- Email: [email protected]
Gone With the Wind? Palliative Care for Persistently Vegetative Patients (507)
Vol. 43 No. 2 February 2012
Schedule With Abstracts
delirium propensity and how this impacts the treatment plan for pain and other symptoms. We will compare and contrast risk factors for delirium in cancer with geriatrics. A review of the literature surrounding opioids, their metabolites, and parenteral hydration in delirium prevention will be discussed. Also, we will deconstruct the results of a large, multi-component prevention trial in Canada which was ineffective in reducing the incidence or severity of delirium in end-stage cancer patients. Lastly, we will discuss the use of antipsychotics to prophylax against delirium. This approach has been investigated in a small number of trials in post-surgical patients. These trials will be reviewed and the relevance to the palliative care population will be addressed.
Is More Necessarily Better? Managing the Complexities of Polypharmacy in Pediatric Patients With Advanced Illnesses (506) Tammy Kang, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA. Elissa Miller, MD, Children’s Hospital of Philadelphia, Philadelphia, PA. Gina Santucci, MSN APRN-BC, Children’s Hospital of Philadelphia, Philadelphia, PA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the problem of polypharmacy for pediatric patients with advanced illnesses cared for by pediatric palliative care and hospice providers. 2. Identify common drug interactions that have the potential to negatively impact patients. 3. Strategize ways in which the problem of polypharmacy can be minimized for children and families. Children with complex chronic progressive illnesses are increasingly being followed by pediatric palliative care teams and hospice providers. Recent studies have shown that the majority of children who utilize pediatric palliative care services are not imminently dying, rather are living with complicated diseases that require the care of multiple subspecialty providers. The complexity of illness also leads to patients requiring a multitude of disease and symptom directed therapies. A recent study of palliative care patients cared for by 6 children’s hospitals in the US and Canada reports extensive medication profiles: the mean number of medications prescribed was 9.1 (SD 5.5), with a median of 9
405
and a range from 0 to 18 medications. With the many of these medications requiring multiple doses per day, it is not difficult to understand why parents often feel more like medical providers than parents. The issue of polypharmacy is not only a logistical one for families but can be dangerous with the increasing possibility of drug-drug interactions and medication side effects that can negatively impact the patient. This session will review the background of polypharmacy in pediatric patients with advanced illnesses utilizing a review of the medical literature and report recent multiinstitutional study results to describe the current problem. In addition, we will discuss common drug-drug interactions and how they might negatively impact the care of pediatric patients. Finally, we will utilize a case based discussion to strategize ways in which we can minimize this problem for our patients and families.
Gone With the Wind? Palliative Care for Persistently Vegetative Patients (507) Kathryn Walker, PharmD BCPS CPE, University of Maryland School of Pharmacy, Baltimore, MD. Christopher Kearney, MD, Union Memorial Hospital, Baltimore, MD. Rene Mayo, MSW, Union Memorial Hospital, Baltimore, MD. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the clinical trajectory of persistently vegetative patients. 2. Outline the approach to conducting a palliative medicine consult for PVS patients. 3. Discuss the unique challenges associated with family meetings to approach goals of care discussions in a productive way. ‘‘Her eyes are open, she is looking at medI know she is still in there!’’ Persistently vegetative patients have been portrayed publically in cases such as Terry Schiavo, Nancy Cruzan, and Karen Quinlan leading to much debate and confusion about appropriate care. The theory that a persistently vegetative state (PVS) is a stable, non-progressive condition significantly affects the decision-making process of families and clinicians, although this proves to be a dangerous myth. Over time, these patients suffer from muscle wasting, contractures, recurrent pneumonias and other infections, intubations, pressure ulcers and other devastating comorbid conditions, ultimately leading to death. These patients often have frequent readmissions and lengthy stays in the hospital.
406
Schedule With Abstracts
PVS patients present unique challenges for everyone involved in caring for them. Families and clinicians often face difficultly in discussing goals of care. Clinicians are often frustrated in what they perceive to be meaningless and futile care, while families are caught in a commitment made long ago. Patients, on the other hand, may be suffering in a ‘‘dimensionless limbo.’’ Palliative medicine specialists have an important responsibility in caring for these patients and their families. This session will focus on the clinical care of PVS patients, guidance for families and support for staff. A series of cases will be presented to illustrate a practical approach for re-evaluating the treatment goals for these patients. This approach requires mastering the following skills: exploring the deeper meaning of decisions made by families, sharing the burden of decision making with the family, explaining the current status and likely future clinical course, while incorporating identified spiritual concerns. Meaningful goals of care discussions for PVS patients are often neglected by the medical community, making them particularly challenging. They represent an opportunity for palliative medicine specialists to spearhead needed reform in the care of these patients.
