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Sunshine Rule Requires Physicians to Report Gifts from Drug, Medical Device Companies
—Joshua Lenchus, DO, RPh, FACP, SFHM
Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.
The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).1
One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.2 The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.
CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”
SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.
“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”
Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.
Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”
“The rule that has been implemented strikes a nice balance between the two,” he said.
Transparent Process
Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.
Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”
“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”
Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.
“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”
Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.
“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”
Richard Quinn is a freelance writer in New Jersey.
References
- Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
- Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.
—Joshua Lenchus, DO, RPh, FACP, SFHM
Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.
The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).1
One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.2 The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.
CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”
SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.
“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”
Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.
Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”
“The rule that has been implemented strikes a nice balance between the two,” he said.
Transparent Process
Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.
Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”
“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”
Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.
“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”
Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.
“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”
Richard Quinn is a freelance writer in New Jersey.
References
- Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
- Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.
—Joshua Lenchus, DO, RPh, FACP, SFHM
Hospitalist leaders are taking a wait-and-see approach to the Physician Payment Sunshine Act, which requires reporting of payments and gifts from drug and medical device companies. But as wary as many are after publication of the Final Rule 1 in February, SHM and other groups already have claimed at least one victory in tweaking the new rules.
The Sunshine Rule, as it’s known, was included in the Affordable Care Act of 2010. The rule, created by the Centers for Medicaid & Medicare Services (CMS), requires manufacturers to publicly report gifts, payments, or other transfers of value to physicians from pharmaceutical and medical device manufacturers worth more than $10 (see “Dos and Don’ts,” below).1
One major change to the law sought by SHM and others was tied to the reporting of indirect payments to speakers at accredited continuing medical education (CME) classes or courses. The proposed rule required reporting of those payments even if a particular industry group did not select the speakers or pay them. SHM and three dozen other societies lobbied CMS to change the rule.2 The final rule says indirect payments don’t have to be reported if the CME program meets widely accepted accreditation standards and the industry participant is neither directly paid nor selected by the vendor.
CME Coalition, a Washington, D.C.-based advocacy group, said in a statement the caveat recognizes that CMS “is sending a strong message to commercial supporters: Underwriting accredited continuing education programs for health-care providers is to be applauded, not restricted.”
SHM Public Policy Committee member Joshua Lenchus, DO, RPh, FACP, SFHM, said the initial rule was too restrictive and could have reduced physician participation in important CME activities. He said the Accreditation Council for Continuing Medical Education (ACCME) and other industry groups already govern the ethical issue of accepting direct payments that could imply bias to patients.
“I’m not so sure we needed the Sunshine Act as part of the ACA at all because these same things were in effect from the ACCME and other CME accrediting organizations,” said Dr. Lenchus, a Team Hospitalist member and president of the medical staff at Jackson Health System in Miami. “What this has done is impose additional administrative requirements that now take time away from our seeing patients or doing clinical activity.”
Those costs will add up quickly, according to figures from the Federal Register, Dr. Lenchus said. CMS projects the administrative costs of reviewing reports at $1.9 million for teaching hospital staff—the category Dr. Lenchus says is most applicable to hospitalists.
Dr. Lenchus says there was discussion within the Public Policy Committee about how much information needed to be publicly reported in relation to CME. Some members “wanted nothing recorded” and “some people wanted everything recorded.”
“The rule that has been implemented strikes a nice balance between the two,” he said.
Transparent Process
Industry groups and group purchasing organizations (GPOs) currently are working to put in place systems and procedures to begin collecting the data in August. Data will be collected through the end of 2013 and must be reported to CMS by March 31, 2014. CMS will then unveil a public website showcasing the information by Sept. 30, 2014.
Public Policy Committee member Jack Percelay, MD, MPH, FAAP, SFHM, said some hospitalists might feel they are “being picked on again” by having to report the added information. He instead looks at the intended push toward added transparency as “a set of obligations we have as physicians.”
“We have tremendous discretion about how health-care dollars are spent and with that comes a fiduciary responsibility, both to the patient and to the public,” he said. “This does not seem terribly burdensome to me. If I was getting nickel and dimed for every piece of candy I took through the exhibit hall during a meeting, that would be ridiculous. I’m happy to do this in a reasoned way.”
Dr. Percelay noted that the Sunshine Rule does not prevent industry payments to physicians or groups, but simply requires the public reporting and display of the remuneration. In that vein, he likened it to ethical rules that govern those who hold elected office.
“Someone should be able to Google and see that I’ve [received] funds from market research,” he said. “It’s not much different from politicians. It’s then up to the public and the media to do their due diligence.”
Dr. Lenchus said the public database has the potential to be misinterpreted by a public unfamiliar with how health care works. In particular, patients might not be able to discern the differences between the value of lunches, the payments for being on advisory boards, and industry-funded research.
“I really fear the public will look at this website, see there is any financial inducement to any physician, and erroneously conclude that any prescription of that company’s medication means that person is getting a kickback,” he says. “And we know that’s absolutely false.”
Richard Quinn is a freelance writer in New Jersey.
References
- Centers for Medicare & Medicaid Services. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Federal Register website. Available at: https://www.federalregister.gov/articles/2013/02/08/2013-02572/medicare-mediaid-childrens-health-insurance-programs-transparency-reports-and-reporting-of. Accessed March 24, 2013.
- Council of Medical Specialty Societies. Letter to CMS. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_ and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=30674. Accessed March 24, 2013.
Hospitalists Poised to Advance Health Care Through Teamwork
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
A Tracheostomy Collar Facilitates Quicker Transition
Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.
A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.
On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.
“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”
In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”
Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.
In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.
Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.
“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”
“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.
Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.
“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”
Susan Kreimer is a freelance writer based in New York.
Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.
A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.
On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.
“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”
In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”
Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.
In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.
Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.
“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”
“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.
Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.
“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”
Susan Kreimer is a freelance writer based in New York.
Each day a patient spends on a ventilator increases pneumonia risk by about 1% (Am J Respir Crit Care Med. 2002;165[7]:867-903). Being unable to move or talk also might induce a sense of helplessness. As a result, many clinicians wean off a ventilator sooner rather than later.
A recent study (JAMA. 2013;309[7]:671-677) has found that unassisted breathing via a tracheostomy collar facilitates a quicker transition than breathing with pressure support after prolonged mechanical ventilation (>21 days). Investigators reported their findings at the Society of Critical Care Medicine’s 42nd Congress in January in San Juan, Puerto Rico.
On average, patients were able to successfully wean four days earlier with unassisted breathing versus pressure support—a significant difference, says lead investigator Amal Jubran, MD, section chief of pulmonary and critical-care medicine at the Edward Hines Jr. VA Hospital in Chicago. No major differences were reported in survival between the two groups at six-month and 12-month intervals after enrollment in the study.
“The faster pace of weaning in the tracheostomy collar group may be related to its effect on clinical decision-making,” says Dr. Jubran, a professor at Loyola University Chicago’s Stritch School of Medicine. “Observing a patient breathing through a tracheostomy collar provides the clinician with a clear view of the patient’s respiratory capabilities.”
In contrast, with pressure support, a clinician’s perception of weanability “is clouded because the patient is receiving ventilator assistance,” she says. “It is extremely difficult to distinguish between how much work the patient is doing and how much work the ventilator is doing.”
Amid this uncertainty, Dr. Jubran adds, clinicians are more likely to accelerate the weaning process in patients who unexpectedly respond well during a tracheostomy collar challenge than in those receiving a low level of pressure support.
In the study, less than 10% of 312 patients—most of whom were elderly—required reconnection to a ventilator after being weaned successfully. Weaning efforts should be restarted only after cardiopulmonary stability has been reached, she says.
Factoring into the equation are the measurements for blood pressure and respiratory rate and the amounts of oxygenation and sedation in patients on ventilators, says Paul Odenbach, MD, SHM, a hospitalist at Abbott Northwestern Hospital in Minneapolis.
“I look at them clinically overall,” he says. “The most important piece is eyeballing them from where they are in their disease trajectory.”
“Are they awake enough to be protecting their airway once they are extubated?” he adds. He has found that a stable airway is more easily achieved with a tracheostomy collar.
Managing heart failure, treating infections, and optimizing nutrition are crucial before weaning off ventilation, says geriatrician Joel Sender, MD, section chief of pulmonary medicine at St. Barnabas Hospital in Bronx, N.Y., and medical director of its Rehabilitation & Continuing Care Center.
“It is important to identify the best candidates for weaning and then apply the best methods,” says Dr. Sender. “Sadly, many patients are not good candidates, and only a portion are successfully weaned.” That’s why “there’s a great need to have a frank discussion with the family to answer their questions and to promote a realistic set of treatment goals.”
Susan Kreimer is a freelance writer based in New York.
Hospitalists Can’t Ignore Rise in CRE Infections
Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”
“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”
Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.
“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”
Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning.
Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.
Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.
Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.
“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.”
Richard Quinn is a freelance writer in New Jersey.
Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”
“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”
Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.
“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”
Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning.
Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.
Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.
Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.
“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.”
Richard Quinn is a freelance writer in New Jersey.
Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”
“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”
Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in 2001, according to data from the National Nosocomial Infection Surveillance system.
“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”
Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning.
Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.
Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.
Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.
“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.”
Richard Quinn is a freelance writer in New Jersey.
Addressing The Joint Commission's Concern About Opioid-Induced Respiratory Depression
The recent article by Susan Kreimer, “Serious Complications from Opioid Overuse in Hospitalized Patients Prompts Nationwide Alert” (February 2013, p. 34) highlights a very important patient safety issue—opioid-induced respiratory depression.
Post-operative patients often manage their pain with patient-controlled analgesia (PCA) pumps. An estimated 14 million patients use PCA annually.1 As the article points out, PCA “offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case.”
As Dr. Jason McKeown says, “While PCA may be the safest mode of opioid delivery, it is true that regardless of the route of administration, respiratory depression may still occur. To help prevent such incidents from happening, it should be remembered that some of the most significant strides in medicine and surgery are directly attributable to anesthesiology’s advances in patient monitoring.”
With the goal of helping to reduce adverse events and deaths with PCA pumps, the Physician-Patient Alliance for Health & Safety (PPAHS) recently released a safety checklist that reminds caregivers of the essential steps needed to be taken to initiate PCA with a patient, and to continue to assess that patient’s use of PCA. This checklist was developed after consultation with a group of 19 renowned health experts and is a free download at www.ppahs.org.
The checklist provides five recommended steps to have been completed when initiating PCA:
- Risk factors that increase risk of respiratory depression have been considered.
- Pre-procedural cognitive assessment has determined patient is capable of participating in pain management.
However, it should be noted that these first two steps are not an attempt at risk stratification. In reviewing current approaches to address failure-to-rescue, Dr. Andreas Taenzer and his colleagues showed that these current approaches are not able to predict which patients are at risk and at which point the crisis can be detected.
- Patient has been provided with information on proper patient use of PCA pump (other recipients of information—family/visitors) and purpose of monitoring.
The Institute for Safe Medical Practice (www.ismp.org) cautions against PCA proxy and stresses the importance of patient education. The safe use of PCA includes making sure the patient controlling the device actually knows how to use it and the importance of the monitoring used to continuously assess their status.
