Lidocaine Infusion for Refractory Pain from Rat Lungworm Disease - Honolulu, Hawai'i.

Human infection with Angiostrongyloides cantonensis, or rat lungworm disease, manifests most commonly with neurologic symptoms that often include severe diffuse pain. While pain is reported by the majority of patients with rat lungworm disease, there are presently no published guidelines on the approach to pain management for these patients. Here we report a case of rat lungworm disease where severe refractory pain was the most prominent symptom and an intravenous lidocaine infusion was used as a successful treatment modality. Intravenous lidocaine has been shown to be safe and effective in neuropathic pain, refractory cancer pain, and peri-operative pain management. To our knowledge, this is the first case report on the use of lidocaine infusion for the management of refractory pain from rat lungworm disease, and among the first reports of any approach, to pain management for rat lungworm disease. We suggest that a lidocaine infusion protocol be considered when pain from rat lungworm disease fails to respond to first-line analgesics.

Wanted and Unwanted Care: The Double-Edged Sword of Partial Do-Not-Resuscitate Orders.

BACKGROUND: The interpretation of do-not-resuscitate orders (DNRs) may vary in nonarrest situations. To reduce ambiguity, many hospitals allow patients to elect partial DNRs. OBJECTIVE: To investigate the effect of partial DNRs on physicians' willingness to perform cardiopulmonary resuscitation (CPR) and nonarrest procedures. DESIGN: Cross-sectional study using scenario-based questionnaires between October 2015 and March 2016. A partial DNR was identified as a DNR with Adult Emergency Protocols (AEP) order. Each survey presented 3 patient scenarios followed by 10 interventions. SETTING/SUBJECTS: Preclerkship and clerkship medical students, and internal medicine residents at a single medical school, and hospitalists at a tertiary-care academic medical center. RESULTS: Responses from 275 of 366 (75.1%) eligible subjects were collected. Compared to the case with a full DNR, the presence of a partial DNR was positively associated with subjects' willingness to provide both nonarrest procedures and CPR (p < 0.05). The number of training or practice years was positively associated with a decision not to perform CPR: case 1 (odds ratio [OR], 1.09; confidence interval [CI], 1.04-1.16; p = 0.003); case 2 (OR, 1.07; CI, 1.01-1.14; p = 0.03); and case 3 (OR, 1.09; CI, 1.04-1.16; p < 0.001). CONCLUSIONS: A partial DNR made our respondents more willing to provide nonarrest procedures, but also CPR. These findings suggest an ongoing need to develop better means of incorporating patients' goals of care into orders that more faithfully guide care for both nonarrest and arrest situations.

What's the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation.

To inform earlier identification of intensive care unit (ICU) patients needing palliative care, we examined factors associated with in-hospital death among ICU patients (N=260) receiving palliative care consultations at a 542-bed tertiary care hospital (2005-2009). High pre-consultation length of stay (LOS, ≥7 days) (adjusted odds ratio (aOR)=5.0, 95% confidence interval (95% CI)=2.5-9.9, P<.01) and consultations for assistance with plan of care (aOR=11.6, 95% CI=5.6-23.9, P<.01) were independently associated with in-hospital death. Patients with both consultation for plan of care and high pre-consult LOS had the highest odds of in-hospital death (aOR=36.3, 95% CI=14.9-88.5, P<.001), followed by patients with consultation for plan of care and shorter pre-consult LOS (aOR=9.8, 95% CI=4.3-22.1, P<.001), and patients with long pre-consult LOS but no consultation for plan of care (aOR=4.7, 95% CI=1.8-12.4, P=.002). Our findings suggest that ICU patients who require assistance with plan of care need to be identified early to optimize end-of-life care and avoid in-hospital death.

Provider Orders for Life-Sustaining Treatment Implementation and Training in Nursing Facilities in Hawai'i.

