A Specialist Palliative Pharmacist Enriches the Interdisciplinary Team: A Case Series Discussion Illustrating the Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists.

Introduction: Palliative care (PC) pharmacists are an integral member of the PC team. Essential roles have been defined and entrustable professional activities (EPAs) have been recently developed for hospice and PC pharmacists. Case Description: We review four different complex patient cases where the specialist PC pharmacist worked with the interdisciplinary team to address whole patient suffering. Through the case series, we highlight the various components of HAPC pharmacist EPAs across the continuum of care. Case Management, Outcome, and Conclusion: Through the case series discussion, we brought to light PC pharmacists' EPAs in pharmacotherapy consultation, assessing and optimizing medication therapy, symptom management, deprescribing, participating in goals-of-care discussions, managing medication therapy in the withdrawal of life-sustaining therapy in collaboration with interdisciplinary team in alignment with patient and family values, prognosis, and plan of care. We also emphasized the importance of PC pharmacists contributing to the advancement of science.

Improving access to palliative care clinical pastoral education.

Palliative care is interprofessional care for seriously ill people. Many clergy, religious leaders, and hospice and palliative care chaplains of color and minority religious backgrounds desire clinical palliative care education. This manuscript presents findings from a three-year quality improvement project which included the development of a palliative care specialty ACPE: The Standard for Spiritual Care and Education (ACPE) accredited program at an academic medical center. The program was designed to improve spiritual care provision in palliative care at the institution and to facilitate the participation of clergy and spiritual leaders of color and minority religious groups. Forty-six students participated in 53 400-h clinical pastoral education units. Strategies from medical education literature were employed to address obstacles to CPE participation including a racially and religiously diverse CPE advisory group, financial assistance, flexible learning (e.g. hybrid, asynchronous), and clinical placement agreements at places of employment. Upon completion of the program students provided written feedback, participated in a structured exit interview and completed a survey. Data were reviewed for common themes and results report student perceptions about the strategies utilized.

Comparing National Methadone Equianalgesic Tools.

Methadone is an effective analgesic with unique pharmacokinetic and pharmacodynamic variables. There is no national consensus on methadone equianalgesia tools. Our study aimed to compare methadone equianalgesic tools from various national institutions with the primary objective to summarize current practice and secondary objective to determine if a national consensus can be established. Out of 25 institutional methadone equianalgesic tools reviewed, 18 contained sufficient data and were included in this study. Fifteen (15) of the institution evaluated tools utilized a wide variety of dose-dependent modalities for methadone conversion with the hospice and palliative care (HAPC) Consensus method being the most common. Based on the variability of the equianalgesia tools evaluated in this study, we were unable to recommend a consensus methadone conversion method. Further trials exploring methadone equianalgesia beyond our study are needed.

A National Survey of Institutional Guidelines for the Use of Ketamine, Lidocaine, and Dexmedetomidine for Refractory Pain.

Background: Although opioids are used first line for cancer pain and commonly for complex noncancer pain, there are risks associated with their use and not effective for all types of pain. There's a need to identify and develop clinical practice guidelines for nonopioids for the treatment of refractory pain. Methods: Our study collected information from national clinical practice guidelines for ketamine, lidocaine, and dexmedetomidine with the aim to identify consensus among the different practices. Results: Fifteen institutions nationally participated in the study and only nine of those institutions had guidelines and were permitted by their health system to share them. Of the institutions that participated, 44% had guidelines for ketamine and lidocaine, and only two institutions (22%) had guidelines for ketamine, lidocaine, and dexmedetomidine for refractory pain. There were variations in restriction of the level of care and prescribers, dosing, and determination of efficacy. There were trends of consensus in monitoring for side effects. Conclusion: This study serves as a starting point for a snapshot of the use of ketamine, lidocaine, and dexmedetomidine for refractory pain, but further studies and increased participation of institutions are needed to develop consensus clinical practice guidelines.

Chlorpromazine's Potential Role in Palliating Distressing Symptoms Associated With Hyperactive Delirium in Patients at End of Life.

Background: The hyperactive subtype of delirium is characterized by agitation, restlessness, delusions, and/or hallucinations, which commonly present near end of life (EoL). Symptom relief often requires the use of medications, such as chlorpromazine (CPZ), to reduce patient distress by inducing proportional sedation. Objective: The purpose of this study was to evaluate CPZ's potential role in managing the distress of hyperactive delirium in patients receiving EoL care. Methods: A retrospective observational study among hospitalized patients with advanced cancer at EoL between January 2020 to December 2021. Results: Sustained improvement in symptoms of delirium was seen in 80% of patients as identified in the palliative psychiatrist's progress notes. Meanwhile, 75% of patient's improvement was reported in nursing-driven Delirium Observation Screening Scale. Conclusion: This study elucidates that at doses of ∼100 mg/day, CPZ is potentially an effective medication for patients with advanced cancer, experiencing hyperactive delirium in their final week of life.