- Two health-care providers have independently double-checked: patient ID; allergies; drug selection and concentration; dosage adjustments; pump settings; and line attachment to patient and tubing insertion.
Error prevention is critical. The Pennsylvania Patient Safety Authority recently released its analysis of medication errors and adverse drug reactions involving intravenous fentanyl that were reported to them. Researchers found 2,319 events between June 2004 to March 2012; that’s almost 25 events per month. Although one error a day may seem high, their analysis is confined to reports that were made to the authority and only include fentanyl, a potent, synthetic narcotic analgesic with a rapid onset and short duration of action.
- Patient is electronically monitored with both pulse oximetry and capnography.
As Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation, recently stated: “The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of [pulse oximetry] and ventilation are not adequate for reliably recognizing clinically significant, evolving, drug-induced, respiratory depression in the postoperative period....APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”
Frank Federico, a member of the Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement, concurs: “Although nurse spot checks on patients are advisable, pulse oximetry and capnography are essential risk prevention tools in any pain management plan.”
PPAHS encourages all hospitals and health-care facilities to download and utilize the PCA Safety Checklist.
The recent article by Susan Kreimer, “Serious Complications from Opioid Overuse in Hospitalized Patients Prompts Nationwide Alert” (February 2013, p. 34) highlights a very important patient safety issue—opioid-induced respiratory depression.
Post-operative patients often manage their pain with patient-controlled analgesia (PCA) pumps. An estimated 14 million patients use PCA annually.1 As the article points out, PCA “offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case.”
As Dr. Jason McKeown says, “While PCA may be the safest mode of opioid delivery, it is true that regardless of the route of administration, respiratory depression may still occur. To help prevent such incidents from happening, it should be remembered that some of the most significant strides in medicine and surgery are directly attributable to anesthesiology’s advances in patient monitoring.”
With the goal of helping to reduce adverse events and deaths with PCA pumps, the Physician-Patient Alliance for Health & Safety (PPAHS) recently released a safety checklist that reminds caregivers of the essential steps needed to be taken to initiate PCA with a patient, and to continue to assess that patient’s use of PCA. This checklist was developed after consultation with a group of 19 renowned health experts and is a free download at www.ppahs.org.
The checklist provides five recommended steps to have been completed when initiating PCA:
- Risk factors that increase risk of respiratory depression have been considered.
- Pre-procedural cognitive assessment has determined patient is capable of participating in pain management.
However, it should be noted that these first two steps are not an attempt at risk stratification. In reviewing current approaches to address failure-to-rescue, Dr. Andreas Taenzer and his colleagues showed that these current approaches are not able to predict which patients are at risk and at which point the crisis can be detected.
- Patient has been provided with information on proper patient use of PCA pump (other recipients of information—family/visitors) and purpose of monitoring.
The Institute for Safe Medical Practice (www.ismp.org) cautions against PCA proxy and stresses the importance of patient education. The safe use of PCA includes making sure the patient controlling the device actually knows how to use it and the importance of the monitoring used to continuously assess their status.
- Two health-care providers have independently double-checked: patient ID; allergies; drug selection and concentration; dosage adjustments; pump settings; and line attachment to patient and tubing insertion.
Error prevention is critical. The Pennsylvania Patient Safety Authority recently released its analysis of medication errors and adverse drug reactions involving intravenous fentanyl that were reported to them. Researchers found 2,319 events between June 2004 to March 2012; that’s almost 25 events per month. Although one error a day may seem high, their analysis is confined to reports that were made to the authority and only include fentanyl, a potent, synthetic narcotic analgesic with a rapid onset and short duration of action.
- Patient is electronically monitored with both pulse oximetry and capnography.
As Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation, recently stated: “The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of [pulse oximetry] and ventilation are not adequate for reliably recognizing clinically significant, evolving, drug-induced, respiratory depression in the postoperative period....APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”
Frank Federico, a member of the Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement, concurs: “Although nurse spot checks on patients are advisable, pulse oximetry and capnography are essential risk prevention tools in any pain management plan.”
PPAHS encourages all hospitals and health-care facilities to download and utilize the PCA Safety Checklist.
The recent article by Susan Kreimer, “Serious Complications from Opioid Overuse in Hospitalized Patients Prompts Nationwide Alert” (February 2013, p. 34) highlights a very important patient safety issue—opioid-induced respiratory depression.
Post-operative patients often manage their pain with patient-controlled analgesia (PCA) pumps. An estimated 14 million patients use PCA annually.1 As the article points out, PCA “offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case.”
As Dr. Jason McKeown says, “While PCA may be the safest mode of opioid delivery, it is true that regardless of the route of administration, respiratory depression may still occur. To help prevent such incidents from happening, it should be remembered that some of the most significant strides in medicine and surgery are directly attributable to anesthesiology’s advances in patient monitoring.”
With the goal of helping to reduce adverse events and deaths with PCA pumps, the Physician-Patient Alliance for Health & Safety (PPAHS) recently released a safety checklist that reminds caregivers of the essential steps needed to be taken to initiate PCA with a patient, and to continue to assess that patient’s use of PCA. This checklist was developed after consultation with a group of 19 renowned health experts and is a free download at www.ppahs.org.
The checklist provides five recommended steps to have been completed when initiating PCA:
- Risk factors that increase risk of respiratory depression have been considered.
- Pre-procedural cognitive assessment has determined patient is capable of participating in pain management.
However, it should be noted that these first two steps are not an attempt at risk stratification. In reviewing current approaches to address failure-to-rescue, Dr. Andreas Taenzer and his colleagues showed that these current approaches are not able to predict which patients are at risk and at which point the crisis can be detected.
- Patient has been provided with information on proper patient use of PCA pump (other recipients of information—family/visitors) and purpose of monitoring.
The Institute for Safe Medical Practice (www.ismp.org) cautions against PCA proxy and stresses the importance of patient education. The safe use of PCA includes making sure the patient controlling the device actually knows how to use it and the importance of the monitoring used to continuously assess their status.
- Two health-care providers have independently double-checked: patient ID; allergies; drug selection and concentration; dosage adjustments; pump settings; and line attachment to patient and tubing insertion.
Error prevention is critical. The Pennsylvania Patient Safety Authority recently released its analysis of medication errors and adverse drug reactions involving intravenous fentanyl that were reported to them. Researchers found 2,319 events between June 2004 to March 2012; that’s almost 25 events per month. Although one error a day may seem high, their analysis is confined to reports that were made to the authority and only include fentanyl, a potent, synthetic narcotic analgesic with a rapid onset and short duration of action.
- Patient is electronically monitored with both pulse oximetry and capnography.
As Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation, recently stated: “The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of [pulse oximetry] and ventilation are not adequate for reliably recognizing clinically significant, evolving, drug-induced, respiratory depression in the postoperative period....APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”
Frank Federico, a member of the Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement, concurs: “Although nurse spot checks on patients are advisable, pulse oximetry and capnography are essential risk prevention tools in any pain management plan.”
PPAHS encourages all hospitals and health-care facilities to download and utilize the PCA Safety Checklist.
'Systems,' Not 'Points,' Is Correct Terminology for ROS Statements
The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”
In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.
What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”
I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.
The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”
In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.
What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”
I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.
The “Billing and Coding Bandwagon” article in the May 2011 issue of The Hospitalist (p. 26) recently was brought to my attention and I have some concerns that the following statement gives a false impression of acceptable documentation: “When I first started working, I couldn’t believe that I could get audited and fined just because I didn’t add ‘10-point’ or ‘12-point’ to my note of ‘review of systems: negative,’” says hospitalist Amaka Nweke, MD, assistant director with Hospitalists Management Group (HMG) at Kenosha Medical Center in Kenosha, Wis. “I had a lot of frustration, because I had to repackage and re-present my notes in a manner that makes sense to Medicare but makes no sense to physicians.”
In fact, that would still not be considered acceptable documentation for services that require a complete review of systems (99222, 99223, 99219, 99220, 99235, and 99236). The documentation guidelines clearly state: “A complete ROS [review of systems] inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.” At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.
What Medicare is saying is the provider must have inquired about all 14 systems, not just 10 or 12. The term “point” means nothing in an ROS statement. “Systems” is the correct terminology, not “points.”
I am afraid the article is misleading and could be providing inappropriate documentation advice to hospitalists dealing with CMS and AMA guidelines.
Some Thoughts on the Patient-Doctor Relationship
There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.
Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.
Some of the key faux pas to avoid when listening to the patient include:
- Not centering oneself before engaging in a “crucial conversation”;
- Not listening because one is thinking ahead to his/her own response;
- Not maintaining eye contact;
- Not being aware of when one feels challenged and/or defensive;
- Discouraging the patient from contributing his/her own ideas;
- Not allowing the patient to give feedback on what s/he heard as instructions; and
- Taking phone calls or allowing interruptions during a consultation.
It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.
The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.
Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.
There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.
Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.
Some of the key faux pas to avoid when listening to the patient include:
- Not centering oneself before engaging in a “crucial conversation”;
- Not listening because one is thinking ahead to his/her own response;
- Not maintaining eye contact;
- Not being aware of when one feels challenged and/or defensive;
- Discouraging the patient from contributing his/her own ideas;
- Not allowing the patient to give feedback on what s/he heard as instructions; and
- Taking phone calls or allowing interruptions during a consultation.
It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.
The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.
Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.
There is an inherent power differential in the patient-doctor relationship: The patient comes to the doctor as an authority on his/her physical or emotional state and is thus either intellectually or emotionally dependent on the doctor’s treatment plan and advice. It is therefore absolutely essential that the doctor respect the patient as an equal participant in the treatment. Although the doctor certainly has knowledge about how similar conditions were successfully treated in the past, hopefully a medical professional will display an attitude of respect and mutual collaboration with the patient to resolve his/her problem.
Listening is a key component of conveying an attitude of respect toward the patient. Nowadays practitioners are most often taking notes at their computers while speaking with the patient. This is certainly time-efficient and may in fact be necessary in order for a medical practice to remain solvent with the demands of Medicare and insurance companies. However, multitasking does not convey to the patient that they are connecting with the doctor. Listening is a complex action, which not only involves the ears, but the eyes, the kinesthetic responses of the whole body, and attention to the patient’s nonverbal communication.
Some of the key faux pas to avoid when listening to the patient include:
- Not centering oneself before engaging in a “crucial conversation”;
- Not listening because one is thinking ahead to his/her own response;
- Not maintaining eye contact;
- Not being aware of when one feels challenged and/or defensive;
- Discouraging the patient from contributing his/her own ideas;
- Not allowing the patient to give feedback on what s/he heard as instructions; and
- Taking phone calls or allowing interruptions during a consultation.
It is always helpful to give a patient clear, written instructions about medications, diet, exercise, etc., that result from the consultation. Some doctors send this report via secure email to the patient for review, which is an excellent technique.