SIG Symposia Supportive and Palliative Oncology Literature: Quantity, Scope, Design, Challenges, and Opportunities (508) Research SIG David Hui, MD MSc FRCPC, MD Anderson Cancer Center, Houston, TX. Masanori Mori, MD, University of Vermont College of Medicine, Burlington, VT. Henrique Parsons, MD, MD Anderson Cancer Center, Houston, TX. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Review the quantity, scope and design of the recent supportive and palliative oncology literature. 2. Examine the challenges unique to supportive and palliative oncology research. 3. Discuss strategies for improving the quantity and quality of supportive and palliative oncology literature. The absolute number of palliative oncology studies has increased over time. However the
Vol. 43 No. 2 February 2012
proportion of palliative oncology publications related to the greater cancer literature has actually decreased. The supportive and palliative oncology literature is extremely diverse and highly complex. This session aims to provide a comprehensive overview of the quantity, scope, and design of the palliative care literature based a recent systematic review, and to identify current challenges and opportunities for growth. The field of palliative care transects numerous health disciplines and domains, and covers a myriad of topics ranging from symptom management to psychosocial care, spiritual issues, health services, communication, decision making, ethics, education and research methodologies. The study population also varies widely, including patients with various oncologic diagnoses and at different stages of illness, their caregivers and health professionals. Common study designs to address research questions in the supportive and palliative oncology literature include case reports, case series, populationbased studies, cross sectional surveys, cohort studies, randomized controlled trials and qualitative studies. Using a framework for classifying supportive and palliative oncology studies systematically, we will discuss various study designs used to investigate different research topics, and highlight areas of deficiency requiring further research. We will also provide an evidence-based review of the many challenges associated with conducting supportive and palliative oncology research, including limited funding, few trained personnel, difficulty in recruiting patients, high attrition rates, limited number of validated outcome measures, and lack of standardized definitions. Finally, we will discuss practical strategies to advance supportive and palliative oncology research. The last 10 minutes will be available for questions and discussions.
Palliative Care for Patients With HIV: Challenges and Controversies (509) HIV SIG Christopher Blais, MD MPH FACP FAAHPM, Ochsner Health System, New Orleans, LA. Peter Selwyn, MD MPH, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Rodney Tucker, MD MMM FAAHPM, UAB Center for Palliative and Supportive Care, Birmingham, AL. Nancy Hutton, MD FAAP FAAHPM,
Schedule With Abstracts
delirium propensity and how this impacts the treatment plan for pain and other symptoms. We will compare and contrast risk factors for delirium in cancer with geriatrics. A review of the literature surrounding opioids, their metabolites, and parenteral hydration in delirium prevention will be discussed. Also, we will deconstruct the results of a large, multi-component prevention trial in Canada which was ineffective in reducing the incidence or severity of delirium in end-stage cancer patients. Lastly, we will discuss the use of antipsychotics to prophylax against delirium. This approach has been investigated in a small number of trials in post-surgical patients. These trials will be reviewed and the relevance to the palliative care population will be addressed.
Is More Necessarily Better? Managing the Complexities of Polypharmacy in Pediatric Patients With Advanced Illnesses (506) Tammy Kang, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA. Elissa Miller, MD, Children’s Hospital of Philadelphia, Philadelphia, PA. Gina Santucci, MSN APRN-BC, Children’s Hospital of Philadelphia, Philadelphia, PA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the problem of polypharmacy for pediatric patients with advanced illnesses cared for by pediatric palliative care and hospice providers. 2. Identify common drug interactions that have the potential to negatively impact patients. 3. Strategize ways in which the problem of polypharmacy can be minimized for children and families. Children with complex chronic progressive illnesses are increasingly being followed by pediatric palliative care teams and hospice providers. Recent studies have shown that the majority of children who utilize pediatric palliative care services are not imminently dying, rather are living with complicated diseases that require the care of multiple subspecialty providers. The complexity of illness also leads to patients requiring a multitude of disease and symptom directed therapies. A recent study of palliative care patients cared for by 6 children’s hospitals in the US and Canada reports extensive medication profiles: the mean number of medications prescribed was 9.1 (SD 5.5), with a median of 9
405
and a range from 0 to 18 medications. With the many of these medications requiring multiple doses per day, it is not difficult to understand why parents often feel more like medical providers than parents. The issue of polypharmacy is not only a logistical one for families but can be dangerous with the increasing possibility of drug-drug interactions and medication side effects that can negatively impact the patient. This session will review the background of polypharmacy in pediatric patients with advanced illnesses utilizing a review of the medical literature and report recent multiinstitutional study results to describe the current problem. In addition, we will discuss common drug-drug interactions and how they might negatively impact the care of pediatric patients. Finally, we will utilize a case based discussion to strategize ways in which we can minimize this problem for our patients and families.