A Provider Orders for Life-Sustaining Treatment (POLST) document transforms medical wishes for end-of-life care into actionable medical orders. This study was conducted to assess the extent of POLST implementation amongst nursing facilities in Hawai'i. We performed a telephone survey . The survey instrument included questions about advance care planning processes, POLST training procedures, and implementation of the POLST paradigm. Data were collected in July 2014, the month POLST signatory capacity expanded to include Advance Practice Registered Nurses (APRNs). Of the 39 nursing facilities contacted, 23 (59%) responded. All but one facility had a POLST program in place. Social workers and nursing staff usually held the POLST discussions. Of the 23 responding facilities, 13 (57%) had at least one APRN provider, and 8 had APRNs involved in POLST discussions. In all but one instance, APRNs were also already signing the document. The percentage of residents with completed POLST forms per facility was reported to be over 50% for 20 out of 23 (87%) of responding nursing facilities with 10 (43%) reporting achieving 100% implementation rates. Training seminars and online educational materials were the main methods for training staff, with social workers and nurses being the focus for training. The results of this study demonstrate significant penetration of the Hawai'i POLST program into the nursing home community. Most nursing facilities required staff to undergo POLST training. Some facilities reported APRNs were already involved in signing the POLST form, only weeks after their signatory capacity was enacted.

Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations.

BACKGROUND: Despite palliative care implementation, most deaths still occur in hospitals. OBJECTIVES: To identify factors associated with in-hospital death among elderly patients receiving palliative care, by site of consultation. DESIGN: Prospective observational study. SETTING/SUBJECTS: All inpatients aged 65 years and older receiving pain and palliative care consultations in a 533-bed acute tertiary care hospital in Honolulu, Hawaii, from January 2005 through December 2009. MEASUREMENTS: During consultation, demographics, diagnoses, consultation site (intensive care unit [ICU], non-ICU medical, non-ICU surgical, and rehabilitation floors), consultation indication (assistance with establishing goals of care versus pain and/or symptom management), Karnofsky scores, length of stay (LOS), discharge disposition, and in-hospital death were collected. Multiple logistic regression analyses examined factors associated with in-hospital death. RESULTS: Of 1630 elderly inpatients receiving palliative care, 305 (19%) died in-hospital. In-hospital death among non-ICU medical patients was associated with needing consultation to assist with plan of care (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.27-2.80). Likelihood of in-hospital death increased 2% for each additional hospital day before consultation (OR=1.02, 95% CI=1.01-1.03). Among elderly ICU patients, likelihood of in-hospital death increased 8% for each additional hospital day before consultation (OR=1.08, 95% CI=1.01-1.16). CONCLUSION: Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.

Five things physicians and patients should question in hospice and palliative medicine.

Overuse or misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation's Choosing Wisely® campaign is a multiyear effort to encourage physician leadership in reducing harmful or inappropriate resource utilization. Via the campaign, medical societies are asked to identify five tests or procedures commonly used in their field, the routine use of which in specific clinical scenarios should be questioned by both physicians and patients based on the evidence that the test or procedure is ineffective or even harmful. The American Academy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed to participate in the campaign. The AAHPM Choosing Wisely Task Force, with input from the AAHPM membership, developed the following five recommendations: 1) Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care; 4) Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis; and 5) Don't use topical lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®) (ABH) gel for nausea. These recommendations and their supporting rationale should be considered by physicians, patients, and their caregivers as they collaborate in choosing those treatments that do the most good and avoid the most harm for those living with serious illness.

Pain outcomes of inpatient pain and palliative care consultations: differences by race and diagnosis.

