I. Course goals and objectives:

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1 Department: Internal Medicine Course: Palliative Care Sub-Internship Faculty Coordinator: Elizabeth Paulk, M.D. Hospital: Parkland Health & Hospital System Periods offered: all Length: one month Maximum number of students: 2 First Day Contact: Betsy Porter, RN-P (214) or (214) First Day Time: 9AM First Day Place: Palliative Care Office, located in the Hematology/Oncology clinic, which is on the second floor at Parkland I. Course goals and objectives: Purpose: To give medical students an opportunity to become proficient in the concepts and principles of palliative care, and to acquire the knowledge, skills and motivation necessary to do so. Comprehensive training will be provided in pain and symptom management, as well as psychosocial and spiritual support of patients and families facing life-threatening illnesses. Objectives: 1.) Understand the pathophysiology of pain and symptoms common at the end of life (e.g., nausea, dyspnea, anxiety, depression) 2.) Understand the pharmacologic management of pain and common symptoms, particularly the appropriate use of opioid medications. 3.) Become familiar with the psychosocial issues facing patients and families at the end of life. 4.) Learn about hospice care: the history and philosophy, what services are provided, how it is paid for, and possible sites of care.

2 II. Structure: This rotation will include clinical and didactic activities Time Monday Tuesday Wednesday Thursday Friday 8 AM Get consult assignments, see patients Get consult assignments, see patients Clinic Clinic Get consult assignments, see patients noon 1 PM Round with McGregor or Palliative Care Lecture Round with Round with B. Porter and Lecture dates: 1 st & 2 nd Tuesdays lecture in conference room, Oncology clinic 3 rd Tuesday Learner presentations on topics of interest 4 th Tuesday Palliative Care Journal Club, 8 th floor, Sprague Building 2 nd Friday Evidence Based Palliative Medicine conference 4 th Friday Patient Safety Conference Round with B. Porter and Palliative Care conferences Round with B. Porter and III. Duties: You will typically see patients in the morning and round with an attending in the afternoon. Wednesday and Thursday are clinic days in which you will participate in seeing both new and established patients in the 2 nd floor clinic. After clinic you will see your floor patients and round with the attending. You will be expected to see new consults and follow established patients in the hospital. For established patients as a courtesy to the primary team it is typical to page the team and let them know this patient is known to the palliative care service and ask if there are any acute palliative care needs. As part of a new consult the team will discuss end of life issues such as code status and medical power of attorney. You should obtain all information necessary for the consult but wait for the attending to initiate discussion about code status unless otherwise directed to do so. Please have notes completed by 1pm. Please plan on being at work each day by 8AM, and working until 5pm. If you are going to be late or absent, please contact Sigy, DO, Betsy Porter, RN-P, or Eileen McMenemy, RN at the numbers below.

3 Quick Guide to Palliative Care Welcome to the Palliative Care service. We are very happy to have you with us, and hope that this will be both a valuable and rewarding learning experience for you. This document will provide you with instructions to help you get the most out of your time with us, whether it be just a few days or an entire month. Important Concepts in Palliative Care What is Palliative Care? Palliative Care is a branch of medicine that focuses on symptom management rather than treatment or cure of specific diseases. Common symptoms we address are pain, nausea/vomiting, constipation or diarrhea, problems with appetite, difficulty sleeping, and mood. As most patients and families are typically unfamiliar with Palliative Care services, it may be helpful to introduce yourself as a member of the palliative care team and to ask the patient if they are familiar with Palliative Care (most are not and are often relieved and thankful when they find out what you are there for---not everyone, but often this is the case). Sometimes it may be helpful to describe palliative care as making symptoms feel better even if we re not able to cure the causes for them. Remember, these patients typically see numerous doctors from multiple specialties and the inpatient experience is a strange one to comprehend when one is not familiar with the mini-world that is the hospital. A hospital is like a foreign country with its own language and customs and particularly as your focus is on symptom management and help through a terminal illness, often simply explaining who you are and what your team does is a relief and help to the patient and their family members. What is Hospice? a type of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments; the goal is to improve quality of life. The modern hospice movement started in 1960 in Britain by Dame Cicely Saunders who established St. Christopher's Hospice near London. Hospice came to America in 1974 when the first was established in New Haven, Connecticut. When is a patient eligible for hospice? two physicians must sign a document stating that the individual has a life-limiting illness and patients with similar conditions have been known not to live longer than six months. A patient may continue to receive hospice services if they live beyond six months and a patient may discontinue hospice services if their condition improves and resume at a later time. DNR status is NOT required. Who is eligible for hospice? anyone is eligible regardless of age, financial status, or citizenship o Funding status does affect timeline for obtaining hospice, if someone has private insurance, Medicare or Medicaid, multiple hospice options are available to them.

