Propofol for painful procedures in palliative care.

Refractory pain during care procedures causes a real challenge for terminally ill patients. We are hereby publishing three cases of patients who received repeated procedural sedations using propofol during the painful care procedures. All patients experience pain relief with no side effects although care procedures initially were a traumatic experience to them despite the usual medication. This therapeutic solution, which would need to be assessed on a case-by-case basis by evaluating the benefit-risk balance, could become a suitable comfort treatment used by palliative care teams.

Sedation by Propofol for Painful Care Procedures at the End of Life: A Pilot Study. PROPOPAL 1.

BACKGROUND: At the end of life, patients may feel refractory pain during care procedures although they receive appropriate analgesia. They can benefit from a short-term sedation. Propofol is used for procedural sedation in emergency or reanimation departments. It may be adapted in a palliative care unit. OBJECTIVE: The main objective was to verify whether propofol could allow us to administer care without causing major pain to patients with refractory pain at the end of life. DESIGN: We conducted an open, prospective, and uncontrolled pilot study. SETTING/SUBJECTS: The study was conducted in one palliative care center in France. The subjects were patients with an estimated prognosis less than three months who experienced pain during care procedures, although they receive appropriate analgesia. RESULTS: Ten patients were included. Care was delivered with no major pain for 9 patients out of 10. The average duration of induction to reach deep sedation was 4 minutes (2-8) and of care procedures was 13 minutes (7-32). On average, the patient woke up 11.5 minutes after we stopped injecting propofol (7-18). Only one patient experienced a significant adverse effect caused by propofol, but it did not have any harmful consequence except the interruption of care procedures. CONCLUSION: Transitory sedation using propofol for terminally ill patients hospitalized in a palliative care unit can offer optimal comfort during painful care procedures without significant complications. Patients woke up quickly. Further studies will have to be conducted to verify these initial results and make sure there are no major drawbacks.

Methadone rotation for cancer patients with refractory pain in a palliative care unit: an observational study.

BACKGROUND: Methadone has been reported to be as effective as morphine for cancer pain management. It is commonly used as an alternative opioid in case of insufficient relief. OBJECTIVE: Our aim was to assess efficacy and tolerance of opioid rotation to methadone for refractory cancer pain management in palliative care unit (PCU) inpatients. METHODS: All the patients undergoing opioid rotation to methadone from 2008 to 2011 in two PCUs (Lyon and Nice, France) were included. Pain assessments were undertaken on day 0 (D0), day 3 (D3), day 7 (D7), and day 14 (D14) using a visual analogue scale (VAS; 0-10) and the Douleur Neuropathique 4 (DN4) scale for neuropathic pain. Patients reported pain relief using a 4-point Likert scale (1=no relief; 4=important relief ). RESULTS: Nineteen patients (7 females) with a median age of 55 (Q1-Q3; 44-58) underwent methadone rotation. The most common type of cancer was gastrointestinal. Seventeen patients had a diagnosis of mixed pain syndromes. Morphine equivalent daily dose (MEDD) prior to switching was 480 mg (Q1-Q3; 100-1021), and at least two nonmethadone opioid rotations had already been done for 13 patients. Between D0 and D7, the VAS score decreased by 4 points (p<0.001). The DN4 score became negative on D7 for 11 of 17 patients (65%). On D7, 16 of 18 patients (89%) expressed moderate to greater than moderate pain relief. Methadone was discontinued in one patient on D7 because it was deemed ineffective and for 8 patients, who were unable to take oral drugs, it was discontinued after D14. CONCLUSION: Our results suggest that methadone is effective and well tolerated for refractory cancer pain.

[Impact of a hospice home visit team on unwanted hospitalization of terminally-ill patients at home in acute medical emergencies]. / Impact d'une équipe d'urgence spécialisée sur les hospitalisations non désirées de patients en phase terminale à domicile.

OBJECTIVES: This study was undertaken to evaluate the impact of paramedical hospice specialists on hospitalization of terminally-ill patients in acute medical emergencies. METHOD: In this intervention, the SAMU (French medical emergency call center) responded to requests for emergency aid at the homes of terminally-ill patients by sending to the patient's home, together with a physician and the emergency ambulance team, a team composed of a nurse and a volunteer, both trained in hospice (terminal) care . When the patient wished to stay at home, the hospice team remained to support the patient and family and to provide comfort care until the crisis situation stabilized. This before-and-after study compares SAMU calls during the first year of the intervention to those in the preceding year. RESULTS: During the intervention period, 14% of patients were hospitalized compared with 48% during the reference year (p<0.0001), for a relative risk of hospitalization of 0.29. The emergency hospice team was considered to be not only complementary but also essential in emergency medical situations for patients receiving palliative care at home. Interaction with existing services did not present problems. Families benefited from considerable assistance in particularly difficult situations. CONCLUSION: A team of paramedical hospice specialists, acting on request of the SAMU, provides a concrete and useful response to problems of unwanted hospitalization in acute emergencies for home-based terminally ill patients. This type of organization is consistent with respect for the patient's choice to remain at home until the end of life. Prevention of unwanted hospitalization and heroic measures should undoubtedly result in cost savings more than sufficient to fund this program.

[Emergencies in patients undergoing palliative care at home. A qualitative study of telephone calls to Center 15]. / Urgences chez les patients en soins palliatifs à domicile. Une étude qualitative des appels vers un Centre 15.

INTRODUCTION: The Samu-Centres 15 (French medical emergency centers) are regularly solicited for patients undergoing palliative treatment at their homes and presenting acute complications. No specific response is foreseen for such situations. However, the problems are frequent and crucial. Who is the most appropriate person to intervene? Should the patient be hospitalised or not? Does the patient require reanimation? What are the patients' and families' needs in such circumstances? In an attempt to outline the answers, we collected the opinion of the families concerned. METHOD: We interviewed all the families soliciting the Samu for emergencies concerning patients undergoing palliative treatment at home. To collect their feelings and experience, we used a survey in the form of non directive interviews. RESULTS: In a month, 12 telephone calls concerning our matter were received by the Centre 15 of the Alpes-Maritimes. The interview with the families revealed many elements such as loneliness, guilty feelings, responsibility, surprise when the death occurs, the poor adaptation of the structures and the lack of training of the emergency medical staff. CONCLUSION: The issues underlined require enhanced attention: how can we help the families in such situations? How should the emergency medical staff be trained in accompanying death and palliative treatment? Are the existing structures adapted?