Episode 35 - Palliative Care and Hospice - a podcast by Rio Bravo Family Medicine Residency Program

Episode 35: Palliative Care and Hospice. 

COVID-19 vaccines and USPSTF recommendations. Palliative care and hospice briefly explained by Dr Tu. Pyogenic granuloma is defined. Feliz Navidad, and jokes.

 

Hepatitis B screening in adolescents and adults

First, on December 15, 2020, the USPSTF recommended to offer screening for Hepatitis B virus infection to all adolescents and adults at increased risk for infection, regardless of their immunization status[1]. Some examples of patients at increased risk are:

Those coming from countries with HepB prevalence above 2% (for example, most countries in Africa and Southeast Asia, South Korea, Italy, Colombia, Ecuador, and Peru, among others). 

Also, US-born children if they did not receive the HepB vaccine as infants AND their parents come from countries with a prevalence above 8% (check the list online).

Other groups include: IV drug users, MSM, HIV, even household contacts of persons known to have POSITIVE HepB surface antigen. 

Remember to order the right test for screening: HepB surface antigen. As a reminder, Hep B screening in pregnant women at the first prenatal visit is a USPSTF “A” recommendation. 

Screening for high blood pressure in children and adolescents

On November 10, 2020, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. This is a Grade I recommendation[2]. When screening, clinicians should consider risk factors, such as obesity, family history of hypertension, and ethnicities such as African-American or Hispanic. The grade I recommendation means that more research is needed. Maybe you guys can use that as a research idea.

Announcement of Coronavirus Vaccines

On December 11, 2020, the FDA granted an Emergency Use Authorization for tozinameran or the BNT162b2 vaccine, manufactured by Pfizer-BioNtech, becoming the first coronavirus vaccine approved in the USA. A week later, on December 18, 2020, the mRNA-1273 vaccine, manufactured by Moderna, was also approved for emergency use. The two vaccines are being administered as we speak to front-line health care providers across the nation. The two vaccines have an efficacy above 90%, and consist of two doses: 3 weeks apart for Pfizer, and 4 weeks apart for Moderna. They seem to reduce the risk of severe COVID-19.

Reported side effects include: injection site pain, fatigue, headache, muscle pain, and joint pain. Some people may experience fever. Side effects are more common after the second dose; younger adults, who have more robust immune systems, reported more side effects than older adults. Staggering vaccinations among staff is recommended.

The vaccines have not been tested in children or pregnant women yet. The American College of Obstetricians and Gynecologists (ACOG), recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups. ACOG recommends that pregnant individuals should be free to make their own decision in conjunction with their clinical care team. 

Efforts across the globe are being made to find a vaccine and medications to treat COVID-19. Sputnik V was a vaccine created in Russia and being distributed in allied countries; the Soberana 1 and Soberana 2 were created in Cuba and are under investigation; and in October, a “molecule” called DR-10 was announced in Venezuela that reportedly neutralizes 100% of SARs-CoV-2. There is so much to say about this topic, and the conversation may go beyond just science, but we invite you to follow the news from trustworthy sources as they continue to evolve. 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA and it is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

“You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”

Dame Cicely Mary Saunders

End-of life care may be challenging but also very rewarding. You get to take care of people during this critical time or their lives. Some people think it’s the end of a life, some people see it as a period of your existence, a passage to a “better life” or whatever your belief is about it. As doctor, we consider seriously the principle of sanctity of life vs quality of life.  Today, we have Dr Tu, who previously talked about wound care, and now he comes with a new topic to discuss. Welcome again Dr Tu.

1.  Question #1: Who are you?

 

Presently I am a second-year family medicine resident.  And I recently finished my palliative care-hospice elective 2 weeks ago with Dr. Warren Wisnoff.  And I had a wonderful and full of learning experience during this rotation.  And I really want to share some of those experiences with you.

 

2.  Question #3: What did you learn this week?

 

Just like what I said I recently finished my elective KM with Dr. Wisnoff for palliative care and hospice.  I learned the difference between palliative care and hospice and the different services that are involved in this specialty. Palliative care and hospice service also known as end-of-life care and focuses more on comfort care and quality of life.

 

Difference between palliative care and hospice  

 

I am not an expert on palliative care and hospice but based on my recent elective and previous experience working in hospice care as a registered nurse there are overlapping similarities but also significant differences in terms of services being offered in palliative care and hospice.

 

Palliative care

 

Palliative care service is not reimbursable under CMS regulation.  Palliative care focuses on improving quality of life for patients with serious illness in their families.  This approach may include providing relief from pain and or other distressing symptoms, integrating psychological and spiritual aspects of care, assisting with difficult decision making, and supporting patients and families.  