BACKGROUND: Pain management disparities exist among patients not receiving palliative care. We examined pain outcomes for disparities among patients receiving palliative care. METHODS: At a 542-bed teaching hospital in Honolulu, The Queens' Medical Center Pain and Palliative Care Department collected patient characteristics and pain severity (initial, final) for each consultation from 2005 through 2009. Analyses compared pain levels by race (white, Asian, Hawaiian/Pacific Islander [PI], other) and consultation diagnosis (cancer, noncancer medical, surgical [59% orthopedic], other). Multiple regression models analyzed factors associated with lower final pain levels and pain reduction. RESULTS: Study population included 4658 patients. No final pain was reported by more non-white patients (33%-39%) than white (27%, p<0.0001) and more cancer and noncancer medical patients (45%-54%) than surgical/other patients (20%-31%, p<0.0001). Asian (adjusted odds ratio [aOR] 1.24; 95% confidence interval [CI] 1.06-1.46; p=0.007) and PI (aOR 1.46, 95% CI 1.20-1.77, p=0.0001) races had increased likelihoods of lower final pain severity versus whites, controlling for age, gender, Karnofsky score, preconsult length of stay, and initial pain severity. Surgical diagnoses had decreased likelihood of lower final pain levels versus cancer (aOR 0.38, 95% CI 0.32-0.46, p<0.0001). Among 2304 patients reporting moderate/severe initial pain, 1738 (75.4%) reported pain reduction to mild/no final pain. PI race was associated with pain reduction versus whites (aOR 1.57, 95% CI 1.17-2.10, p=0.003). Surgical diagnoses had decreased likelihood of pain reduction vs. cancer (aOR 0.52, 95% CI 0.39-0.71, p<0.0001). CONCLUSION: Pain outcomes were similar or better among non-white races than whites. Surgical patients reported more final pain than cancer patients.

Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer.

CONTEXT: Intensive palliative care consultations for plan of care may reduce racial differences in end-of-life care. OBJECTIVES: To compare cancer patients' hospice referrals and code status changes after inpatient palliative care consultations by patient ethnicity and consultation intensity. METHODS: This observational cohort study prospectively recorded data for all adult cancer patients receiving palliative care consultations at the largest teaching hospital in Hawaii from 2005 through 2009. Chi-squared analyses compared hospice referral and code status changes with "Do Not Attempt Resuscitation" by patient characteristics and consultation intensity (more intensive plan of care vs. pain and/or symptom management without plan of care). Multiple logistic regression models analyzed factors associated with hospice referral and code status change. RESULTS: The 1362 consultations generated 454 (33.3%) hospice referrals and 234 (17.2%) code status changes. Controlling for age, gender, Karnofsky score, and preconsultation hospital days, Asian, Pacific Islander, and "other" ethnicities demonstrated increased likelihood of hospice referral vs. whites (adjusted odds ratios [AORs] 1.46-2.34, P<0.05). Intensive plan-of-care consultations were strongly associated with hospice referral (AOR 3.08, 95% confidence interval [CI] 2.33-4.07, P<0.0001). Controlling for consultation intensity reduced the association between ethnicity and hospice referral (AORs 1.35-2.06, P=0.03, "other" ethnicity; P=nonsignificant, Asian and Pacific Islander). Intensive consultations were strongly associated with code status change (AOR 2.96; 95% CI 2.08-4.22, P<0.0001). Ethnicity was not significantly associated with code status change. CONCLUSION: Consultation intensity was the strongest predictor of hospice referrals and code status changes and reduced the ethnic variations associated with hospice referral.

A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery.

OBJECTIVES: To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery. DESIGN: Controlled prospective propensity score-matched clinical trial. SETTING: New York City acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty. INTERVENTION: Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care. MEASUREMENTS: Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge. RESULTS: In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P=.004) and with PT (52% vs 38%, P=.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P=.02) and 7 (6.9 vs 9.2 seconds, P=.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P<.001), were more likely to receive standing orders for analgesia (98% vs 48%, P<.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P=.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P=.02) and that pain did not interfere with walking (7% vs 18%, P=.004) and were less likely to be taking analgesics (35% vs 51%, P=.03). CONCLUSION: The intervention improved postoperative pain, reduced chronic pain, and improved function.

Improving the management of pain in hospitalized adults.

BACKGROUND: Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management. METHODS: This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing. RESULTS: Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores. CONCLUSIONS: A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.

Prevalence of meperidine use in older surgical patients.