Gone With the Wind? Palliative Care for Persistently Vegetative Patients (507) Kathryn Walker, PharmD BCPS CPE, University of Maryland School of Pharmacy, Baltimore, MD. Christopher Kearney, MD, Union Memorial Hospital, Baltimore, MD. Rene Mayo, MSW, Union Memorial Hospital, Baltimore, MD. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the clinical trajectory of persistently vegetative patients. 2. Outline the approach to conducting a palliative medicine consult for PVS patients. 3. Discuss the unique challenges associated with family meetings to approach goals of care discussions in a productive way. ‘‘Her eyes are open, she is looking at medI know she is still in there!’’ Persistently vegetative patients have been portrayed publically in cases such as Terry Schiavo, Nancy Cruzan, and Karen Quinlan leading to much debate and confusion about appropriate care. The theory that a persistently vegetative state (PVS) is a stable, non-progressive condition significantly affects the decision-making process of families and clinicians, although this proves to be a dangerous myth. Over time, these patients suffer from muscle wasting, contractures, recurrent pneumonias and other infections, intubations, pressure ulcers and other devastating comorbid conditions, ultimately leading to death. These patients often have frequent readmissions and lengthy stays in the hospital.
406
Schedule With Abstracts
PVS patients present unique challenges for everyone involved in caring for them. Families and clinicians often face difficultly in discussing goals of care. Clinicians are often frustrated in what they perceive to be meaningless and futile care, while families are caught in a commitment made long ago. Patients, on the other hand, may be suffering in a ‘‘dimensionless limbo.’’ Palliative medicine specialists have an important responsibility in caring for these patients and their families. This session will focus on the clinical care of PVS patients, guidance for families and support for staff. A series of cases will be presented to illustrate a practical approach for re-evaluating the treatment goals for these patients. This approach requires mastering the following skills: exploring the deeper meaning of decisions made by families, sharing the burden of decision making with the family, explaining the current status and likely future clinical course, while incorporating identified spiritual concerns. Meaningful goals of care discussions for PVS patients are often neglected by the medical community, making them particularly challenging. They represent an opportunity for palliative medicine specialists to spearhead needed reform in the care of these patients.
SIG Symposia Supportive and Palliative Oncology Literature: Quantity, Scope, Design, Challenges, and Opportunities (508) Research SIG David Hui, MD MSc FRCPC, MD Anderson Cancer Center, Houston, TX. Masanori Mori, MD, University of Vermont College of Medicine, Burlington, VT. Henrique Parsons, MD, MD Anderson Cancer Center, Houston, TX. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Review the quantity, scope and design of the recent supportive and palliative oncology literature. 2. Examine the challenges unique to supportive and palliative oncology research. 3. Discuss strategies for improving the quantity and quality of supportive and palliative oncology literature. The absolute number of palliative oncology studies has increased over time. However the
Vol. 43 No. 2 February 2012
proportion of palliative oncology publications related to the greater cancer literature has actually decreased. The supportive and palliative oncology literature is extremely diverse and highly complex. This session aims to provide a comprehensive overview of the quantity, scope, and design of the palliative care literature based a recent systematic review, and to identify current challenges and opportunities for growth. The field of palliative care transects numerous health disciplines and domains, and covers a myriad of topics ranging from symptom management to psychosocial care, spiritual issues, health services, communication, decision making, ethics, education and research methodologies. The study population also varies widely, including patients with various oncologic diagnoses and at different stages of illness, their caregivers and health professionals. Common study designs to address research questions in the supportive and palliative oncology literature include case reports, case series, populationbased studies, cross sectional surveys, cohort studies, randomized controlled trials and qualitative studies. Using a framework for classifying supportive and palliative oncology studies systematically, we will discuss various study designs used to investigate different research topics, and highlight areas of deficiency requiring further research. We will also provide an evidence-based review of the many challenges associated with conducting supportive and palliative oncology research, including limited funding, few trained personnel, difficulty in recruiting patients, high attrition rates, limited number of validated outcome measures, and lack of standardized definitions. Finally, we will discuss practical strategies to advance supportive and palliative oncology research. The last 10 minutes will be available for questions and discussions.
Palliative Care for Patients With HIV: Challenges and Controversies (509) HIV SIG Christopher Blais, MD MPH FACP FAAHPM, Ochsner Health System, New Orleans, LA. Peter Selwyn, MD MPH, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Rodney Tucker, MD MMM FAAHPM, UAB Center for Palliative and Supportive Care, Birmingham, AL. Nancy Hutton, MD FAAP FAAHPM,