- Email: [email protected]
Ketamine: Making Sense of Multiple Routes and Dosing Protocols (306)
Vol. 43 No. 2 February 2012
Schedule With Abstracts
Continuing Education in Nursing: Continuing Competence for the Future. The task force culminated its work in ‘‘The Statement on Continuing Competence for Nursing.’’ The Statement includes a crosswalk between core competencies set forth in Nursing: Scope and Standards of Practice (American Nurses Association, 2010) and the Hospice and Palliative Nurses Association (HPNA)’s Competence Topics for RNs and APRNs. In partnership with the American Board of Nurse Specialties (ABNS) and Accreditation Board for Specialty Nursing Certification (ABNSC), the task force continues to explore uses of its Statement to further the ABNS Research Agenda, ABNS success markers, refinement of certification and recertification requirements, and other endeavors. This presentation describes the process that the task force employed and the product which it produced. The process included an extensive literature review and structured discussions during web-enhanced conference calls. The presentation invites dialogue about the use of the Statement in defining credentialing criteria and in exploring the concept of continuing competence in the practice of hospice and palliative care.
The Use of Video Technology for Caregiver Involvement in Interdisciplinary Hospice Teams: Preliminary Experiences From the ACTIVE Randomized Clinical Trial (305) Debra Parker Oliver, PhD MSW, University of Missouri, Columbia, MO. George Demiris, PhD, University of Washington, Seattle, WA. Elaine Wittenberg-Lyles, PhD, University of Kentucky, Lexington, KY. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Identify the benefits and challenges of caregiver participation in hospice team meetings. 2. Discuss the preliminary findings of one study on caregiver participation. 3. Discuss the implications of caregiver participation on pain management in hospice patients. Licensing and certification agencies require hospices to convene an interdisciplinary team (IDT) at least every 14 days. The meeting’s
331
purpose is to bring together at least nurses, social workers, physicians, and chaplains to collaborate and develop a care plan. Despite the hospice philosophy of patients and family empowerment with decision making regarding their care, they are routinely absent from these meetings. This research team has designed an intervention using video technology to involve informal caregivers (and patients when they are able) in the hospice interdisciplinary team care plan meetings. A NIH funded, multisite, 4-year randomized controlled trial is being conducted to test the effects of the intervention. Using videoconferencing to connect the informal caregivers (and patients) to the hospice team, we have reduced their fears by addressing questions about pain medication and offering emotional support. This intervention has been named ACTIVE (Assessing Caregivers for Team Intervention through Video Encounters). Our preliminary results show that the intervention is not only feasible but that it holds promise to change caregiver perceptions of pain management and potentially reduce patient pain. Caregivers can and do talk freely to the hospice team about pain concerns and hospice staff members are positive about the intervention. Additionally, the preliminary observation of these encounters is giving insight on ways hospice team members can improve collaboration and overall patient care. This session will share the first year experiences and findings of this intervention. The videoconferencing technology will be demonstrated and anonymized videotapes of actual team encounters will be shared, illustrating the potential impact of caregiver participation. Finally, participants will be asked to reflect on the feasibility and impact of this intervention on their individual hospice teams, helping the research team explore the translation issues of the intervention into the larger hospice community.
Ketamine: Making Sense of Multiple Routes and Dosing Protocols (306) Eric Prommer, MD FAAHPM, Mayo Clinic, Phoenix, AZ. Andrew Wilcock, DM FRCP, University of Nottingham, Nottingham, UK. Robert Twycross, DM (Oxon) FRCP, Oxford University, Oxford, UK. (All authors listed above for this session have disclosed no relevant financial relationships with the following exception: Wilcock is a company
332
Schedule With Abstracts
director and shareholder with Palliativedrugs. com Ltd.) Objectives 1. Discuss how to use ketamine across multiple routes. 2. Identify optimal methods of ketamine administration. 3. Recognize the evidence base for the best methods and routes of administration associated with optimal analgesic outcomes. Ketamine is a dissociative anesthetic that has been used clinically for over 40 years and, when given at subanesthetic doses, is a potent analgesic. Ketamine interacts with nicotinic, muscarinic, and opioid receptors and is a noncompetitive NMDA receptor antagonist. The targeting of the NMDA receptor leads to reversal of opioid tolerance and central sensitization, common phenomena associated with neuropathic pain and difficult pain syndromes. Administration of ketamine is reported to reduce pain in patients with neuropathic pain of various origins, including postherpetic neuralgia, complex regional pain syndrome (CRPS), cancer pain, orofacial pain, and phantom limb pain. It is commercially available as injection solution containing a 1:1 racemic mixture of ketamine or the S-ketamine isomer. S-ketamine is approximately twice as potent in analgesia as the racemic mixture of ketamine. Ketamine can be administered by multiple routes including parenteral (intravenous, subcutaneous, and intramuscular), oral, topical, intranasal, and sublingual routes of administration. In addition to the multiple options that the clinician faces for administration, the method of administration may play a role in enhancing analgesic efficacy. The purpose of this session is to enable the practitioner to confidently prescribe ketamine across multiple routes and enhance their knowledge base as to the optimal methods of administration. The session will enable the attendee to (a) review the pharmacology, dosing, and adverse effects associated with ketamine use (S-ketamine use will be reviewed); (b) understand how to administer ketamine via unconventional routes; (c) identify dosing methods that have yielded the best clinical trial data for efficacy; and (d) understand the evidence base for the best methods and routes of administration associated with optimal analgesic outcomes.
