Palliative Care Focus on Suffering instead of pain Bernard P Sweeney, MD Medical Director, Teresa House Geneseo, NY

Treatment Model GOAL: Relieve suffering while maintaining quality of life Physical symptoms Social Factors Emotional State Spiritual Status

INTERDISCIPLINARY TEAM Nurse Chaplain Physician Social worker Pharmacist Home aide/volunteer

PHYSICIAN Control physical symptoms very quickly Focus attention on patient exclusively Simple language Touch Prognosticate Family is integral

NEJM August, 2010 (Temel et al) 157 pts (107 completing) with metastatic non-small cell lung cancer, 12 week study Usual oncologic care vs Usual plus early palliative care Primary outcome change in quality of life at 12 weeks Measured by using following scales FACT-L Hospital Anxiety and Depression

Pts started on early palliative care: Better quality of life ( using FACT-L scale) 98 vs 91 Pts started on early palliative care lived longer 11.6 vs 8.9 months Less depression 16% vs 38% Results

CONCLUSION Significant improvements in quality of life and mood Lived longer

78 y.o. old male with metastatic prostate cancer, diagnosed 3 yrs prior. Was admitted to Teresa house due to overall decline in physical status. Family unable to provide safe environment but willing to assist in care CASE STUDY

Admit meds from home included: Amitriptyline 100 mg po qhs Gabapentin 600 mg TID Motrin 800 mg TID MS Contin 60 mg TID MSIR 15 mg q 4 hrs prn breakthrough pain

Physical Exam Lethargic male who responded to verbal command then quickly fell asleep again Tender over lumbar and thoracic spine processes Diffuse generalized weakness with flat Babinski bilaterally No neurological focal defect

Initially meet with wife, daughter and Nurse director Both understood terminal condition but ?? if his quality of Life could be improved Could current meds be adjusted to limit lethargy Control suffering CONCERNS

CARE PLAN Devised in concert with Nurse director Stopped amitripytyline Weaned gabapentin to 900 mg po qhs Added decadron 4 mg po bid Continued MS Contin Consultant pharmacist

With med changes pt was very comfortable Still lethargic and weak Continued

Decrease Total daily dose of morphine by 1/3 Start Methadone at to 2.5 mg po tid 2 Days later decrease morphine dose by another 1/3 Increase methadone to 5 mg po tid as comfort worsened 2 days later MS Contin stopped SLOWLY Transitioned Off morphine to methadone NEXT STEP Methadone increased to 10 mg BID

Within 7 weeks of admission to Teresa house Patient was up ambulating, alert,having discussions Was discharged to Home with spouse and daughter Passed away peacefully 8 months later Follow -Up