 

Another main difference of palliative care from hospice is specialty services that patient can still benefit from chemotherapy and other specialty visits.

 

History

 

The specialty of palliative medicine arose as a direct result of the hospice movement.  Palliative medicine incorporates the holistic care developed by hospice, focusing on symptom management, supporting and assisting with communication, and providing such care to avoid a group of patients including those who are not dying or who cannot receive or choose not to receive hospice services.  Palliative care aims to relieve suffering and no stages of disease and is not limited to end-of-life care.

 

Type of services offered by palliative care service

 

Assessment and treatment of physical symptoms most especially pain.  Around 80% of cancer patient patients will complain of severe pain.  Or patient will also complain of breathlessness especially patients with congestive heart failure.  Symptom assessment and management are necessary not only to provide diagnosis but also to help in controlling these symptoms.  The symptoms are a big burden to patient's quality of life and there are management available to address these symptoms.  Pain management is critical and cancer patient and opiate management in patients with breathlessness.

 

Psychological, social, cultural, and spiritual aspect of care. Attention to the psychological, social, cultural, and social needs of patients and families is an important part of good medical care.  Symptoms of depression, anxiety, social and financial stressors, and caregiver burden are, and serious illnesses.  Patient's and family's approach of serious illness, death, and dying, and spiritual needs are often heightened near the end of life.  All clinicians who care for patients with serious illness need basic skills to recognize and treat uncomplicated depression and anxiety, recommending appropriate social supports, and eliciting and respecting cultural traditions since with well preferences.

 

Serious illness communication skills.  Basic serious illness communication skills include communicating bad news, eliciting patient preferences, establishing goals of care, identifying a surrogate decision maker, deciding about future CPR and mechanical ventilation and providing emotional support.  These skills are required routinely in the care of seriously ill patients and should therefore be familiar to all clinicians who provide palliative care.

 

Care coordination.  Basic care coordination in serious illness means of ensuring the transfer between healthcare settings are timely and reflect patient/family needs and goals.  Primary team must also have basic knowledge about how to refer patients for hospice care.

 

 

Hospice care is a model and philosophy of care that focuses on providing palliative care to patients with life limiting illness, focusing on palliating patient's pain and other symptoms, attending to their and their family's emotional and spiritual needs and providing support for their caregivers.

 

Candidates for hospice

Hospice is appropriate when patients are entering the last week to months of life and patients and their families decide to forego disease modifying therapies with curative/life-prolonging intent in order to focus on maximizing comfort and quality of life.  In the United States guidelines from Medicare are available to help in the determination of terminal status for hospice qualification.  Commonly if the patient meets the indication for an estimate of 6-month life expectancy using a decline in clinical status.

 

The hospice team

 

Registered hospice nurse: Primary case manager and is responsible for skilled nursing care and coordination of other members of the interdisciplinary team.

 

Hospice physician: They have medical and administrative roles, they may be board-certified in the specialty of hospice and palliative medicine.  Some hospice physicians visit patients at home particularly if the patient does not have an involved attending physician.  Hospice physician also acts as a liaison with attending clinicians and can assist with symptom management.

 

Primary attending physician or referring physician: They are encouraged to remain involved in the care of their patients after referral to hospice, unfortunately for the continuity of the doctor-patient relationship, this does not occur often. Ideally, the primary attending physician works directly with the hospice nurse and also in collaboration with the hospice medical director to monitor symptoms in order intervention such as medications or skilled nursing care.

 

Social worker: They provide psychological support for patients and families including counseling, bereavement support, burial/funeral planning, and/or referrals to other support systems.

 

Chaplain: He or she oversees the spiritual needs of patients and families.  Spiritual care is offered to patients with both formal and unstructured religious beliefs.

 

Home health aides: Home health aides and other direct care workers help the patient and caregivers in the home, including personal care, food preparation, and shopping.

 

Bereavement counselors: They are available to provide support to bereave once of hospice patients for the 13 months after patients that.

 

Community volunteers: Volunteers are a mandatory component of hospice care and received training and support for their work. They will provide extra support for patients and families such as reading to patients, visiting, and assisting with errands.

 

 

Managing common symptoms during end-of-life care

Clinician should follow certain guiding principles when prescribing medication for symptoms management at the end of life.  Medication should be used to treat the primary etiology of these symptoms.  For example, if the patient is anxious because of shortness of breath, treatment should focus on the dyspnea to alleviate the primary symptom and the resulting anxiety.  Medication should generally start at lower doses a titrate up or down until you get desired effect.  The dosing should initially be as needed (prn) and then transition to a standing dosage or long-acting medication for symptom management. Whenever possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than treating an acute symptom.