The art of apology is another topic that greatly impacts the doctor-patient relationship, as well as the doctor’s relationship with the patient’s family members. This art is a process that has recently emerged in the medical and medical insurance industries. Kaiser Permanente’s director of medical-legal affairs has adopted the practice of asking permission to videotape the actual conversation in which a physician apologizes to a patient for a mistake in a procedure. These conversations are meant to help medical professionals learn how to admit mistakes and ask for forgiveness. Oftentimes patients are looking for just such a communication, which may allow them to put to rest feelings of resentment, bitterness, and regret.
Our patients’ well-being is our ideal goal. Knowing that they have been heard and their feelings understood may in the long run allow patients and their families to heal mind/body/soul more powerfully than we had ever thought. Of course, in our litigious society this may well be an art that remains to be developed over the long term.
Coordinated Approach May Help in Caring for Hospitals’ Neediest Patients
To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.
Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”
The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.
The Role of Care Plans
It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.
For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.
A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.
Your Hospital Needs a Care Plan
Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.
Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.
Unanswered Questions
Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.
My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.
So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.
An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.
Conclusion
I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.
Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”
The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.
The Role of Care Plans
It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.
For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.
A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.
Your Hospital Needs a Care Plan
Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.
Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.
Unanswered Questions
Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.
My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.
So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.
An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.
Conclusion
I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.
Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”
The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.
The Role of Care Plans
It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.
For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.
A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.
Your Hospital Needs a Care Plan
Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.
Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.
Unanswered Questions
Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.
My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.
So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.
An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.
Conclusion
I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
Surviving Sepsis Campaign 2012 Guidelines: Updates For the Hospitalist
Background
Sepsis is a clinical syndrome with systemic effects that can progress to severe sepsis and/or septic shock. The incidence of severe sepsis and septic shock is rising in the United States, and these syndromes are associated with significant morbidity and a mortality rate as high as 25% to 35%.1 In fact, sepsis is one of the 10 leading causes of death in the U.S., accounting for 2% of hospital admissions but 17% of in-hospital deaths.1
The main principles of effective treatment for severe sepsis and septic shock are timely recognition and early aggressive therapy. Launched in 2002, the Surviving Sepsis Campaign (SSC) was the result of a collaboration of three professional societies. The goal of the SSC collaborative was to reduce mortality from severe sepsis and septic shock by 25%. To that end, the SSC convened representatives from several international societies to develop a set of evidence-based guidelines as a means of guiding clinicians in optimizing management of patients with severe sepsis and septic shock. Since the original publication of the SSC guidelines in 2004, there have been two updates—one in 2008 and one in February 2013.2
Guideline Updates
Quantitative, protocol-driven initial resuscitation in the first six hours for patients with severe sepsis and septic shock remains a high-level recommendation, but SSC has added normalization of the lactate level as a resuscitation goal. This new suggestion is based on two studies published since the 2008 SCC guidelines that showed noninferiority to previously established goals and absolute mortality benefit.3,4
There is a new focus on screening for sepsis and the use of hospital-based performance-improvement programs, which were not previously addressed in the 2008 SCC guidelines. Patients with suspected infections and who are seriously ill should be screened in order to identify sepsis early during the hospital course. Additionally, it is recommended that hospitals implement performance-improvement measures by which multidisciplinary teams can address treatment of sepsis by improving compliance with the SSC bundles, citing their own data as the model but ultimately leaving this recommendation as ungradable in regards to the quality of available supporting evidence.5
Cultures drawn before antibiotics and early imaging to confirm potential sources are still recommended, but the committee has added the use of one: 3 beta D-glucan and the mannan antigen and anti-mannan antibody assays when considering invasive candidiasis as your infective agent. They do note the known risk of false positive results with these assays and warn that they should be used with caution.
Early, broad-spectrum antibiotic administration within the first hour of presentation was upgraded for severe sepsis and downgraded for septic shock. The decision to initiate double coverage for suspected gram-negative infection is not recommended specifically but can be considered in situations when highly antibiotic resistant pathogens are potentially present. Daily assessment of the appropriate antibiotic regimen remains an important tenet, and the use of low procalcitonin levels as a tool to assist in the decision to discontinue antibiotics has been introduced. Source control is still strongly recommended in the first 12 hours of treatment.
The SSC 2012 guidelines specifically address the rate of fluid administered and the type of fluid that should be used. It is now recommended that a fluid challenge of 30 mL/kg be used for initial resuscitation, but the guidelines leave it up to the clinician to give more fluid if needed. There is a strong push for use of crystalloids rather than colloids during initial resuscitation and thereafter. Disfavor for colloids stemmed from trials showing increased mortality when comparing resuscitation with hydroxyethyl starch versus crystalloid for patients in septic shock.6,7 Albumin, on the other hand, is recommended to resuscitate patients with severe sepsis and septic shock in cases for which large amounts of crystalloid are required.
The 2012 SSC guidelines recommend norepinephrine (NE) alone as the first-line vasopressor in sepsis and no longer include dopamine in this category. In fact, the use of dopamine in septic shock has been downgraded and should only to be considered in patients at low risk of tachyarrhythmia and in bradycardia syndromes. Epinephrine is now favored as the second agent or as a substitute to NE. Phenylephrine is no longer recommended unless there is contraindication to using NE, the patient has a high cardiac output, or it is used as a salvage therapy. Vasopressin is considered only an adjunctive agent to NE and should never be used alone.
Recommendations regarding corticosteroid therapy remain largely unchanged from 2008 SCC guidelines, which only support their use when adequate volume resuscitation and vasopressor support has failed to achieve hemodynamic stability. Glucose control is recommended but at the new target of achieving a level of <180 mg/dL, up from a previous target of <150 mg/dL.
Notably, recombinant human activated protein C was completely omitted from the 2012 guidelines, prompted by the voluntary removal of the drug by the manufacturer after failing to show benefit. Use of selenium and intravenous immunoglobulin received comment, but there is insufficient evidence supporting their benefit at the current time. They also encourage clinicians to incorporate goals of care and end-of-life issues into the treatment plan and discuss this with patients and/or surrogates early in treatment.
Guideline Analysis
Prior versions of the SSC guidelines have been met with a fair amount of skepticism.8 Much of the criticism is based on the industry sponsorship of the 2004 version, the lack of transparency regarding potential conflicts of interest of the committee members, and that the bundle recommendations largely were based on only one trial and, therefore, not evidenced-based.9 The 2012 SSC committee seems to have addressed these issues as the guidelines are free of commercial sponsorship in the 2008 and current versions. They also rigorously applied the GRADE system to methodically assess the strength and quality of supporting evidence. The result is a set of guidelines that are partially evidence-based and partially based on expert opinion, but this is clearly delineated in these newest guidelines. This provides clinicians with a clear and concise recommended approach to the patient with severe sepsis and septic shock.
The guidelines continue to place a heavy emphasis on three- and six-hour treatment bundles, and with the assistance of the Institute for Health Care Improvement efforts to improve implementation of the bundle, they are already are widespread with an eye to expand across the country. The components of the three-hour treatment bundle (lactate measurement, blood cultures prior to initiation of antibiotics, broad-spectrum antibiotics, and IV crystalloids for hypotension or for a lactate of >4 mmol/L) recommended by the SSC have not changed substantially since 2008. The one exception is the rate at which IV crystalloid should be administered of 30 mL/kg, which is up from 20 mL/kg. Only time will tell how this change will affect bundle compliance or reduce mortality. But this does pose a significant challenge to quality and performance improvement groups accustomed to tracking compliance with IV fluid administration under the old standard and the educational campaigns associated with a change.
It appears that the SSC is here to stay, now in its third iteration. The lasting legacy of the SSC guidelines might not rest with the content of the guidelines, per se, but in raising awareness of severe sepsis and septic shock in a way that had not previously been considered.
HM Takeaways
The revised 2012 SCC updates bring some new tools to the clinician for early recognition and effective management of patients with sepsis. The push for institutions to adopt screening and performance measures reflects a general trend in health care to create high-performance systems. As these new guidelines are put into practice, there are several changes that might require augmentation of quality metrics being tracked at institutions nationally and internationally.
Dr. Pendharker is assistant professor of medicine in the division of hospital medicine at the University of California San Francisco and San Francisco General Hospital. Dr. Gomez is assistant professor of medicine in the division of pulmonary and critical care medicine at UCSF and San Francisco General Hospital.
References
- Hall MJ, Williams SN, DeFrances CJ, et al. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief. 2011:1-8.
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
- Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752-761.
- Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
- Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38:367-374.
- Guidet B, Martinet O, Boulain T, et al. Assessment of hemodynamic efficacy and safety of 6% hydroxyethylstarch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study. Crit Care. 2012;16:R94.
- Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367:124-134.
- Marik PE. Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011;1:17.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.
Background
Sepsis is a clinical syndrome with systemic effects that can progress to severe sepsis and/or septic shock. The incidence of severe sepsis and septic shock is rising in the United States, and these syndromes are associated with significant morbidity and a mortality rate as high as 25% to 35%.1 In fact, sepsis is one of the 10 leading causes of death in the U.S., accounting for 2% of hospital admissions but 17% of in-hospital deaths.1
The main principles of effective treatment for severe sepsis and septic shock are timely recognition and early aggressive therapy. Launched in 2002, the Surviving Sepsis Campaign (SSC) was the result of a collaboration of three professional societies. The goal of the SSC collaborative was to reduce mortality from severe sepsis and septic shock by 25%. To that end, the SSC convened representatives from several international societies to develop a set of evidence-based guidelines as a means of guiding clinicians in optimizing management of patients with severe sepsis and septic shock. Since the original publication of the SSC guidelines in 2004, there have been two updates—one in 2008 and one in February 2013.2
Guideline Updates
Quantitative, protocol-driven initial resuscitation in the first six hours for patients with severe sepsis and septic shock remains a high-level recommendation, but SSC has added normalization of the lactate level as a resuscitation goal. This new suggestion is based on two studies published since the 2008 SCC guidelines that showed noninferiority to previously established goals and absolute mortality benefit.3,4
There is a new focus on screening for sepsis and the use of hospital-based performance-improvement programs, which were not previously addressed in the 2008 SCC guidelines. Patients with suspected infections and who are seriously ill should be screened in order to identify sepsis early during the hospital course. Additionally, it is recommended that hospitals implement performance-improvement measures by which multidisciplinary teams can address treatment of sepsis by improving compliance with the SSC bundles, citing their own data as the model but ultimately leaving this recommendation as ungradable in regards to the quality of available supporting evidence.5
Cultures drawn before antibiotics and early imaging to confirm potential sources are still recommended, but the committee has added the use of one: 3 beta D-glucan and the mannan antigen and anti-mannan antibody assays when considering invasive candidiasis as your infective agent. They do note the known risk of false positive results with these assays and warn that they should be used with caution.
Early, broad-spectrum antibiotic administration within the first hour of presentation was upgraded for severe sepsis and downgraded for septic shock. The decision to initiate double coverage for suspected gram-negative infection is not recommended specifically but can be considered in situations when highly antibiotic resistant pathogens are potentially present. Daily assessment of the appropriate antibiotic regimen remains an important tenet, and the use of low procalcitonin levels as a tool to assist in the decision to discontinue antibiotics has been introduced. Source control is still strongly recommended in the first 12 hours of treatment.