Vol. 43 No. 2 February 2012
Management of Distressing Non-Pain Symptoms in Pediatric End-of-Life Care (307) Stefan Friedrichsdorf, MD, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN. (Friedrichsdorf has disclosed no relevant financial relationships.) Objectives 1. Review the epidemiology and prevalence of distressing symptoms during pediatric palliative and end-of-life care. 2. Discuss the current evidence of integrative and pharmacological therapies to manage nausea, vomiting, dyspnea, and noisy breathing. 3. Evaluate a step-by-step approach using supportive, integrative non-pharmacological and pharmacological therapies to manage nausea, vomiting, dyspnea, and noisy breathing in pediatric palliative and end-of-life care. More than 15,000 infants, children, and adolescents are dying each year in the U.S. due to a life-limiting condition, the majority to nonmalignant diseases. A large number of those children suffer from distressing symptoms in their last week of life. In order for a family and the pediatric patient to embrace psycho-socialspiritual dimensions of death and dying it might be paramount for pediatric palliative care to ensure excellent pain and symptom management. This session will review the existing evidence of successfully managing nausea and vomiting, dyspnea, and noisy breathing in pediatric hospice and palliative care. At the end of this session, participants will be able to formulate a systematic approach in evaluating and managing nausea and vomiting. A rational integrative (including acupressure, self-hypnosis, imagery, music therapy, and aromatherapy) and pharmacological (including 5-HT3-, D2-, H1-, AChm-, NK1-receptor antagonists, cannabinoids, corticosteroids, benzodiazepines, and low-dose propofol) approach will be discussed. A step-by-step approach in the management of dyspnea using pharmacological (including review of evidence regarding oxygen versus opioid and benzodiazepine administration) as well as supportive and integrative, non-pharmacological treatment modalities (such as a fan or breathing exercises) will be developed.
Schedule With Abstracts
Continuing Education in Nursing: Continuing Competence for the Future. The task force culminated its work in ‘‘The Statement on Continuing Competence for Nursing.’’ The Statement includes a crosswalk between core competencies set forth in Nursing: Scope and Standards of Practice (American Nurses Association, 2010) and the Hospice and Palliative Nurses Association (HPNA)’s Competence Topics for RNs and APRNs. In partnership with the American Board of Nurse Specialties (ABNS) and Accreditation Board for Specialty Nursing Certification (ABNSC), the task force continues to explore uses of its Statement to further the ABNS Research Agenda, ABNS success markers, refinement of certification and recertification requirements, and other endeavors. This presentation describes the process that the task force employed and the product which it produced. The process included an extensive literature review and structured discussions during web-enhanced conference calls. The presentation invites dialogue about the use of the Statement in defining credentialing criteria and in exploring the concept of continuing competence in the practice of hospice and palliative care.
The Use of Video Technology for Caregiver Involvement in Interdisciplinary Hospice Teams: Preliminary Experiences From the ACTIVE Randomized Clinical Trial (305) Debra Parker Oliver, PhD MSW, University of Missouri, Columbia, MO. George Demiris, PhD, University of Washington, Seattle, WA. Elaine Wittenberg-Lyles, PhD, University of Kentucky, Lexington, KY. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Identify the benefits and challenges of caregiver participation in hospice team meetings. 2. Discuss the preliminary findings of one study on caregiver participation. 3. Discuss the implications of caregiver participation on pain management in hospice patients. Licensing and certification agencies require hospices to convene an interdisciplinary team (IDT) at least every 14 days. The meeting’s
331
purpose is to bring together at least nurses, social workers, physicians, and chaplains to collaborate and develop a care plan. Despite the hospice philosophy of patients and family empowerment with decision making regarding their care, they are routinely absent from these meetings. This research team has designed an intervention using video technology to involve informal caregivers (and patients when they are able) in the hospice interdisciplinary team care plan meetings. A NIH funded, multisite, 4-year randomized controlled trial is being conducted to test the effects of the intervention. Using videoconferencing to connect the informal caregivers (and patients) to the hospice team, we have reduced their fears by addressing questions about pain medication and offering emotional support. This intervention has been named ACTIVE (Assessing Caregivers for Team Intervention through Video Encounters). Our preliminary results show that the intervention is not only feasible but that it holds promise to change caregiver perceptions of pain management and potentially reduce patient pain. Caregivers can and do talk freely to the hospice team about pain concerns and hospice staff members are positive about the intervention. Additionally, the preliminary observation of these encounters is giving insight on ways hospice team members can improve collaboration and overall patient care. This session will share the first year experiences and findings of this intervention. The videoconferencing technology will be demonstrated and anonymized videotapes of actual team encounters will be shared, illustrating the potential impact of caregiver participation. Finally, participants will be asked to reflect on the feasibility and impact of this intervention on their individual hospice teams, helping the research team explore the translation issues of the intervention into the larger hospice community.
