this is a patient who should be considered for palliative care.
3 Types of Pain
- Nociceptive Pain: This is from stretching or compression of organs
- Neuropathic Pain: This is the hardest pain to treat and comes from nerve injury
- Bone Pain: This is from bony mets or pathological fractures
Nociceptive Pain Treatment
Use a scale up strategy starting with nonopioids and increasing in strength. A great resource for this is the World Health Organization (WHO) Analgesic Ladder
This is the hardest pain to treat. The best two options here are gabapentin (Neurontin) and pregabalin (Lyrica) (The paper does make other medication recommendations). Mari stated that gabapentin is cheaper and covered by most insurance companies, but pregabalin is generally not. Both medications are equally effective, but gabapentin has a longer up titration period of almost 9 days compared to 2 – 3 days for pregabalin.
- Typical dosing for Neurontin starts at 100mg three times a day but this needs to be titrated up to 2400mg – 3600mg in 24hrs over several weeks
- Neurontin can also cause fatigue, but if the medication is continued for 1 – 2 weeks, the fatigue goes away
Mari likes to use NSAIDs as her first line medication. The reason for this is that osteolytic activity in bony mets is most likely mediated by prostaglandins. NSAIDs are prostaglandin inhibitors. Dexamethasone 8 – 10mg also does a great job treating bony pain. If the pain is not treated with the NSAIDs or steroids, the second line agents would be opiates.
We talked about this medication as well. Tramadol PO 25 – 50mg q6h is the typical starting dose. Tramadol is considered a second line agent in the WHO analgesic ladder. The problem with tramadol is the metabolites can be toxic, and people metabolize it at different rates, so it’s not clear how much of an opioid you are giving any one patient. Mari recommends using this medication with caution in patients with renal failure or liver failure and on SSRIs, SNRIs, MOIs, Triptans or any other medications that can lower seizure threshold or cause serotonin syndrome (At doses of <200mg/day you are not lowering seizure threshold).
- Depends if the patient is opioid naïve or opioid tolerant:
- Opioid naïve: Start with low doses (i.e. Outpatient = PO Oxycodone 5mg q6hr and/or Oxycontin 10mg PO BID; Inpatient = IV morphine 2mg or IV hydromorphone 0.5mg)
- Opioid tolerant: Patients on chronic narcotics can be handled by increasing their home doses by 50% or change them to a different opioid (when changing narcotics, use an opioid conversion chart and start at 50 – 75% of the equivalent dose)
- IMPORTANT POINT brought up by Mari: Opioids should be ordered as standing orders and not as needed to keep ahead of the patients pain
- Also always prescribe stool softeners to go along with the opioid medications (Colace + Senna)
- Fear of Hastening Death? Not so fast…Starting patients on low doses of opioids will not hasten death, but even if this did occur, there is a law of double effect, which states anyone prescribing medications to manage symptoms of pain are legally protected
- Converting between narcotics can be done using a narcotic conversion chart which can be found online, but Mari likes to use a FREE app called Opioids Dosage Conversion
Logo for the Opioids Dosage Conversion App
Example of Opioid Conversion Discussed on the Podcast
- When converting from one drug to another calculate the morphine equivalent in milligrams and figure out what they are on over 24 hours:
- So a patient is on 100mg PO long acting morphine q12hr (200mg over 24hrs) + 30mg of oxycodone in 24 hours = 245mg of oral morphine (30mg of oral morphine = 20mg of oral oxycodone –> so 30mg of oxycodone = 45mg of oral morphine)
- When converting a patient to another opioid, dose the patient at 75% of the morphine equivalent dose to ensure you do not over-medicate the patient
- Converting to hydromorphone for example: 245mg of oral morphine per day ≈ 60mg of hydromorphone –> 75% of this is 45mg of hydromorphone, which is what you would give the patient
- So the patient would get 8mg of hydromorphone q8hr + their oxycodone for breakthrough pain
Nausea and Vomiting
Treatment is very complex, as there can be multiple causes for vomiting. The most common causes of nausea and vomiting come for the chemoreceptor trigger zone (CTZ). Mari stated that low dose haloperidol 2mg or chlorpromazine 1mg/kg IV are the best agents in these cases. Ondansetron would be a first line medication for chemotherapy-induced nausea and vomiting.
This is a common complaint. The reflexive 1stline treatment is not oxygen, it is opioids. Starting with a low dose of morphine IV 2mg is a good starting dose to relieve dyspnea. Benzodiazepines are also useful if opioids fail to alleviate the patients pain (i.e. 0.5mg IV lorazepam). These medications are synergistic, so starting at lower doses is recommended
1stline treatment for this is haloperidol 1 – 2mg IV hourly with titration to effect. Mari brought up a good point that benzodiazepines can cause paradoxical agitation, especially in the elderly.
Terminal Secretions (“The Death Rattle”)
- 1st line treatment is with anticholinergics including atropine and glycopyrrolate.
- Atropine 1% SL drops (ophthalmic drops) = 0.1mg IV –> Place 2 drops under the tongue to help dry up secretions
- Glycopyrrolate 0.2mg IV q6hrs
How to Talk to Patients
- Set the scene (quiet room with privacy)
- Make sure you sit down so you are at eye level
- Questions to help initiate conversation:
- Ask the patient what do you know about your illness/condition?
- Then ask, do you want me to tell you what I know? This really lets you know where the patient is at
- What does it look like for you to have peace at the end of your life?
- Comfort directed care is not giving up. Use positive terms like aggressively treat your pain
- Siegel M and Bigelow S. Palliative Care Symptom Management in the Emergency Department: The ABC’s of Symptom Management for the Emergency Physician. JEM 2018. PMID: 28987298
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)