The SSC 2012 guidelines specifically address the rate of fluid administered and the type of fluid that should be used. It is now recommended that a fluid challenge of 30 mL/kg be used for initial resuscitation, but the guidelines leave it up to the clinician to give more fluid if needed. There is a strong push for use of crystalloids rather than colloids during initial resuscitation and thereafter. Disfavor for colloids stemmed from trials showing increased mortality when comparing resuscitation with hydroxyethyl starch versus crystalloid for patients in septic shock.6,7 Albumin, on the other hand, is recommended to resuscitate patients with severe sepsis and septic shock in cases for which large amounts of crystalloid are required.
The 2012 SSC guidelines recommend norepinephrine (NE) alone as the first-line vasopressor in sepsis and no longer include dopamine in this category. In fact, the use of dopamine in septic shock has been downgraded and should only to be considered in patients at low risk of tachyarrhythmia and in bradycardia syndromes. Epinephrine is now favored as the second agent or as a substitute to NE. Phenylephrine is no longer recommended unless there is contraindication to using NE, the patient has a high cardiac output, or it is used as a salvage therapy. Vasopressin is considered only an adjunctive agent to NE and should never be used alone.
Recommendations regarding corticosteroid therapy remain largely unchanged from 2008 SCC guidelines, which only support their use when adequate volume resuscitation and vasopressor support has failed to achieve hemodynamic stability. Glucose control is recommended but at the new target of achieving a level of <180 mg/dL, up from a previous target of <150 mg/dL.
Notably, recombinant human activated protein C was completely omitted from the 2012 guidelines, prompted by the voluntary removal of the drug by the manufacturer after failing to show benefit. Use of selenium and intravenous immunoglobulin received comment, but there is insufficient evidence supporting their benefit at the current time. They also encourage clinicians to incorporate goals of care and end-of-life issues into the treatment plan and discuss this with patients and/or surrogates early in treatment.
Guideline Analysis
Prior versions of the SSC guidelines have been met with a fair amount of skepticism.8 Much of the criticism is based on the industry sponsorship of the 2004 version, the lack of transparency regarding potential conflicts of interest of the committee members, and that the bundle recommendations largely were based on only one trial and, therefore, not evidenced-based.9 The 2012 SSC committee seems to have addressed these issues as the guidelines are free of commercial sponsorship in the 2008 and current versions. They also rigorously applied the GRADE system to methodically assess the strength and quality of supporting evidence. The result is a set of guidelines that are partially evidence-based and partially based on expert opinion, but this is clearly delineated in these newest guidelines. This provides clinicians with a clear and concise recommended approach to the patient with severe sepsis and septic shock.
The guidelines continue to place a heavy emphasis on three- and six-hour treatment bundles, and with the assistance of the Institute for Health Care Improvement efforts to improve implementation of the bundle, they are already are widespread with an eye to expand across the country. The components of the three-hour treatment bundle (lactate measurement, blood cultures prior to initiation of antibiotics, broad-spectrum antibiotics, and IV crystalloids for hypotension or for a lactate of >4 mmol/L) recommended by the SSC have not changed substantially since 2008. The one exception is the rate at which IV crystalloid should be administered of 30 mL/kg, which is up from 20 mL/kg. Only time will tell how this change will affect bundle compliance or reduce mortality. But this does pose a significant challenge to quality and performance improvement groups accustomed to tracking compliance with IV fluid administration under the old standard and the educational campaigns associated with a change.
It appears that the SSC is here to stay, now in its third iteration. The lasting legacy of the SSC guidelines might not rest with the content of the guidelines, per se, but in raising awareness of severe sepsis and septic shock in a way that had not previously been considered.
HM Takeaways
The revised 2012 SCC updates bring some new tools to the clinician for early recognition and effective management of patients with sepsis. The push for institutions to adopt screening and performance measures reflects a general trend in health care to create high-performance systems. As these new guidelines are put into practice, there are several changes that might require augmentation of quality metrics being tracked at institutions nationally and internationally.
Dr. Pendharker is assistant professor of medicine in the division of hospital medicine at the University of California San Francisco and San Francisco General Hospital. Dr. Gomez is assistant professor of medicine in the division of pulmonary and critical care medicine at UCSF and San Francisco General Hospital.
References
- Hall MJ, Williams SN, DeFrances CJ, et al. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief. 2011:1-8.
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
- Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752-761.
- Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
- Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38:367-374.
- Guidet B, Martinet O, Boulain T, et al. Assessment of hemodynamic efficacy and safety of 6% hydroxyethylstarch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study. Crit Care. 2012;16:R94.
- Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367:124-134.
- Marik PE. Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011;1:17.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.
Background
Sepsis is a clinical syndrome with systemic effects that can progress to severe sepsis and/or septic shock. The incidence of severe sepsis and septic shock is rising in the United States, and these syndromes are associated with significant morbidity and a mortality rate as high as 25% to 35%.1 In fact, sepsis is one of the 10 leading causes of death in the U.S., accounting for 2% of hospital admissions but 17% of in-hospital deaths.1
The main principles of effective treatment for severe sepsis and septic shock are timely recognition and early aggressive therapy. Launched in 2002, the Surviving Sepsis Campaign (SSC) was the result of a collaboration of three professional societies. The goal of the SSC collaborative was to reduce mortality from severe sepsis and septic shock by 25%. To that end, the SSC convened representatives from several international societies to develop a set of evidence-based guidelines as a means of guiding clinicians in optimizing management of patients with severe sepsis and septic shock. Since the original publication of the SSC guidelines in 2004, there have been two updates—one in 2008 and one in February 2013.2
Guideline Updates
Quantitative, protocol-driven initial resuscitation in the first six hours for patients with severe sepsis and septic shock remains a high-level recommendation, but SSC has added normalization of the lactate level as a resuscitation goal. This new suggestion is based on two studies published since the 2008 SCC guidelines that showed noninferiority to previously established goals and absolute mortality benefit.3,4
There is a new focus on screening for sepsis and the use of hospital-based performance-improvement programs, which were not previously addressed in the 2008 SCC guidelines. Patients with suspected infections and who are seriously ill should be screened in order to identify sepsis early during the hospital course. Additionally, it is recommended that hospitals implement performance-improvement measures by which multidisciplinary teams can address treatment of sepsis by improving compliance with the SSC bundles, citing their own data as the model but ultimately leaving this recommendation as ungradable in regards to the quality of available supporting evidence.5
Cultures drawn before antibiotics and early imaging to confirm potential sources are still recommended, but the committee has added the use of one: 3 beta D-glucan and the mannan antigen and anti-mannan antibody assays when considering invasive candidiasis as your infective agent. They do note the known risk of false positive results with these assays and warn that they should be used with caution.
Early, broad-spectrum antibiotic administration within the first hour of presentation was upgraded for severe sepsis and downgraded for septic shock. The decision to initiate double coverage for suspected gram-negative infection is not recommended specifically but can be considered in situations when highly antibiotic resistant pathogens are potentially present. Daily assessment of the appropriate antibiotic regimen remains an important tenet, and the use of low procalcitonin levels as a tool to assist in the decision to discontinue antibiotics has been introduced. Source control is still strongly recommended in the first 12 hours of treatment.
The SSC 2012 guidelines specifically address the rate of fluid administered and the type of fluid that should be used. It is now recommended that a fluid challenge of 30 mL/kg be used for initial resuscitation, but the guidelines leave it up to the clinician to give more fluid if needed. There is a strong push for use of crystalloids rather than colloids during initial resuscitation and thereafter. Disfavor for colloids stemmed from trials showing increased mortality when comparing resuscitation with hydroxyethyl starch versus crystalloid for patients in septic shock.6,7 Albumin, on the other hand, is recommended to resuscitate patients with severe sepsis and septic shock in cases for which large amounts of crystalloid are required.
The 2012 SSC guidelines recommend norepinephrine (NE) alone as the first-line vasopressor in sepsis and no longer include dopamine in this category. In fact, the use of dopamine in septic shock has been downgraded and should only to be considered in patients at low risk of tachyarrhythmia and in bradycardia syndromes. Epinephrine is now favored as the second agent or as a substitute to NE. Phenylephrine is no longer recommended unless there is contraindication to using NE, the patient has a high cardiac output, or it is used as a salvage therapy. Vasopressin is considered only an adjunctive agent to NE and should never be used alone.
Recommendations regarding corticosteroid therapy remain largely unchanged from 2008 SCC guidelines, which only support their use when adequate volume resuscitation and vasopressor support has failed to achieve hemodynamic stability. Glucose control is recommended but at the new target of achieving a level of <180 mg/dL, up from a previous target of <150 mg/dL.
Notably, recombinant human activated protein C was completely omitted from the 2012 guidelines, prompted by the voluntary removal of the drug by the manufacturer after failing to show benefit. Use of selenium and intravenous immunoglobulin received comment, but there is insufficient evidence supporting their benefit at the current time. They also encourage clinicians to incorporate goals of care and end-of-life issues into the treatment plan and discuss this with patients and/or surrogates early in treatment.
Guideline Analysis
Prior versions of the SSC guidelines have been met with a fair amount of skepticism.8 Much of the criticism is based on the industry sponsorship of the 2004 version, the lack of transparency regarding potential conflicts of interest of the committee members, and that the bundle recommendations largely were based on only one trial and, therefore, not evidenced-based.9 The 2012 SSC committee seems to have addressed these issues as the guidelines are free of commercial sponsorship in the 2008 and current versions. They also rigorously applied the GRADE system to methodically assess the strength and quality of supporting evidence. The result is a set of guidelines that are partially evidence-based and partially based on expert opinion, but this is clearly delineated in these newest guidelines. This provides clinicians with a clear and concise recommended approach to the patient with severe sepsis and septic shock.
The guidelines continue to place a heavy emphasis on three- and six-hour treatment bundles, and with the assistance of the Institute for Health Care Improvement efforts to improve implementation of the bundle, they are already are widespread with an eye to expand across the country. The components of the three-hour treatment bundle (lactate measurement, blood cultures prior to initiation of antibiotics, broad-spectrum antibiotics, and IV crystalloids for hypotension or for a lactate of >4 mmol/L) recommended by the SSC have not changed substantially since 2008. The one exception is the rate at which IV crystalloid should be administered of 30 mL/kg, which is up from 20 mL/kg. Only time will tell how this change will affect bundle compliance or reduce mortality. But this does pose a significant challenge to quality and performance improvement groups accustomed to tracking compliance with IV fluid administration under the old standard and the educational campaigns associated with a change.
It appears that the SSC is here to stay, now in its third iteration. The lasting legacy of the SSC guidelines might not rest with the content of the guidelines, per se, but in raising awareness of severe sepsis and septic shock in a way that had not previously been considered.
HM Takeaways
The revised 2012 SCC updates bring some new tools to the clinician for early recognition and effective management of patients with sepsis. The push for institutions to adopt screening and performance measures reflects a general trend in health care to create high-performance systems. As these new guidelines are put into practice, there are several changes that might require augmentation of quality metrics being tracked at institutions nationally and internationally.