4 If a patient is unfunded they qualify for charity hospice which typically has a wait time of 4-6 weeks. check funding in the facesheet in EPIC Parkland Health Plus does NOT cover hospice What does hospice entail? typically a nurse will come visit the patient at home once or twice a week and the patient and family have access to 24 hr a day advice via telephone. Nurses help teach the family how to care for their loved one in their own home. Hospice is NOT 24-hour a day nursing care, however part of hospice is crisis care in which a patient may qualify for around-the-clock care for a limited time (typically 5 days). What kinds of services are available through hospice? typically hospice employs nurses, doctors, social workers, psychologists/psychiatrists, and chaplains. Patients can get their medicines through hospice and can get medical equipment such as a hospital bed, oxygen, wheelchairs, etc.. What services can a patient not get on hospice? patients do not usually get IV medications or IV hydration. A patient can go to the ER and remain on hospice so long as the patient/family get agreement from the hospice agency (ie if it is in the plan of care) and they are advised to take the patient to the ER. If a patient goes to the ER without consulting the hospice agency they may have to revoke from and then reapply for hospice during their hospital stay. Where can a patient receive hospice services? patients may receive hospice at home, in a nursing facility, or in some hospitals. If a patient is not funded it is unlikely they will qualify for hospice at a nursing home; they must have family members or friends to help care for them 24 hrs a day. There is one inpatient hospice facility in Dallas, and it is typically not available to unfunded patients, though there are some exceptions. Pharmacotherapy in Palliative Care In considering appropriate therapies for patients when treating symptoms like pain, nausea, constipation, difficulty sleeping, anxiety, depression, etc. it is particularly important to consider the following: o What route of administration is appropriate in a given seting? As IV medication is not generally available outside of the hospital it is important to consider if your patient is able to swallow pills, able to swallow liquids, has a feeding tube by which medication can be administered, or if a transdermal route is best o Renal function certain medications will need adjustment in dosing (gabapentin for example), other medications can be avoided if an appropriate substitute is available (morphine, NSAIDs) o Hepatic function if a patient has significant liver damage avoid products containing acetaminophen whenever possible i.e don t forget that norco and lortab contain acetaminophen and if a patient is taking them around the clock this isn t helping their liver. o Allergies always ask what the patient s reaction was to a particular drug as certain things one must avoid and others can be worked with (i.e. nausea/vomiting, rashes)

5 Pain Control It is critical in the evaluation of a patient to determine the characteristics of their pain so that appropriate pharmacology may be applied to each individual situation. Early in your rotation you will receive information on pain control from Carol Chamberlain, one of the pharmacists at Parkland who specializes in the treatment of pain. Neuropathic pain Nociceptive pain Visceral pain Psychogenic pain Nausea and Vomiting Like pain control, determine as best you can the characteristics of your patient s nausea. Is it motion based? i.e. worse when they move their head? Is it central? i.e. worse when they think about chemo/food, is there something exerting a mass effect in their brain? (tumor or mets breast cancer, lung cancer commonly have brain mets) Do they experience heartburn concurrently with nausea? underlying GERD that is not being treated Do they have an underlying potentially treatable condition causing their nausea? gastric outlet obstruction, bowel obstruction, gastroparesis, gastroenteritis, constipation, etc. Always remember that if a patient is vomiting, prescribing something that they take orally is not likely to be very effective if they simply throw it up. Many antiemetics can be prescribed IV in the hospital or PR (per rectum) in an outpatient setting. If they are not able to ingest pills, the scopolamine patch may be an option. It can cause dry mouth which can be intensified if the patient is taking anticholinergics or high dose opioid pain medication concurrently. Dry mouth may be alleviated by increasing oral care/sips/ice chips or the addition of hard candy or artificial saliva products. Anxiety/Agitation A key thing to try and determine is what the source of the anxiety/agitation may be. Certain medications can increase agitation in elderly patients ie., steroids, benzos, anticholinergics, so a careful review of the patient s medication list is critical (i.e. are they being given Benadryl, ativan, etc). On the other hand, a common reason for anxiety/agitation can be a sudden cessation of a medication or substance (ie alcohol) that the patient may no longer have access to. An alternative to benzodiazepines is low-dose haloperidol, and is preferred over benzos if the patient is disoriented. If a patient has had a prolonged hospitalization and is likely to be in-house for a week or more, consider offering a psychology consult as an option to the patient. Constipation Patients on opioid pain medication will commonly become constipated if not treated prophylactically with a stool softener and addition of a laxative when needed. Look at the dose of pain medication in oral morphine equivalents that a patient is taking and look at the amount of colace they are taking---if a patient is on 500 OME, 100 BID of colace probably isn t going to cut it. Often patients will be on senna/colace combination therapy but if they are

6 still not having regular bowel movements, addition of lactulose (prescription) or miralax (over the counter) may be appropriate. If a patient comes to the hospital having gone without a bowel movement for more than 4-5 days then the time to consider therapy from below enemas/suppositories is sooner rather than later. Constipation can be a source of pain and nausea and it is a mostly avoidable situation. Resources - contains short, easily digestible one page summaries of most major issues in Hospice and Palliative Medicine EPIC Tips On the first day of your rotation, please prompt Paulk to give you access to the shared Palliative Care list. The Login context for clinic is Onc Palliative Care and for consults is SA Med. The important smart phrases to know are:.palliconsult for consults, and.palliclinic for clinic notes. Each includes a template that will prompt you to address the most significant Palliative Care issues. Please DO NOT use the computer in the Palliative Care office unless specifically asked to do so. We love you but the office is very small! Contact Information Name Role Cell Pager Office Elizabeth Paulk Medical (214) * (214) Director Sigy Faculty Physician (954) * (214) Tamara Faculty (214) (214) McGregor Physician Betsy Porter Nurse (817) * 3656 (214) Practitioner Eileen RN Case (214) * McMenemy Manager Amanda Daniel Social Worker 1150 (214) * Carol Pain PharmD 0190 Chamberlain Stacey Merlin Chaplain 0272 (214) Karen Jones Clerk (214) Donald Cochran Fellow 6820 Daniel Ahn Fellow 9776 *Preferred mode of communication

Be comfortable with comfort Meds

DIAMOND PHARMACY SERVICES Be comfortable with comfort Meds Understanding Hospice medications Presented By: Daniel Barnes, RN Infusion RN Annual Educational Conference Thursday, April 16, 2015 1 Diamond