HYPOTHESIS: The unique toxic and adverse effects of meperidine hydrochloride have prompted a number of expert panels convened by national health care policy organizations to recommend that meperidine not be used in older patients. We hypothesized that the prescription of meperidine was less likely to reflect these recommendations in older surgical patients than in older medical patients. The current study examined the use of meperidine in 2 urban hospitals as 1 quality indicator of the care of older adults, measuring the prevalence of its use and characteristics of the patients to whom it is administered. DESIGN: Retrospective analysis. SETTING: Two urban hospitals: a large private tertiary care teaching hospital and a smaller academically affiliated Veterans Affairs medical center. PATIENTS: Patients 65 years or older and hospitalized on medical and surgical services between February 19, 2001, and February 14, 2003. MAIN OUTCOME MEASURES: Patient demographics, medication administration, and department of admitting physician. RESULTS: Meperidine was administered to approximately 1 in 8 older surgical patients at both institutions. Surgical patients were more likely than medical patients to receive a dose of meperidine (hospital A, 12.2% vs 4.3%, P<.001; hospital B, 12.9% vs 1.9%, P<.001). Of those administered meperidine, surgical patients were also more likely than medical patients to receive multiple doses (hospital A, 86.0% vs 65.5%, P = .045; hospital B, 73.8% vs 48.4%, P = .02). CONCLUSIONS: Contrary to national recommendations, meperidine continues to be administered to many hospitalized older adults, particularly those on surgical services. Several alternatives to meperidine exist that provide equal or better pain relief with fewer toxic effects. Hospitals and, in particular, departments of surgery should address this cause of preventable morbidity in this vulnerable population.

Factors associated with reductions in patients' analgesia at hospital discharge.

OBJECTIVE: To describe the patterns of opioid prescribing and the factors associated with reductions in the potency of patients' analgesic medications at the time of hospital discharge. DESIGN: Prospective cohort. SETTING: Two hundred forty-four patients (171 surgical and 73 nonsurgical) hospitalized in an urban academic medical center who have experienced moderate or severe pain and who are taking opioid analgesics prior to discharge. OUTCOME: Step-down (or reduction) in the potency of patients' analgesic medication at the time of discharge. A step-down is defined as the analgesic medication that a patient is prescribed for outpatient analgesia at the time of discharge being less potent then the last pain medication administered to that patient just prior to hospital discharge. RESULTS: Thirty-three percent of all patients had reductions in the potency of their opioid pain medication at the time of discharge (36% for surgical and 26% for nonsurgical patients). For nonsurgical patients, we found a trend toward Hispanic ethnicity being an independent risk factor for having a step-down in analgesic potency at discharge (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 0.9-14.9). CONCLUSION: Physicians frequently reduce the potency of hospitalized patients' pain medications at discharge and Hispanic patients may be at increased risk of this occurring. Further research is needed to determine if the reductions in analgesic potency we observed are associated with poor posthospital pain outcomes.

Palliative care in hospitals.

Hospital-based palliative care teams have evolved as a natural outgrowth of the modern hospice movement. This article examines why these hospital-based palliative care programs have proliferated, how they typically function, and what data exist as to their effectiveness. Crucial steps necessary for the design and implementation of a successful hospital-based palliative care service also are reviewed.

Acceptability of severe pain among hospitalized adults.

BACKGROUND: It is unclear why some hospitalized adults experiencing severe pain report that this degree of pain is acceptable to them. METHODS: A 25% random sample of cognitively intact patients admitted to nine medical/surgical units in a New York City hospital were enrolled. Patients were interviewed daily, Monday to Friday from April 1, 2001 through February 14, 2003, to collect information on the presence of pain, pain intensity, analgesic use, and acceptance of pain. Patients were asked to rate their current level of pain using a four-point scale. RESULTS: Three hundred ninety-two of 1254 patients ( 31%) experiencing severe pain reported that their pain was acceptable to them. Variables significantly associated with an episode of acceptable severe pain in multivariate analyses included resolution of the painful episode (odds ratio = 4.7; 95% confidence interval [CI], 3.54-6.17), recent surgery (odds ratio = 1.5; 95% CI, 1.11-1.99), African American compared to white (odds ratio = 0.7; 95% CI, 0.48-0.955), age (odds ratio = 0.985; 95% CI, 0.977-0.993), and patients taking analgesics (odds ratio = 0.7; 95% CI, 0.46-0.964 for nonsteroidal anti-inflammatory drugs [NSAIDs]/acetaminophen and odds ratio = 0.6; 95% CI, 0.46-0.85 for opioids). Overall, 86 of 252 (34%) reported the pain was acceptable because it had resolved, 47 (19%) believed the pain would eventually go away, and 47 (19%) reported they were able to tolerate the pain. CONCLUSIONS: A substantial percentage of patients reporting severe pain report this experience as acceptable. Given recent research linking high intensity pain to adverse outcomes, future studies directed at improving the management of pain need to target both pain intensity and patients' beliefs about the acceptability of severe pain.