Dr. Pendharker is assistant professor of medicine in the division of hospital medicine at the University of California San Francisco and San Francisco General Hospital. Dr. Gomez is assistant professor of medicine in the division of pulmonary and critical care medicine at UCSF and San Francisco General Hospital.
References
- Hall MJ, Williams SN, DeFrances CJ, et al. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief. 2011:1-8.
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
- Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752-761.
- Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
- Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38:367-374.
- Guidet B, Martinet O, Boulain T, et al. Assessment of hemodynamic efficacy and safety of 6% hydroxyethylstarch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study. Crit Care. 2012;16:R94.
- Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367:124-134.
- Marik PE. Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011;1:17.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.
How Should Common Symptoms at the End of Life be Managed?
Case
A 58-year-old male with colon cancer metastatic to the liver and lungs presents with vomiting, dyspnea, and abdominal pain. His disease has progressed through third-line chemotherapy and his care is now focused entirely on symptom management. He has not had a bowel movement in five days and he began vomiting two days ago.
Overview
The majority of patients in the United States die in acute-care hospitals. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT), which evaluated the courses of close to 10,000 hospitalized patients with serious and life-limiting illnesses, illustrated that patients’ end-of-life (EOL) experiences often are characterized by poor symptom management and invasive care that is not congruent with the patients’ overall goals of care.1 Studies of factors identified as priorities in EOL care have consistently shown that excellent pain and symptom management are highly valued by patients and families. As the hospitalist movement continues to grow, hospitalists will play a large role in caring for patients at EOL and will need to know how to provide adequate pain and symptom management so that high-quality care can be achieved.
Pain: A Basic Tenet
A basic tenet of palliative medicine is to evaluate and treat all types of suffering.2 Physical pain at EOL is frequently accompanied by other types of pain, such as psychological, social, religious, or existential pain. However, this review will focus on the pharmacologic management of physical pain.
Pain management must begin with a thorough evaluation of the severity, location, and characteristics of the discomfort to assess which therapies are most likely to be beneficial (see Table 1).3 The consistent use of one scale of pain severity (such as 0-10, or mild/moderate/severe) assists in the choice of initial dose of pain medication, in determining the response to the medication, and in assessing the need for change in dose.4
Opioids are the foundation of pain management in advanced diseases because they are available in a number of formulations and, when dosed appropriately, they are effective and safe. Starting doses and equianalgesic doses of common opioids are presented in Table 2. Guidelines recommend the use of short-acting opioids for dose titration to gain control of poorly controlled pain.3 If a patient is experiencing mild pain on a specific regimen, the medication dose can be increased up to 25%; by 25% to 50%, if pain is moderate; and 50% to 100%, if severe.5 When the pain is better-controlled, the total amount of pain medication used in 24 hours (24-hour dose) can be converted to a long-acting formulation for more consistent pain management. Because there is a constant component to most advanced pain syndromes, it is recommended that pain medication is given on a standing basis, with as-needed (prn) doses available for exacerbations of pain.3 Prn doses of short-acting medication (equivalent to approximately 10% of the 24-hour dose of medication) should be available at one- or two-hour intervals prn (longer if hepatic or renal impairment is present) for IV or PO medications, respectively.
Opioids often are categorized as low potency (i.e. codeine, hydrocodone) and high-potency (i.e. oxycodone, morphine, hydromorphone, fentanyl). When given in “equianalgesic doses,” the analgesic effect and common side effects (nausea/vomiting, constipation, sedation, confusion, pruritis) of different opioids can vary in different patients. Due to differences in levels of expressed subtypes of opioid receptors, a given patient might be more sensitive to the analgesic effect or side effects of a specific medication. Therefore, if dose escalation of one opioid is inadequate to control pain and further increases in dose are limited by intolerable side effects, rotation to another opioid is recommended.4 Tables documenting equianalgesic doses of different opioids are based on only moderate evidence from equivalency trials performed in healthy volunteers.6 Due to interpatient differences in responses, it is recommended that the equianalgesic dose of the new medication be decreased by 25% to 50% for initial dosing.5
Certain treatments are indicated for specific pain syndromes. Bony metastases respond to NSAIDs, bisphosphonates, and radiation therapy in addition to opioid medications. As focal back pain is the first symptom of spinal cord compression, clinicians should have a high index of suspicion for compression in any patient with malignancy and new back pain. Steroids and radiation therapy are considered emergent treatments for pain control and to prevent paralysis in this circumstance. Pain due to bowel obstruction is usually colicky in nature and responds well to octreotide as discussed in the section on nausea and vomiting. Steroids (such as dexamethasone 4 mg PO bid-tid) might be an effective adjuvant medication in bone pain, tumor pain, or inflammation.
*Half this dose should be used in renal or liver dysfunction and in the elderly.
Preferred in renal dysfunction.
SOURCES: Adapted from Assessment and treatment of physical pain associated with life-limiting illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 3. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008, and Evidence-based standards for cancer pain management. J Clin Oncol. 2008;26(23):3879-3885.
Back to the Case
At home, the patient was taking 60 mg of extended-release morphine twice daily and six doses per day of 15-mg immediate-release morphine for breakthrough pain. This is the equivalent of 210 mg of oral morphine in 24 hours. His pain is severe on this regimen, but it is unclear how much of this medication he is absorbing due to his vomiting. Using the IV route of administration and a patient-controlled analgesia (PCA) system will enable rapid dose titration and pain control. The equivalent of the 24-hour dose of 210 mg oral morphine is 70 mg IV morphine, which is equivalent to a drip basal rate of approximately 3 mg IV morphine per hour. This basal rate with a bolus dose of 7 mg (10% of the 24-hour dose) IV morphine q1 hour prn is reasonable as a starting point.
Review of the Data: Nausea and Vomiting
Nausea and vomiting affect 40% to 70% of patients in a palliative setting.7 A thorough history and physical exam can enable one to determine the most likely causes, pathways, and receptors involved in the process of nausea and vomiting. It is important to review the timing, frequency, and triggers of vomiting. The oral, abdominal, neurologic, and rectal exams, in addition to a complete chemistry panel, offer helpful information. The most common etiologies and recommended medications are included in Table 3. It is worthwhile to note that serotonin-antagonists (i.e. ondansetron) are first-line therapies only for chemotherapy and radiation-therapy-induced emesis. If a 24-hour trial of one antiemetic therapy is ineffective, one should reassess the etiology and escalate the antiemetic dose, or add a second therapy with a different (pertinent) mechanism of action. Although most studies of antiemetic therapy are case series, there is good evidence for this mechanistic approach.8
*EPS: extrapyramidal symptoms
The various insults and pathways that can cause vomiting are quite complex. The medullary vomiting center (VC) receives vestibular, peripheral (via splanchnic and vagal nerves), and higher cortical inputs and is the final common pathway in the vomiting reflex. The chemoreceptor trigger zone (CTZ) near the fourth ventricle receives input from the vagal and splanchnic nerves, and generates output to the VC.
General dietary recommendations are to avoid sweet, fatty, and highly salted or spiced foods. Small portions of bland foods without strong odors are best tolerated.7 Constipation commonly contributes to nausea and vomiting and should be managed with disimpaction, enemas, and laxatives as tolerated. Imaging may be required to make the important distinction between partial and complete bowel obstruction, as the treatments differ. Surgical procedures, such as colostomy or placement of a venting gastrostomy tube, can relieve pain and vomiting associated with complete bowel obstruction.
Back to the Case
The patient is found to have a fecal impaction on rectal exam, but vomiting persists after disimpaction and enema use. Imaging documents a complete bowel obstruction at the site of a palpable mass in the right upper quadrant and multiple large hepatic metastases. Octreotide is initiated to decrease intestinal secretions and peristalsis. Steroids are given to decrease tumor burden and associated inflammation in the intestine and liver, as well as to relieve distension of the hepatic capsule. Haloperidol is used in low doses to control episodes of nausea.
Review of the Data: Dyspnea
Dyspnea is a common symptom faced by patients at EOL. An estimated 50% of patients who are evaluated in acute-care hospitals seek treatment for the management of this often-crippling symptom.10 Unfortunately, as disease burden progresses, the incidence of dyspnea increases towards EOL, and the presence and severity of dyspnea is strongly correlated with mortality.
It is imperative for providers to appreciate that dyspnea is a subjective symptom, similar to pain. The presence and severity of dyspnea, therefore, depends on patient report. Given its subjective nature, the degree of dyspnea experienced by a patient might not correlate with objective laboratory findings or test results. In practice, the severity of dyspnea is commonly assessed with a numeric rating scale (0-10), verbal analogue scale, or with verbal descriptors (mild, moderate, severe). It is important to determine the underlying etiology of the dyspnea and, if possible, to target interventions to relieve the underlying cause. However, at the end of life, the burdens of invasive studies to determine the exact cause of dyspnea might outweigh the benefits, and invasive testing might not correlate with patients’ and families’ goals of care. In that instance, the goal of treatment should be aggressive symptom management and providers should use clinical judgment to tailor therapies based on the patient’s underlying illness, physical examination, and perhaps on noninvasive radiological or laboratory findings. Below are nonpharmacological and pharmacological interventions that can be employed to help alleviate dyspnea in the actively dying patient.
Nonpharmacological Management
A handheld fan aimed near the patient’s face has been shown to reduce the sensation of dyspnea.11 This relatively safe and inexpensive intervention has no major side effects and can provide improvement in this distressing symptom.
Often, the first line of therapy in the hospital setting for a patient reporting dyspnea is the administration of oxygen therapy. However, recent evidence does not show superiority of oxygen over air inhalation via nasal prongs for dyspnea in patients with advanced cancer or heart failure.12,13
Pharmacological Management
Opioids are first-line therapy for alleviating dyspnea in patients at EOL. The administration of opioids has been shown in systematic reviews to provide effective management of dyspnea.14,15 Practice guidelines by leading expert groups advocate for the use of opioids in the management of dyspnea for patients with advanced malignant and noncancer diseases.10,16 Fear of causing unintended respiratory sedation with opioids limits the prescription of opioids for dyspnea. However, studies have not found a change in mortality with the use of opioids appropriately titrated to control dyspnea.17
Studies examining the role of benzodiazepines in dyspnea management are conflicting. Anecdotal clinical evidence in actively dying patients supports treating dyspnea with benzodiazepines in conjunction with opioid therapy. Benzodiazepines are most beneficial when there is an anxiety-related component to the dyspnea.
Many patients with advanced disease and evidence of airflow obstruction will benefit from nebulized bronchodilator therapy for dyspnea. Patients with dyspnea from fluid overload (i.e. end-stage congestive heart failure or renal disease) might benefit from systemic diuretics. An increasing number of trials are under way to evaluate the efficacy of nebulized furosemide in the symptomatic management of dyspnea.
Back to the Case
The patient’s clinical course decompensates, and he begins to report worsening dyspnea in addition to his underlying pain. He becomes increasingly anxious about what this new symptom means. In addition to having a discussion about disease progression and prognosis, you increase his PCA basal dose to morphine 4 mg/hour to help him with this new symptom. You also add low-dose lorazepam 0.5 mg IV q8 hours as an adjunct agent for his dyspnea. The patient reports improvement of his symptom burden.