Dexmedetomidine Continuous Infusion for Refractory Cancer Pain at End of Life: A Case Report.

Refractory cancer-related pain at end-of-life (EoL) is multifaceted and may require utilizing medications with different mechanism of actions beyond opioids. We report the successful use of dexmedetomidine in a 63-year old female with recurrent breast cancer and intractable left arm pain and swelling admitted to University of California, San Diego, Health (UC San Diego Health), palliative care unit. Patient's pain and agitation continued to persist and she declined clinically despite efforts to start methadone, continuous infusion opioids, continuous infusion lidocaine and intravenous chlorpromazine by the palliative care team. On hospital day (HD) 11 patient was started on dexmedetomidine continuous infusion for refractory pain per our protocol at UC San Diego Health. The next day the patient appeared much improved in terms of pain and agitation with grimacing and moaning completely resolved. She was able to have some lucid periods and interacting with her family. With the addition of dexmedetomidine to her pain regiment, the patient was able to peacefully die 5 days later. This case report highlights the clinical utility of demedetomidine in a palliative care unit for refractory pain at EoL.

A Comparison of Institutional Opioid Equianalgesia Tools: A National Study.

Context: Equianalgesic tools are commonly utilized to guide dose of analgesic therapy, but there is no national consensus on equianalgesic calculations in the United States. Objectives: To propose a summary of current opioid equianalgesic data that include variations and trends among national institutions. Methods: Opioid equianalgesic tools were obtained between May and September 2021. For meperidine, tramadol, codeine, hydrocodone, morphine, oxycodone, oxymorphone, hydromorphone, levorphanol, fentanyl, and tapentadol, details of adjustment for incomplete tolerance, opioid equianalgesic ratios, and formulation types were collected and analyzed. Baseline opioid pharmaco kinetic data were obtained through manufacturer labels on FDA databases, including half-life (T1/2), volume of distribution (Vd), clearance (Cl), area under the curve (AUC), max concentration (Cmax), and time to max concentration (Tmax). Results: Thirty-two institutions' equianalgesic tools were included with each study opioid appearing on an average of 23 institutions' tools. Few tools contained guidance on levorphanol or tapentadol; or included minimum and maximum recommended doses. All tools included guidance on fentanyl, hydromorphone, oxycodone, morphine, and hydrocodone. A minority of tools included guidance on cross-tolerance considerations (n = 12, 37.5%). Oral-tramadol-to-oral-morphine and oral-hydromorphone-to-intravenous (IV)-hydromorphone had the largest variances across equianalgesic tools (6.7 ± 2.8 and 4.06 ± 1.2 mg, respectively). Conclusion: Opioid equianalgesia tools from across the United States demonstrated significant variation in their inclusion of guidance on adjustment for incomplete cross-tolerance, oral-to-IV, and oral-to-oral opioid equianalgesic ratios, and which opioids and formulations were listed. Tramadol and hydromorphone had the most variation in their equianalgesic guidance among the opioids.

A Case Report of Phenobarbital for Proportionate Sedation to Control Refractory Symptoms at the End of Life in an Opioid Tolerant Patient.

End of life (EoL) and refractory symptom management is a growing clinical topic and there is minimal literature to support effective treatment strategies, especially in individuals with a substance use disorder or opioids and/or benzodiazepine tolerance. We report the successful use of phenobarbital for proportionate EoL sedation in a 57-year-old man with opioid use disorder (heroin) and metastatic urothelial carcinoma presenting to an acute care hospital with intractable back pain related to bone metastases. During his hospitalization, his daily opioid requirement exceeded 1 gram of morphine equivalent daily dose (MEDD) with suboptimal pain control. The patient's clinical course was complicated by active heroin withdrawal, psychosocial suffering, and disease progression. Despite use of high-dose opioids and benzodiazepines, pain and anxiety were poorly controlled. After an acute medical decompensation, a goals of care discussion was held with his family and a determination with informed consent was made to change patient status to do not attempt resuscitation and proportionate sedation with phenobarbital was initiated to target refractory pain and agitation. Phenobarbital was continued for approximately 15 hours before patient peacefully died. Findings from this case report demonstrate the successful use of phenobarbital in opioid use disorder and benzodiazepine tolerance with intractable pain.