 

Pain: It is a common symptom occurring in approximately 50% of person in the last month of life.  It is important to recognize the patient's total pain which includes not only physical symptoms but also the psychological, social, and spiritual components of distress. Some medications include fentanyl, hydromorphone, morphine, oxycodone, and hydrocodone.

 

Dyspnea: Although dyspnea is common in patients with end-stage pulmonary and cardiac disease, it is also regularly observed in patients with cancer, CVA, or dementia. Opiates are the medications of choice for the management of breathlessness and end-of-life care, especially morphine.

 

Delirium and agitation: Patients often experience delirium and agitation in the last days and weeks of life.  Symptoms that do not cause the patient distress can be managed conservatively without medication.  It is essential to assess reversible or treatable causes of delirium such as medication adverse effects, uncontrolled pain or discomfort, constipation, or urinary retention. Medications: antipsychotics such as haloperidol and risperidone are effective in the treatment of delirium and agitation at the end of life.  Dosing for delirium tends to be significantly lower than for psychosis and schizophrenia.  Benzodiazepine should be used with caution for the treatment of agitation and delirium because they can potentially provoke increased symptoms in older patients.  However, benzodiazepines can effectively treat anxiousness and agitation in the last hours and days of life because of the potentially sedating effects.

 

Nausea and vomiting: These are common symptoms during the end of life. Multiple receptor pathways in the brain and in the gastrointestinal tract mediate nausea and vomiting. Medications that target dopaminergic pathways are effective like haloperidol, risperidone, metoclopramide, and prochlorperazine.

 

 

Constipation: Effective management of constipation is critical because constipation can lead to pain, vomiting, restlessness, and delirium. Common causes of constipation are low oral intake of food and fluids and adverse effects of opiates. Medications: stimulant laxative like senna, stool softener like docusate, and polyethylene glycol.

 

Oropharyngeal secretions: It is common for patients to lose the ability to manage oropharyngeal secretions as they progressed through the dying process.  This can result in noisy breathing pattern, sometimes referred to as death rattle. Medications: hyoscyamine, atropine sulfate, glycopyrrolate, and scopolamine.

 

Fever: Treatment of fever at the end of life is based on the patient's life expectancy and goals of care. Medication: acetaminophen, NSAIDs, corticosteroids.

 

Common end-of-life medications (hospice comfort kit):  Effective management of symptoms at the end of life is challenging but often can be achieved with fewer than 4 or 5 key medications which are commonly found in hospice comfort kit in the patient's home. The kit is composed of antipsychotics, antipyretics, benzodiazepines, opiates, and secretion medication.

 

Question #3: Why is that knowledge important for you and your patients?

There are significant number of patients that during the end of life still suffer significantly whether it is from pain, nausea and vomiting, severe dyspnea, or constipation. Hospice care provides medical care and support services that focus on quality of life rather than life prolongation or cure. Hospice philosophy seems to help patient achieve comfort and quality of life until they die with dignity, and the care and treatment provided are based on the patient and family goals and values.  As of 2015 and estimated 1.38 million Americans yearly are being served by hospice programs around the country, and around 50% of Medicare patients utilize hospice at some point in their care.

 

Question #4: How did you get that knowledge?

Before getting accepted in the residency program I worked as an RN case manager both in home health and hospice here in Bakersfield, and recently I finished an elective at Kern Medical with Dr. Warren Wisnoff. My other sources include the American Academy of Palliative and Hospice Medicine book, up-to-date, and the American Academy Family Physician website.

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Speaking Medical: Pyogenic Granuloma
by Muhammad Suleman, MS4 

I’m going to present to you a case and then I’ll explain our Medical word of the week. Just imagine you have a patient who is an 8-year-old child with no significant past medical history. He comes to the clinic with a concern of a red ball-like mass on his lower lip. The mother states it started as a small pimple and has progressively gotten bigger over the last 2 weeks. It is mildly tender, nothing makes it better or worse. Patient denies trauma, recent sick contact, or infections, or weight loss. Skin lesion is a friable, pedunculated mass on right side of lower lip, beefy red, moist, with no purulent discharge. It measures 1 cm x 1cm. What do you think it is?