Review of the Data: Secretions
Physiological changes occur as a patient enters the active phase of dying. Two such changes are the loss of the ability to swallow and a reduced cough reflex. These changes culminate in an inability to clear secretions, which pool in the oropharynx and the airways. As the patient breathes, air moves over the pooled secretions and produces a gurgling sound that is referred to as the “death rattle.” The onset of this clinical marker has been shown to have significant prognostic significance for predicting imminent death within a period of hours to days. Proposed treatments for the symptom are listed below.
Nonpharmacological Management
Nonpharmacological options include repositioning the patient in a manner that facilitates postural draining.18 Careful and gentle oral suctioning might help reduce secretions if they are salivary in origin. This will not help to clear deeper bronchial secretions. Suctioning of deeper secretions often causes more burden than benefit, as this can cause repeated trauma and possible bleeding.
Family and caregivers at the bedside can find the “death rattle” quite disturbing and often fear that their loved one is “drowning.” Education and counseling that this is not the case, and that the development of secretions is a natural part of the dying process, can help alleviate this concern. Explaining that pharmacological agents can be titrated to decrease secretions is also reassuring to caregivers.
Pharmacological Management
Pharmacological options for secretion management include utilizing anticholinergic medications to prevent the formation of further secretions. These medications are standard of care for managing the death rattle and have been found to be most efficacious if started earlier in the actively dying phase.19,20 Anticholinergic medications include glycopyrrolate (0.2 mg IV q8 hours), atropine sulfate ophthalmological drops (1% solution, 1-2 drops SL q6 hours), hyoscyamine (0.125 mg one to four times a day), and scopolamine (1.5 mg patch q72 hours). These medications all have possible side effects typical of anticholinergic agents, including delirium, constipation, blurred vision, and urinary retention.
Back to the Case
The patient becomes increasingly lethargic. You meet with his family and explain that he is actively dying. His family reiterates that the goals of medical care should focus on maximizing symptom management. His family is concerned about the “gurgly” sound they hear and want to know if that means he is suffering. You educate the family about expected changes that occur with the dying process and inform them that glycopyrrolate 0.2 mg IV q8 hour will be started to minimize further secretions.
Bottom Line
Pain, nausea, dyspnea, and secretions are common end-of-life symptoms that hospitalists should be competent in treating.
Dr. Litrivis is an associate director and assistant professor at the Mount Sinai School of Medicine in New York, and Dr. Neale is an assistant professor at the University of New Mexico School of Medicine in Albuquerque.
References
- The SUPPORT Principal Investigators. A controlled trial to improve the care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591-1598.
- World Health Organization Definition of Palliative Care. World Health Organization website. Available at: http://www.who.int/cancer/palliative/definition/en/. Accessed April 12, 2012.
- NCCN Guidelines Version 2. 2011 Adult Cancer Pain. National Comprehensive Cancer Network website. Available at: http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed April 12, 2012.
- Whitecar PS, Jonas AP, Clasen ME. Managing pain in the dying patient. Am Fam Physician. 2000;61(3):755-764.
- Bial A, Levine S. Assessment and treatment of physical pain associated with life-limiting illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 3. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008.
- Sydney M, et al. Evidence-based standards for cancer pain management. J Clin Oncol. 2008;26(23):3879-3885.
- Mannix KA. Gastrointestinal symptoms. In: Doyle D, Hanks G, Cherny N, Calman K, eds. Oxford Textbook of Palliative Medicine. 3rd ed. New York, NY: Oxford University Press; 2005.
- Tyler LS. Nausea and vomiting in palliative care. In: Lipman AG, Jackson KC, Tyler LS, eds. Evidence-Based Symptom Control in Palliative Care. New York, NY: The Hawthorn Press; 2000.
- Policzer JS, Sobel J. Management of Selected Nonpain Symptoms of Life-Limiting Illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 4. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008.
- Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4): 435-452.
- Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized controlled, crossover trial. J Pain Symptom Manage. 2010;39(5): 831-838.
- Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2006;32(6):541-550.
- Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnea in adults. Cochrane Database Syst Rev. 2008;(3):CD004769.
- Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev. 2001;(4):CD002066.
- Ben-Aharon I, Gafter-Gvili A, Paul M, Leibovici, L, Stemmer, SM. Interventions for alleviating cancer-related dyspnea. A systematic review. J Clin Oncol. 2008;26(14): 2396-2404.
- Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(2):141-146
- Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol. 2008;5(2):90–100.
- Bickel K, Arnold R. EPERC Fast Facts Documents #109 Death Rattle and Oral Secretions, 2nd ed. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_109.htm. Accessed April 15, 2012.
- Wildiers H, Dhaenekint C, Demeulenaere P, et al. Atropine, hyoscine butylbromide, or scopalamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009;38(1):124-133.
- Hugel H, Ellershaw J, Gambles M. Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide. J Palliat Med. 2006;9(2):279-285.
Case
A 58-year-old male with colon cancer metastatic to the liver and lungs presents with vomiting, dyspnea, and abdominal pain. His disease has progressed through third-line chemotherapy and his care is now focused entirely on symptom management. He has not had a bowel movement in five days and he began vomiting two days ago.
Overview
The majority of patients in the United States die in acute-care hospitals. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT), which evaluated the courses of close to 10,000 hospitalized patients with serious and life-limiting illnesses, illustrated that patients’ end-of-life (EOL) experiences often are characterized by poor symptom management and invasive care that is not congruent with the patients’ overall goals of care.1 Studies of factors identified as priorities in EOL care have consistently shown that excellent pain and symptom management are highly valued by patients and families. As the hospitalist movement continues to grow, hospitalists will play a large role in caring for patients at EOL and will need to know how to provide adequate pain and symptom management so that high-quality care can be achieved.
Pain: A Basic Tenet
A basic tenet of palliative medicine is to evaluate and treat all types of suffering.2 Physical pain at EOL is frequently accompanied by other types of pain, such as psychological, social, religious, or existential pain. However, this review will focus on the pharmacologic management of physical pain.
Pain management must begin with a thorough evaluation of the severity, location, and characteristics of the discomfort to assess which therapies are most likely to be beneficial (see Table 1).3 The consistent use of one scale of pain severity (such as 0-10, or mild/moderate/severe) assists in the choice of initial dose of pain medication, in determining the response to the medication, and in assessing the need for change in dose.4
Opioids are the foundation of pain management in advanced diseases because they are available in a number of formulations and, when dosed appropriately, they are effective and safe. Starting doses and equianalgesic doses of common opioids are presented in Table 2. Guidelines recommend the use of short-acting opioids for dose titration to gain control of poorly controlled pain.3 If a patient is experiencing mild pain on a specific regimen, the medication dose can be increased up to 25%; by 25% to 50%, if pain is moderate; and 50% to 100%, if severe.5 When the pain is better-controlled, the total amount of pain medication used in 24 hours (24-hour dose) can be converted to a long-acting formulation for more consistent pain management. Because there is a constant component to most advanced pain syndromes, it is recommended that pain medication is given on a standing basis, with as-needed (prn) doses available for exacerbations of pain.3 Prn doses of short-acting medication (equivalent to approximately 10% of the 24-hour dose of medication) should be available at one- or two-hour intervals prn (longer if hepatic or renal impairment is present) for IV or PO medications, respectively.
Opioids often are categorized as low potency (i.e. codeine, hydrocodone) and high-potency (i.e. oxycodone, morphine, hydromorphone, fentanyl). When given in “equianalgesic doses,” the analgesic effect and common side effects (nausea/vomiting, constipation, sedation, confusion, pruritis) of different opioids can vary in different patients. Due to differences in levels of expressed subtypes of opioid receptors, a given patient might be more sensitive to the analgesic effect or side effects of a specific medication. Therefore, if dose escalation of one opioid is inadequate to control pain and further increases in dose are limited by intolerable side effects, rotation to another opioid is recommended.4 Tables documenting equianalgesic doses of different opioids are based on only moderate evidence from equivalency trials performed in healthy volunteers.6 Due to interpatient differences in responses, it is recommended that the equianalgesic dose of the new medication be decreased by 25% to 50% for initial dosing.5
Certain treatments are indicated for specific pain syndromes. Bony metastases respond to NSAIDs, bisphosphonates, and radiation therapy in addition to opioid medications. As focal back pain is the first symptom of spinal cord compression, clinicians should have a high index of suspicion for compression in any patient with malignancy and new back pain. Steroids and radiation therapy are considered emergent treatments for pain control and to prevent paralysis in this circumstance. Pain due to bowel obstruction is usually colicky in nature and responds well to octreotide as discussed in the section on nausea and vomiting. Steroids (such as dexamethasone 4 mg PO bid-tid) might be an effective adjuvant medication in bone pain, tumor pain, or inflammation.
*Half this dose should be used in renal or liver dysfunction and in the elderly.
Preferred in renal dysfunction.
SOURCES: Adapted from Assessment and treatment of physical pain associated with life-limiting illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 3. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008, and Evidence-based standards for cancer pain management. J Clin Oncol. 2008;26(23):3879-3885.
Back to the Case
At home, the patient was taking 60 mg of extended-release morphine twice daily and six doses per day of 15-mg immediate-release morphine for breakthrough pain. This is the equivalent of 210 mg of oral morphine in 24 hours. His pain is severe on this regimen, but it is unclear how much of this medication he is absorbing due to his vomiting. Using the IV route of administration and a patient-controlled analgesia (PCA) system will enable rapid dose titration and pain control. The equivalent of the 24-hour dose of 210 mg oral morphine is 70 mg IV morphine, which is equivalent to a drip basal rate of approximately 3 mg IV morphine per hour. This basal rate with a bolus dose of 7 mg (10% of the 24-hour dose) IV morphine q1 hour prn is reasonable as a starting point.
Review of the Data: Nausea and Vomiting
Nausea and vomiting affect 40% to 70% of patients in a palliative setting.7 A thorough history and physical exam can enable one to determine the most likely causes, pathways, and receptors involved in the process of nausea and vomiting. It is important to review the timing, frequency, and triggers of vomiting. The oral, abdominal, neurologic, and rectal exams, in addition to a complete chemistry panel, offer helpful information. The most common etiologies and recommended medications are included in Table 3. It is worthwhile to note that serotonin-antagonists (i.e. ondansetron) are first-line therapies only for chemotherapy and radiation-therapy-induced emesis. If a 24-hour trial of one antiemetic therapy is ineffective, one should reassess the etiology and escalate the antiemetic dose, or add a second therapy with a different (pertinent) mechanism of action. Although most studies of antiemetic therapy are case series, there is good evidence for this mechanistic approach.8
*EPS: extrapyramidal symptoms
The various insults and pathways that can cause vomiting are quite complex. The medullary vomiting center (VC) receives vestibular, peripheral (via splanchnic and vagal nerves), and higher cortical inputs and is the final common pathway in the vomiting reflex. The chemoreceptor trigger zone (CTZ) near the fourth ventricle receives input from the vagal and splanchnic nerves, and generates output to the VC.