Ketamine: Making Sense of Multiple Routes and Dosing Protocols (306) Eric Prommer, MD FAAHPM, Mayo Clinic, Phoenix, AZ. Andrew Wilcock, DM FRCP, University of Nottingham, Nottingham, UK. Robert Twycross, DM (Oxon) FRCP, Oxford University, Oxford, UK. (All authors listed above for this session have disclosed no relevant financial relationships with the following exception: Wilcock is a company
332
Schedule With Abstracts
director and shareholder with Palliativedrugs. com Ltd.) Objectives 1. Discuss how to use ketamine across multiple routes. 2. Identify optimal methods of ketamine administration. 3. Recognize the evidence base for the best methods and routes of administration associated with optimal analgesic outcomes. Ketamine is a dissociative anesthetic that has been used clinically for over 40 years and, when given at subanesthetic doses, is a potent analgesic. Ketamine interacts with nicotinic, muscarinic, and opioid receptors and is a noncompetitive NMDA receptor antagonist. The targeting of the NMDA receptor leads to reversal of opioid tolerance and central sensitization, common phenomena associated with neuropathic pain and difficult pain syndromes. Administration of ketamine is reported to reduce pain in patients with neuropathic pain of various origins, including postherpetic neuralgia, complex regional pain syndrome (CRPS), cancer pain, orofacial pain, and phantom limb pain. It is commercially available as injection solution containing a 1:1 racemic mixture of ketamine or the S-ketamine isomer. S-ketamine is approximately twice as potent in analgesia as the racemic mixture of ketamine. Ketamine can be administered by multiple routes including parenteral (intravenous, subcutaneous, and intramuscular), oral, topical, intranasal, and sublingual routes of administration. In addition to the multiple options that the clinician faces for administration, the method of administration may play a role in enhancing analgesic efficacy. The purpose of this session is to enable the practitioner to confidently prescribe ketamine across multiple routes and enhance their knowledge base as to the optimal methods of administration. The session will enable the attendee to (a) review the pharmacology, dosing, and adverse effects associated with ketamine use (S-ketamine use will be reviewed); (b) understand how to administer ketamine via unconventional routes; (c) identify dosing methods that have yielded the best clinical trial data for efficacy; and (d) understand the evidence base for the best methods and routes of administration associated with optimal analgesic outcomes.
Vol. 43 No. 2 February 2012
Management of Distressing Non-Pain Symptoms in Pediatric End-of-Life Care (307) Stefan Friedrichsdorf, MD, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN. (Friedrichsdorf has disclosed no relevant financial relationships.) Objectives 1. Review the epidemiology and prevalence of distressing symptoms during pediatric palliative and end-of-life care. 2. Discuss the current evidence of integrative and pharmacological therapies to manage nausea, vomiting, dyspnea, and noisy breathing. 3. Evaluate a step-by-step approach using supportive, integrative non-pharmacological and pharmacological therapies to manage nausea, vomiting, dyspnea, and noisy breathing in pediatric palliative and end-of-life care. More than 15,000 infants, children, and adolescents are dying each year in the U.S. due to a life-limiting condition, the majority to nonmalignant diseases. A large number of those children suffer from distressing symptoms in their last week of life. In order for a family and the pediatric patient to embrace psycho-socialspiritual dimensions of death and dying it might be paramount for pediatric palliative care to ensure excellent pain and symptom management. This session will review the existing evidence of successfully managing nausea and vomiting, dyspnea, and noisy breathing in pediatric hospice and palliative care. At the end of this session, participants will be able to formulate a systematic approach in evaluating and managing nausea and vomiting. A rational integrative (including acupressure, self-hypnosis, imagery, music therapy, and aromatherapy) and pharmacological (including 5-HT3-, D2-, H1-, AChm-, NK1-receptor antagonists, cannabinoids, corticosteroids, benzodiazepines, and low-dose propofol) approach will be discussed. A step-by-step approach in the management of dyspnea using pharmacological (including review of evidence regarding oxygen versus opioid and benzodiazepine administration) as well as supportive and integrative, non-pharmacological treatment modalities (such as a fan or breathing exercises) will be developed.