An Exploratory Study of Demographics and Outcomes for Patients Seen by Specialist Palliative Care Social Work in the Inpatient Setting at an Academic Medical Center.

CONTEXT: Specialist palliative care social work (PCSW) across a four-team palliative care (PC) service in the inpatient setting at a tertiary academic medical center. OBJECTIVES: to describe the population of patients seen by inpatient PCSW, quantification of the involvement of PCSW in PC consultations, as well as comparisons of patient characteristics for those seen by PCSW and the overall population seen by the PC team. METHODS: Retrospective chart review of patients admitted to a tertiary academic medical center between January, 1 2015 and October 31, 2019 who received a PC consult. RESULTS: Over the study period, PCSW saw 2,381 out of the 4907 patients seen by the palliative care teams for a PCSW penetration rate of 52% with an 83% increase in the percent of consults seen by PCSW and a 133% increase in PCSW staffing over the study period. Compared to all PC consults, when PCSW was involved in the case, the LOS is longer (average 15.6d vs. 14.4d; P = 0.0062); goals of care are more likely to be addressed (90.7% vs. 87.4%, P = 0.004); dyspnea was more likely to improve (43.3% vs. 31.9%, P = 0.018) and pain was less likely to improve (28.2% vs. 49.4%, P < 0.001). CONCLUSION: Involvement of PCSW increased dramatically over the study period. Compared to the rest of the PC team, when PCSW was involved, length of stay was longer, whole-person care components were more likely to be addressed, dyspnea was significantly improved, and pain was significantly worse when compared to those consults not seen by PCSW. Other symptoms such as nausea and anxiety as well as discharge characteristics such as death or hospice discharge were not significantly different with involvement of PCSW.

Clinical Tolerability and Safety of Tramadol in Hospitalized Patients.

Tramadol is a schedule IV, monoaminergic and µ-opioid-receptor analgesic with unique pharmacology properties. Though it is well established and widely utilized, there is little guidance on tramadol's place in therapy, including tolerability, safety and monitoring guidelines. Retrospective chart review of 250 patients who received oral tramadol during their hospitalization from January 1, 2018 to December 31, 2018. Of the 250 patients, 10.8% had cancer as their primary diagnosis while 8.8% were admitted for hematologic reasons. 79.1% of patients had acute pain. Palliative care consult or ICU admission resulted in significant discontinuation of tramadol (p < 0.05 odds ratio 6.88, 2.39). There was no significant relationship of hypoglycemia when evaluating days on tramadol, total number of doses on tramadol, and MEDD start and end (p = 0.36, 0.88, 0.15, 0.23 consecutively). The longer that patients were on tramadol and the more doses they received during their inpatient stay, the greater risk of a severe drug-drug interaction (p < 0.05; R 0.29). In hospitalized patients, the risk of major and severe drug-drug interactions with tramadol increased with dose and duration. Hospital medicine, bone marrow transplant, and emergency medicine teams predominantly used tramadol.

Exploiting Technology to Popularize Goals-of-Care Conversations and Advance Care Planning.

BACKGROUND: Goals-of-care conversations are a central component of high-quality patient-centered care. However, clinicians may not engage in such conversations until patients are critically ill. OBJECTIVE: To assess the frequency and quality of goals-of-care conversation documentation among patients who died in an intensive care unit, and then to develop and implement mechanisms to improve the quantity and quality of such conversations. METHODS: A baseline retrospective medical records review of intensive care unit deaths that occurred within 1 year was conducted to assess the barriers to high-quality goals-of-care conversations. A nurse-led inter-professional task force was formed to address possible solutions. INTERVENTIONS: A new electronic health record tab, note type, and preformatted template known as a SmartPhrase for goals-of-care conversations were created. Nurses and physicians were educated and encouraged to perform and document goals-of-care conversations. RESULTS: Before implementation of the initiative, the electronic health record lacked a consistent place to document goals-of-care conversations, and such conversations were not occurring until patients required intensive care. Moreover, the content of documentation of the conversations was inconsistent. Three years after implementation of the initiative, the goals-of-care conversation documentation tab was used for 75% of hospital deaths, and 67% of goals-of-care conversation notes included use of the SmartPhrase template. CONCLUSIONS: Electronic health record platforms can be used to improve the frequency, consistency of documentation, and quality of goals-of-care conversations. A standardized process coupled with effective work tools can foster a culture of advance care planning.