Palliative care module within a required geriatrics clerkship: taking advantage of existing partnerships.

OBJECTIVE: LCME has recently required that all graduating medical students learn about end-of-life care. This program describes the design and integration into an existing geriatrics clerkship of a palliative care module that teaches the foundations of end-of-life and palliative care to medical students. DESCRIPTION: Faculty experts in geriatrics met during a series of weekly meetings in 1999 to design a mandatory four-week-long clinical clerkship in geriatrics. Since the palliative care program is based within the geriatrics department, faculty members with interest and expertise in both geriatrics and palliative care were invited to design a palliative care module that can be integrated into the clerkship. Since LCME does not specify details of what students must learn about end-of-life care, and our goal is to educate and prepare students for any chosen specialty, we wanted to design a basic core curriculum in palliative care that would be useful to any graduating student. After reviewing potential palliative care topics, and given limited curriculum time, we condensed the medical student core curriculum to the following sessions: (1) Systematic Pain Assessment Management, (2) Management of Distressing Symptoms, (3) Communicating Bad News, and (4) Advance Directives. We developed PowerPoint presentations, teaching case vignettes, and a set of reference articles, which can be distributed to students as well as to help faculty teachers prepare for the sessions. Teaching sessions occur in small groups, using case discussions and interactive lectures. Sessions 3 and 4 are co-facilitated by palliative care physicians and ethicists, who use role-plays, reflections, and discussions to teach the topics. At the end of the clerkship, students practice these communication skills with videotaped standardized patient encounters, and debrief with faculty members about their performances and ways to improve their communication skills. DISCUSSION: Palliative care sessions are welcomed by the students, who traditionally have not received much teaching in this area. Even though students have learned about mechanisms regulating pain and other symptoms in the past, they have not learned to assess or treat symptoms in a systematic way. Students often have good questions about the decision-making, legal, and ethical issues that emerge for patients near the end of life. Thus, co-facilitation of physicians with ethicists presents both the practical clinical and the theoretical perspectives, and provides a good model for team teaching. In terms of teaching style, students are more involved and participatory when teachers use case vignettes as compared with slide presentations, even if they are case-based. When using role-plays to teach students how to communicate bad news, we found that students need to feel safe in that environment, need to know they can call for time out when necessary, and want to have seen one done before they are asked to do one.

Pitfalls of opioid rotation: substituting another opioid for methadone in patients with cancer pain.

The successful use of methadone in cancer pain has been supported by numerous case reports and clinical studies. Methadone is usually used as a second or third line opioid medication. As the use of methadone increases we are facing the challenge of converting methadone to other opioids as part of sequential opioid trials. Data on the equianalgesic ratios for the substitution of other opioids for methadone are lacking. We present prospective data on 13 consecutive rotations from methadone to a different opioid. The opioid rotation was followed by escalation of pain and/or severe dysphoria, not controlled by a rapid increase in the dose of the second opioid, in 12 of the 13 patients. Only one patient was successfully maintained on the second opioid after the discontinuation of methadone, while 12 patients required a switch back to methadone. We conclude that opioid rotation from methadone to another opioid is often complicated by worsening pain and dysphoria. These symptoms may not improve despite upward titration of the second opioid. A uniformly accepted conversion ratio for substituting methadone with another opioid is currently not available. More data on the rotation from methadone to other opioids are needed.