General dietary recommendations are to avoid sweet, fatty, and highly salted or spiced foods. Small portions of bland foods without strong odors are best tolerated.7 Constipation commonly contributes to nausea and vomiting and should be managed with disimpaction, enemas, and laxatives as tolerated. Imaging may be required to make the important distinction between partial and complete bowel obstruction, as the treatments differ. Surgical procedures, such as colostomy or placement of a venting gastrostomy tube, can relieve pain and vomiting associated with complete bowel obstruction.
Back to the Case
The patient is found to have a fecal impaction on rectal exam, but vomiting persists after disimpaction and enema use. Imaging documents a complete bowel obstruction at the site of a palpable mass in the right upper quadrant and multiple large hepatic metastases. Octreotide is initiated to decrease intestinal secretions and peristalsis. Steroids are given to decrease tumor burden and associated inflammation in the intestine and liver, as well as to relieve distension of the hepatic capsule. Haloperidol is used in low doses to control episodes of nausea.
Review of the Data: Dyspnea
Dyspnea is a common symptom faced by patients at EOL. An estimated 50% of patients who are evaluated in acute-care hospitals seek treatment for the management of this often-crippling symptom.10 Unfortunately, as disease burden progresses, the incidence of dyspnea increases towards EOL, and the presence and severity of dyspnea is strongly correlated with mortality.
It is imperative for providers to appreciate that dyspnea is a subjective symptom, similar to pain. The presence and severity of dyspnea, therefore, depends on patient report. Given its subjective nature, the degree of dyspnea experienced by a patient might not correlate with objective laboratory findings or test results. In practice, the severity of dyspnea is commonly assessed with a numeric rating scale (0-10), verbal analogue scale, or with verbal descriptors (mild, moderate, severe). It is important to determine the underlying etiology of the dyspnea and, if possible, to target interventions to relieve the underlying cause. However, at the end of life, the burdens of invasive studies to determine the exact cause of dyspnea might outweigh the benefits, and invasive testing might not correlate with patients’ and families’ goals of care. In that instance, the goal of treatment should be aggressive symptom management and providers should use clinical judgment to tailor therapies based on the patient’s underlying illness, physical examination, and perhaps on noninvasive radiological or laboratory findings. Below are nonpharmacological and pharmacological interventions that can be employed to help alleviate dyspnea in the actively dying patient.
Nonpharmacological Management
A handheld fan aimed near the patient’s face has been shown to reduce the sensation of dyspnea.11 This relatively safe and inexpensive intervention has no major side effects and can provide improvement in this distressing symptom.
Often, the first line of therapy in the hospital setting for a patient reporting dyspnea is the administration of oxygen therapy. However, recent evidence does not show superiority of oxygen over air inhalation via nasal prongs for dyspnea in patients with advanced cancer or heart failure.12,13
Pharmacological Management
Opioids are first-line therapy for alleviating dyspnea in patients at EOL. The administration of opioids has been shown in systematic reviews to provide effective management of dyspnea.14,15 Practice guidelines by leading expert groups advocate for the use of opioids in the management of dyspnea for patients with advanced malignant and noncancer diseases.10,16 Fear of causing unintended respiratory sedation with opioids limits the prescription of opioids for dyspnea. However, studies have not found a change in mortality with the use of opioids appropriately titrated to control dyspnea.17
Studies examining the role of benzodiazepines in dyspnea management are conflicting. Anecdotal clinical evidence in actively dying patients supports treating dyspnea with benzodiazepines in conjunction with opioid therapy. Benzodiazepines are most beneficial when there is an anxiety-related component to the dyspnea.
Many patients with advanced disease and evidence of airflow obstruction will benefit from nebulized bronchodilator therapy for dyspnea. Patients with dyspnea from fluid overload (i.e. end-stage congestive heart failure or renal disease) might benefit from systemic diuretics. An increasing number of trials are under way to evaluate the efficacy of nebulized furosemide in the symptomatic management of dyspnea.
Back to the Case
The patient’s clinical course decompensates, and he begins to report worsening dyspnea in addition to his underlying pain. He becomes increasingly anxious about what this new symptom means. In addition to having a discussion about disease progression and prognosis, you increase his PCA basal dose to morphine 4 mg/hour to help him with this new symptom. You also add low-dose lorazepam 0.5 mg IV q8 hours as an adjunct agent for his dyspnea. The patient reports improvement of his symptom burden.
Review of the Data: Secretions
Physiological changes occur as a patient enters the active phase of dying. Two such changes are the loss of the ability to swallow and a reduced cough reflex. These changes culminate in an inability to clear secretions, which pool in the oropharynx and the airways. As the patient breathes, air moves over the pooled secretions and produces a gurgling sound that is referred to as the “death rattle.” The onset of this clinical marker has been shown to have significant prognostic significance for predicting imminent death within a period of hours to days. Proposed treatments for the symptom are listed below.
Nonpharmacological Management
Nonpharmacological options include repositioning the patient in a manner that facilitates postural draining.18 Careful and gentle oral suctioning might help reduce secretions if they are salivary in origin. This will not help to clear deeper bronchial secretions. Suctioning of deeper secretions often causes more burden than benefit, as this can cause repeated trauma and possible bleeding.
Family and caregivers at the bedside can find the “death rattle” quite disturbing and often fear that their loved one is “drowning.” Education and counseling that this is not the case, and that the development of secretions is a natural part of the dying process, can help alleviate this concern. Explaining that pharmacological agents can be titrated to decrease secretions is also reassuring to caregivers.
Pharmacological Management
Pharmacological options for secretion management include utilizing anticholinergic medications to prevent the formation of further secretions. These medications are standard of care for managing the death rattle and have been found to be most efficacious if started earlier in the actively dying phase.19,20 Anticholinergic medications include glycopyrrolate (0.2 mg IV q8 hours), atropine sulfate ophthalmological drops (1% solution, 1-2 drops SL q6 hours), hyoscyamine (0.125 mg one to four times a day), and scopolamine (1.5 mg patch q72 hours). These medications all have possible side effects typical of anticholinergic agents, including delirium, constipation, blurred vision, and urinary retention.
Back to the Case
The patient becomes increasingly lethargic. You meet with his family and explain that he is actively dying. His family reiterates that the goals of medical care should focus on maximizing symptom management. His family is concerned about the “gurgly” sound they hear and want to know if that means he is suffering. You educate the family about expected changes that occur with the dying process and inform them that glycopyrrolate 0.2 mg IV q8 hour will be started to minimize further secretions.
Bottom Line
Pain, nausea, dyspnea, and secretions are common end-of-life symptoms that hospitalists should be competent in treating.
Dr. Litrivis is an associate director and assistant professor at the Mount Sinai School of Medicine in New York, and Dr. Neale is an assistant professor at the University of New Mexico School of Medicine in Albuquerque.
References
- The SUPPORT Principal Investigators. A controlled trial to improve the care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591-1598.
- World Health Organization Definition of Palliative Care. World Health Organization website. Available at: http://www.who.int/cancer/palliative/definition/en/. Accessed April 12, 2012.
- NCCN Guidelines Version 2. 2011 Adult Cancer Pain. National Comprehensive Cancer Network website. Available at: http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed April 12, 2012.
- Whitecar PS, Jonas AP, Clasen ME. Managing pain in the dying patient. Am Fam Physician. 2000;61(3):755-764.
- Bial A, Levine S. Assessment and treatment of physical pain associated with life-limiting illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 3. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008.
- Sydney M, et al. Evidence-based standards for cancer pain management. J Clin Oncol. 2008;26(23):3879-3885.
- Mannix KA. Gastrointestinal symptoms. In: Doyle D, Hanks G, Cherny N, Calman K, eds. Oxford Textbook of Palliative Medicine. 3rd ed. New York, NY: Oxford University Press; 2005.
- Tyler LS. Nausea and vomiting in palliative care. In: Lipman AG, Jackson KC, Tyler LS, eds. Evidence-Based Symptom Control in Palliative Care. New York, NY: The Hawthorn Press; 2000.
- Policzer JS, Sobel J. Management of Selected Nonpain Symptoms of Life-Limiting Illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 4. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008.
- Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4): 435-452.
- Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized controlled, crossover trial. J Pain Symptom Manage. 2010;39(5): 831-838.
- Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2006;32(6):541-550.
- Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnea in adults. Cochrane Database Syst Rev. 2008;(3):CD004769.
- Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev. 2001;(4):CD002066.
- Ben-Aharon I, Gafter-Gvili A, Paul M, Leibovici, L, Stemmer, SM. Interventions for alleviating cancer-related dyspnea. A systematic review. J Clin Oncol. 2008;26(14): 2396-2404.
- Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(2):141-146
- Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol. 2008;5(2):90–100.
- Bickel K, Arnold R. EPERC Fast Facts Documents #109 Death Rattle and Oral Secretions, 2nd ed. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_109.htm. Accessed April 15, 2012.
- Wildiers H, Dhaenekint C, Demeulenaere P, et al. Atropine, hyoscine butylbromide, or scopalamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009;38(1):124-133.
- Hugel H, Ellershaw J, Gambles M. Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide. J Palliat Med. 2006;9(2):279-285.
Case
A 58-year-old male with colon cancer metastatic to the liver and lungs presents with vomiting, dyspnea, and abdominal pain. His disease has progressed through third-line chemotherapy and his care is now focused entirely on symptom management. He has not had a bowel movement in five days and he began vomiting two days ago.
Overview
The majority of patients in the United States die in acute-care hospitals. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT), which evaluated the courses of close to 10,000 hospitalized patients with serious and life-limiting illnesses, illustrated that patients’ end-of-life (EOL) experiences often are characterized by poor symptom management and invasive care that is not congruent with the patients’ overall goals of care.1 Studies of factors identified as priorities in EOL care have consistently shown that excellent pain and symptom management are highly valued by patients and families. As the hospitalist movement continues to grow, hospitalists will play a large role in caring for patients at EOL and will need to know how to provide adequate pain and symptom management so that high-quality care can be achieved.
Pain: A Basic Tenet
A basic tenet of palliative medicine is to evaluate and treat all types of suffering.2 Physical pain at EOL is frequently accompanied by other types of pain, such as psychological, social, religious, or existential pain. However, this review will focus on the pharmacologic management of physical pain.
Pain management must begin with a thorough evaluation of the severity, location, and characteristics of the discomfort to assess which therapies are most likely to be beneficial (see Table 1).3 The consistent use of one scale of pain severity (such as 0-10, or mild/moderate/severe) assists in the choice of initial dose of pain medication, in determining the response to the medication, and in assessing the need for change in dose.4
Opioids are the foundation of pain management in advanced diseases because they are available in a number of formulations and, when dosed appropriately, they are effective and safe. Starting doses and equianalgesic doses of common opioids are presented in Table 2. Guidelines recommend the use of short-acting opioids for dose titration to gain control of poorly controlled pain.3 If a patient is experiencing mild pain on a specific regimen, the medication dose can be increased up to 25%; by 25% to 50%, if pain is moderate; and 50% to 100%, if severe.5 When the pain is better-controlled, the total amount of pain medication used in 24 hours (24-hour dose) can be converted to a long-acting formulation for more consistent pain management. Because there is a constant component to most advanced pain syndromes, it is recommended that pain medication is given on a standing basis, with as-needed (prn) doses available for exacerbations of pain.3 Prn doses of short-acting medication (equivalent to approximately 10% of the 24-hour dose of medication) should be available at one- or two-hour intervals prn (longer if hepatic or renal impairment is present) for IV or PO medications, respectively.