A Multi-Centered Case Series Highlighting the Clinical Use and Dosing of Lidocaine and Mexiletine for Refractory Cancer Pain.

Lidocaine infusion for pain control has been used for years. While some centers transition from continuous infusion lidocaine to oral mexiletine, there are no published studies to guide this conversion in pain and palliative care settings. This is a retrospective case series of 10 cancer patients across four institutions, with attention to dosing of both agents, and subsequent decrease in morphine-equivalent daily dosing (MEDD). The mean age was 55 years (range 34-78). The mean bolus dose of lidocaine was 1.6 mg/kg, infused over an average of 24 minutes, followed by a mean continuous infusion rate of 1.1 mg/kg/hr, and the infusion was continued for an average of 14.1 hours (range of 0.2 - 28 hours). The mean starting daily mexiletine dose was 400 mg (in 2-3 divided doses) and final dosing averaged 500 mg/day. The mean MEDD prior to starting lidocaine was 1118 mg/24 hours, which, by the time of final mexiletine dosing, was 882 mg/24 hours, a 21% MEDD reduction. The average hospital length of stay was 14 days. There was no lidocaine-induced toxicity and no lidocaine levels were obtained. Two of the 10 patients stopped mexiletine early, one from confusion four days after initiation of mexiletine, and the other after six weeks due to dizziness and visual changes. For cancer patients with suboptimal pain control on large doses of opioid, lidocaine infusion followed by oral mexiletine was well tolerated and effective.

Characteristics of Hospitalized Patients Screening Positive for Delirium.

BACKGROUND: Delirium in the hospitals leads to worse outcomes for patients. There were no previous studies that characterize patients with delirium from multiple hospital locations. OBJECTIVE: To describe patient characteristics screening positive for delirium and identify any correlations with hospital location and medication use. DESIGN, SETTINGS, PATIENTS: Retrospective chart review of 227 hospitalized patients from a large, academic, tertiary referral, 2-campus health system. Patients were ≥18 years old and had delirium for at least ≥24 hours. Validated delirium screening tools were utilized. MEASUREMENTS: Patients' demographics, inpatient stay information, delirium episodes characteristics, drugs, and palliative and psychiatry teams' involvement. RESULTS: Most patients were older with a mean age of 64.1 years. The most common primary diagnoses were infection, cardiac, and pulmonary. Average length of delirium was 7.2 days (standard deviation [SD] = 8.2), and average length of stay (LOS) was 18.7 days (median = 10.5, SD = 35.1, 95% confidence interval = 14.1-23). Thirty-day readmission rate was 24.8% (65/262 hospitalizations); 12.8% of patients died in the hospital (29/227). Around one-third of hospitalizations had involvement of palliative care, palliative psychiatry, or general psychiatry team. There was a decrease in the number of medications administered 24 hours after the first recording of delirium compared to the immediate preceding 48 hours. Those hospitalizations where delirium first occurred in the intensive care unit (ICU) did have a longer LOS (average = 22.9, SD = 45.7) than those where delirium first occurred outside the ICU (average = 14.8, SD = 20.5). Patients were likely to have received an opioid within 48 hours in 51% of hospitalizations and to have received benzodiazepines in 16% of hospitalizations. CONCLUSION: In our study, we found that delirium significantly impacted length of delirium episode, number of episodes of delirium, length of hospital admission, and mortality. The population most sensitive to the impacts of delirium were elderly patients.

Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations.

Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.

Do We Know What We Mean? An Examination of the Use of the Phrase "Goals of Care" in the Literature.

Background: There is no consensus approach to describe the process or components of goals of care (GOC) conversations. Objective: The objective was to review the utilization of the phrase "GOC" in PubMed-indexed literature to contextualize the use of the phrase. Secondary aim was to describe the use of this phrase within journals focused on palliative care. Methods: A review of articles in the PubMed-indexed literature published during a single year utilizing the phrase "goals of care." Results: A total of 191 articles were reviewed after exclusions. Few articles included an operant definition for GOC (n = 27, 14%). It was often used to describe conversations focused on determining intent for treatment (n = 57, 30%), talks about death or dying (n = 52, 27%), or simply vague discussions (n = 39, 20%). The agenda was focused on the outcomes of the conversation (n = 169, 88%) compared with factors such as hopes, worries, values, and personhood (n = 22, 12%). The majority did not utilize the phrase "palliative care" (n = 77, 40%); those who did frequently used "palliative care" incorrectly (n = 72, 38%). Conclusions: The definition of the phrase GOC is most often assumed with its context centered on the needs of the health care system and linked to a specific medical topic. It is most commonly used to describe determinations of the patient's therapy intent, second most commonly to describe end-of-life conversations. The use of the phrase GOC within the palliative literature does not differ notably from its use in the broader literature.