 

This is a pyogenic granuloma (PG). Not to be confused with the other PG Pyoderma gangrenosum (another type of PG). Pyogenic granuloma is a benign vascular tumor of the skin or mucous membranes characterized by rapid growth and friable surface. Pyogenic granuloma occurs at any age, although it is seen more often in children and young adults. In children, most common in age 6-10 years old. Trauma can be a trigger of PG. It may also be drug induced (antineoplastic agents). It may also be found in chronic inflammation in ingrown toenails.

 

PG is usually solitary but can be disseminated. Sizes rarely exceed 1cm. PG may be pedunculated or sessile. The base is often surrounded by thick ring of epidermis. In pregnant women 2-3 trimester, we can see PGs in the oral cavity, which tends to regress after birth. 

 

PG usually regresses but can be treated with surgical treatments, such as full-thickness excision or cryotherapy) and topical and intralesional therapies.

 

So, remember the medical word of the week: Pyogenic granuloma (PG).

 

Espanish Por Favor: Feliz Navidad
by Yosbel Martinez, MD

As residents, we always want to have a good relationship with our patients. That is what we call rapport. Rapport is all we need to have a bidirectional conversation. Having a harmonious relationship with your patient will allow you to collect a more comprehensive history, perform an effective physical exam, discuss treatments and have a more enjoyable patient encounter. The ideal doctor-patient relationship should be one full of trust, accountability, and respect. This Christmas, if you have a Spanish-speaking patient, an easy way to break the ice may be telling them “Feliz Navidad”. We wish everyone of you a Merry Christmas and a Happy New Year from our Rio Bravo Family. 

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For your Sanity: Christmas Jokes
by Julia Peters, MS3, and Jennifer Amezcua, MA

Resident 1: What do you get when you cross a snowman with a vampire?
Resident 2: A mean, flying snowman? I don’t know. 
Resident 1: A Frostbite!

Resident 1: What do you get if you cross Santa with a detective?
Resident2: Santa Holmes?
Resident 1: Good thought: Santa Clues!

Resident 1: What do you call Santa when he's got no money?
Resident 2: Saint-NICKEL-less!

Resident 2: What do elves post on social media?
Resident 1: Elf-ies!

Resident 2: Someone must be mad at Frosty the Snowman.
Resident 1: Why?
Resident 2: Because they gave him two black eyes

Now we conclude our episode 35, “Palliative Care and Hospice.” We gave you an update on the USPSTF screening guidelines, and gave you the long-waited news about the coronavirus vaccines. Yes, we are full of excitement and hope. Then, Dr Tu explained the importance of providing palliative and hospice services to our chronically-ill and terminally-ill patients. Our patients deserve special care during those critical moments of their lives. Moe explained pyogenic granuloma, a small growth that can be alarming for patients but easily treated in office. Dr Martinez reminded us of the holidays by wishing us “Feliz Navidad”, and Jenni and Julia made us laugh with their silly jokes about Santa. May you enjoy the holidays!

This is the end of Rio Bravo qWeek. If you have any feedback about this podcast, send us an email to RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ariana Lundquist, Manual Tu, Xeng Xiong, Yosbel Martinez, Julia Peters, and Jennifer Amezcua. Audio edition: Suraj Amrutia. See you soon! 

 

References:

Screening for Hepatitis B Virus Infection in Adolescents and Adults, December 15, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening.

 

High Blood Pressure in Children and Adolescents: Screening, November 10, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening#bootstrap-panel--6.

 

“Your questions about the coronavirus vaccine, answered”, The Washington Post, 

https://www.washingtonpost.com/health/2020/11/17/covid-vaccines-what-you-need-to-know/?arc404=true , accessed on December 21, 2020.

 

“Venezuela Developed A Drug That Eliminates The Coronavirus 100 Percent”, The Venezuelan Journal, https://thevenezuelanjournal.com/maduro-bivenezuela-developed-a-drug-that-eliminates-the-coronavirus-p2791-155.htm, accessed on November, 12, 2020.

 

Ross H. Albert, MD, PhD, End-of-Life Care: Managing Common Symptoms, Am Fam Physician. 2017 Mar 15;95(6):356-361. https://www.aafp.org/afp/2017/0315/p356.html, accessed on November 9, 2020.

 

Thompson Ruth M., Chirag Rajni Patel, and Kate M. Lally, Essential Practices in Hospice and Palliative Me, 5th edition, Unipac 1, Medical Care of People with Serious Illness, AAHPM.

 

Dawn A. Marcus, M.D., Treatment of Nonmalignant Chronic Pain, Am Fam Physician. 2000 Mar 1;61(5):1331-1338. https://www.aafp.org/afp/2000/0301/p1331.html.

 

 

 

 

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