Opioids often are categorized as low potency (i.e. codeine, hydrocodone) and high-potency (i.e. oxycodone, morphine, hydromorphone, fentanyl). When given in “equianalgesic doses,” the analgesic effect and common side effects (nausea/vomiting, constipation, sedation, confusion, pruritis) of different opioids can vary in different patients. Due to differences in levels of expressed subtypes of opioid receptors, a given patient might be more sensitive to the analgesic effect or side effects of a specific medication. Therefore, if dose escalation of one opioid is inadequate to control pain and further increases in dose are limited by intolerable side effects, rotation to another opioid is recommended.4 Tables documenting equianalgesic doses of different opioids are based on only moderate evidence from equivalency trials performed in healthy volunteers.6 Due to interpatient differences in responses, it is recommended that the equianalgesic dose of the new medication be decreased by 25% to 50% for initial dosing.5
Certain treatments are indicated for specific pain syndromes. Bony metastases respond to NSAIDs, bisphosphonates, and radiation therapy in addition to opioid medications. As focal back pain is the first symptom of spinal cord compression, clinicians should have a high index of suspicion for compression in any patient with malignancy and new back pain. Steroids and radiation therapy are considered emergent treatments for pain control and to prevent paralysis in this circumstance. Pain due to bowel obstruction is usually colicky in nature and responds well to octreotide as discussed in the section on nausea and vomiting. Steroids (such as dexamethasone 4 mg PO bid-tid) might be an effective adjuvant medication in bone pain, tumor pain, or inflammation.
*Half this dose should be used in renal or liver dysfunction and in the elderly.
Preferred in renal dysfunction.
SOURCES: Adapted from Assessment and treatment of physical pain associated with life-limiting illness. Hospice and Palliative Care Training for Physicians: UNIPAC. Vol 3. 3rd ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008, and Evidence-based standards for cancer pain management. J Clin Oncol. 2008;26(23):3879-3885.
Back to the Case
At home, the patient was taking 60 mg of extended-release morphine twice daily and six doses per day of 15-mg immediate-release morphine for breakthrough pain. This is the equivalent of 210 mg of oral morphine in 24 hours. His pain is severe on this regimen, but it is unclear how much of this medication he is absorbing due to his vomiting. Using the IV route of administration and a patient-controlled analgesia (PCA) system will enable rapid dose titration and pain control. The equivalent of the 24-hour dose of 210 mg oral morphine is 70 mg IV morphine, which is equivalent to a drip basal rate of approximately 3 mg IV morphine per hour. This basal rate with a bolus dose of 7 mg (10% of the 24-hour dose) IV morphine q1 hour prn is reasonable as a starting point.
Review of the Data: Nausea and Vomiting
Nausea and vomiting affect 40% to 70% of patients in a palliative setting.7 A thorough history and physical exam can enable one to determine the most likely causes, pathways, and receptors involved in the process of nausea and vomiting. It is important to review the timing, frequency, and triggers of vomiting. The oral, abdominal, neurologic, and rectal exams, in addition to a complete chemistry panel, offer helpful information. The most common etiologies and recommended medications are included in Table 3. It is worthwhile to note that serotonin-antagonists (i.e. ondansetron) are first-line therapies only for chemotherapy and radiation-therapy-induced emesis. If a 24-hour trial of one antiemetic therapy is ineffective, one should reassess the etiology and escalate the antiemetic dose, or add a second therapy with a different (pertinent) mechanism of action. Although most studies of antiemetic therapy are case series, there is good evidence for this mechanistic approach.8
*EPS: extrapyramidal symptoms
The various insults and pathways that can cause vomiting are quite complex. The medullary vomiting center (VC) receives vestibular, peripheral (via splanchnic and vagal nerves), and higher cortical inputs and is the final common pathway in the vomiting reflex. The chemoreceptor trigger zone (CTZ) near the fourth ventricle receives input from the vagal and splanchnic nerves, and generates output to the VC.
General dietary recommendations are to avoid sweet, fatty, and highly salted or spiced foods. Small portions of bland foods without strong odors are best tolerated.7 Constipation commonly contributes to nausea and vomiting and should be managed with disimpaction, enemas, and laxatives as tolerated. Imaging may be required to make the important distinction between partial and complete bowel obstruction, as the treatments differ. Surgical procedures, such as colostomy or placement of a venting gastrostomy tube, can relieve pain and vomiting associated with complete bowel obstruction.
Back to the Case
The patient is found to have a fecal impaction on rectal exam, but vomiting persists after disimpaction and enema use. Imaging documents a complete bowel obstruction at the site of a palpable mass in the right upper quadrant and multiple large hepatic metastases. Octreotide is initiated to decrease intestinal secretions and peristalsis. Steroids are given to decrease tumor burden and associated inflammation in the intestine and liver, as well as to relieve distension of the hepatic capsule. Haloperidol is used in low doses to control episodes of nausea.
Review of the Data: Dyspnea
Dyspnea is a common symptom faced by patients at EOL. An estimated 50% of patients who are evaluated in acute-care hospitals seek treatment for the management of this often-crippling symptom.10 Unfortunately, as disease burden progresses, the incidence of dyspnea increases towards EOL, and the presence and severity of dyspnea is strongly correlated with mortality.
It is imperative for providers to appreciate that dyspnea is a subjective symptom, similar to pain. The presence and severity of dyspnea, therefore, depends on patient report. Given its subjective nature, the degree of dyspnea experienced by a patient might not correlate with objective laboratory findings or test results. In practice, the severity of dyspnea is commonly assessed with a numeric rating scale (0-10), verbal analogue scale, or with verbal descriptors (mild, moderate, severe). It is important to determine the underlying etiology of the dyspnea and, if possible, to target interventions to relieve the underlying cause. However, at the end of life, the burdens of invasive studies to determine the exact cause of dyspnea might outweigh the benefits, and invasive testing might not correlate with patients’ and families’ goals of care. In that instance, the goal of treatment should be aggressive symptom management and providers should use clinical judgment to tailor therapies based on the patient’s underlying illness, physical examination, and perhaps on noninvasive radiological or laboratory findings. Below are nonpharmacological and pharmacological interventions that can be employed to help alleviate dyspnea in the actively dying patient.
Nonpharmacological Management
A handheld fan aimed near the patient’s face has been shown to reduce the sensation of dyspnea.11 This relatively safe and inexpensive intervention has no major side effects and can provide improvement in this distressing symptom.
Often, the first line of therapy in the hospital setting for a patient reporting dyspnea is the administration of oxygen therapy. However, recent evidence does not show superiority of oxygen over air inhalation via nasal prongs for dyspnea in patients with advanced cancer or heart failure.12,13
Pharmacological Management
Opioids are first-line therapy for alleviating dyspnea in patients at EOL. The administration of opioids has been shown in systematic reviews to provide effective management of dyspnea.14,15 Practice guidelines by leading expert groups advocate for the use of opioids in the management of dyspnea for patients with advanced malignant and noncancer diseases.10,16 Fear of causing unintended respiratory sedation with opioids limits the prescription of opioids for dyspnea. However, studies have not found a change in mortality with the use of opioids appropriately titrated to control dyspnea.17
Studies examining the role of benzodiazepines in dyspnea management are conflicting. Anecdotal clinical evidence in actively dying patients supports treating dyspnea with benzodiazepines in conjunction with opioid therapy. Benzodiazepines are most beneficial when there is an anxiety-related component to the dyspnea.
Many patients with advanced disease and evidence of airflow obstruction will benefit from nebulized bronchodilator therapy for dyspnea. Patients with dyspnea from fluid overload (i.e. end-stage congestive heart failure or renal disease) might benefit from systemic diuretics. An increasing number of trials are under way to evaluate the efficacy of nebulized furosemide in the symptomatic management of dyspnea.
Back to the Case
The patient’s clinical course decompensates, and he begins to report worsening dyspnea in addition to his underlying pain. He becomes increasingly anxious about what this new symptom means. In addition to having a discussion about disease progression and prognosis, you increase his PCA basal dose to morphine 4 mg/hour to help him with this new symptom. You also add low-dose lorazepam 0.5 mg IV q8 hours as an adjunct agent for his dyspnea. The patient reports improvement of his symptom burden.
Review of the Data: Secretions
Physiological changes occur as a patient enters the active phase of dying. Two such changes are the loss of the ability to swallow and a reduced cough reflex. These changes culminate in an inability to clear secretions, which pool in the oropharynx and the airways. As the patient breathes, air moves over the pooled secretions and produces a gurgling sound that is referred to as the “death rattle.” The onset of this clinical marker has been shown to have significant prognostic significance for predicting imminent death within a period of hours to days. Proposed treatments for the symptom are listed below.
Nonpharmacological Management
Nonpharmacological options include repositioning the patient in a manner that facilitates postural draining.18 Careful and gentle oral suctioning might help reduce secretions if they are salivary in origin. This will not help to clear deeper bronchial secretions. Suctioning of deeper secretions often causes more burden than benefit, as this can cause repeated trauma and possible bleeding.
Family and caregivers at the bedside can find the “death rattle” quite disturbing and often fear that their loved one is “drowning.” Education and counseling that this is not the case, and that the development of secretions is a natural part of the dying process, can help alleviate this concern. Explaining that pharmacological agents can be titrated to decrease secretions is also reassuring to caregivers.
Pharmacological Management
Pharmacological options for secretion management include utilizing anticholinergic medications to prevent the formation of further secretions. These medications are standard of care for managing the death rattle and have been found to be most efficacious if started earlier in the actively dying phase.19,20 Anticholinergic medications include glycopyrrolate (0.2 mg IV q8 hours), atropine sulfate ophthalmological drops (1% solution, 1-2 drops SL q6 hours), hyoscyamine (0.125 mg one to four times a day), and scopolamine (1.5 mg patch q72 hours). These medications all have possible side effects typical of anticholinergic agents, including delirium, constipation, blurred vision, and urinary retention.
Back to the Case
The patient becomes increasingly lethargic. You meet with his family and explain that he is actively dying. His family reiterates that the goals of medical care should focus on maximizing symptom management. His family is concerned about the “gurgly” sound they hear and want to know if that means he is suffering. You educate the family about expected changes that occur with the dying process and inform them that glycopyrrolate 0.2 mg IV q8 hour will be started to minimize further secretions.
Bottom Line
Pain, nausea, dyspnea, and secretions are common end-of-life symptoms that hospitalists should be competent in treating.
Dr. Litrivis is an associate director and assistant professor at the Mount Sinai School of Medicine in New York, and Dr. Neale is an assistant professor at the University of New Mexico School of Medicine in Albuquerque.
References
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