Results of a Naloxone Screening Quality-Improvement Project in an Academic Emergency Department.

BACKGROUND: The Emergency Department (ED) is a medical setting increasingly utilized by opioid users. In January 2016, our health system initiated a take-home naloxone education and distribution program. From July to August 2016, screening was performed in the ED to identify patients for take-home naloxone. OBJECTIVE: To evaluate the outcomes of routine screening for take-home naloxone in the ED setting and to determine key screening questions. Secondary analysis of Electronic Health Records for discrete elements that could help identify individuals for naloxone. METHODS: This is a single-center, retrospective cohort study conducted at two EDs within an academic health system. A screening tool was verbally administered to a convenience sample of ED patients as part of a pilot project to identify patients for overdose education and naloxone. Patient charts were reviewed retrospectively for pre-determined historical elements, medications prescribed, and substance use history. Descriptive and comparative analysis using Fisher two-tailed tests were performed with regard to historical elements, naloxone recommendation and prescription. RESULTS: A total of 182 patients were included. Following screening, 58 (31.9%) were identified as candidates for take-home naloxone. Of those, 36 (62.1%) accepted naloxone recommendation and 19 (32.8%) were prescribed naloxone. Individuals not prescribed naloxone despite recommendation either declined naloxone 22 (37.9%) or were not prescribed naloxone 17 (29.3%). Subanalysis of questions with binary yes/no answers (N = 171) demonstrated significant prediction of both naloxone recommendation (ROC = 0.944) and prescription (ROC = 0.897). CONCLUSIONS: Routine screening for take-home naloxone can help identify patients at-risk for opioid overdose and increase naloxone access in the ED.

Feasibility and Effectiveness of a Mnemonic Approach to Teach Residents How to Assess Goals of Care.

Background: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together. There is an imperative to teach young physicians early in their training the importance of engaging in a shared decision-making process to define overall goals of care (GOC). The PERSON mnemonic proposes a structured format that allows providers to evaluate GOC across the spectrum of serious illnesses, outside of breaking bad news or end-of-life planning. Objectives: This study evaluated the utility of the PERSON mnemonic in training residents to have GOC with their patients, and investigated if these skills translated to the bedside with real patient encounters. Methods: First-year residents were divided into groups to participate in an in-depth education session. A pre-/postbaseline survey was administered immediately after the education intervention and approximately seven months later to assess retention and utility. Results: Thirty first-year residents were eligible for this study; 30 attended the educational sessions and completed the immediate baseline pre-/postsurvey and the seven-month follow-up survey, resulting in 100% retention rate throughout study. Residents found sustained utility in the mnemonic. It was significantly successful in increasing the knowledge and confidence level in exploring GOC. Patient-centered outcomes could not be analyzed due to low response rates and limited granularity of hospital-level data. Conclusion: The PERSON mnemonic is a feasible and useful format for teaching residents how to have a GOC discussion.

Identifying Patterns of Delirium in Hospitalized Patients on Dexamethasone Using a Chart Abstraction Tool.

Delirium is a neuropsychiatric syndrome that can occur in hospitalized patients, including in palliative care settings. The aim of this study is to describe patterns of delirium in patients receiving dexamethasone at the request of an inpatient palliative consultation team by using a modified chart abstraction tool. This retrospective study analyzed patterns of delirium development in adult hospitalized patients receiving opioids for cancer-related pain and initiated on dexamethasone with recommendation from the palliative care team. Primary end point described patterns of delirium, and the study secondarily analyzed source delirium documentation, Glasgow Coma Scale score, Richmond Agitation-Sedation Scale score, and Eastern Cooperative Oncology Group Performance pre- and post-dexamethasone administration. A total 59 patients were included in this retrospective chart review. There was no difference in delirium rate during the pre- and post-dexamethasone periods (n = 35 and 31, respectively; P = .62). There also were no significant differences in mental status, agitation, or functional status before or after dexamethasone, although data were limited by electronic health record incompleteness. Evidence of delirium was most commonly documented in physician notes (n = 58, 71%). The findings showed that incidence and severity of delirium were not impacted after patients were started on dexamethasone as recommended by an inpatient palliative team, although data were limited.