Potpourri from Clinical Work II

I’ve been on the palliative care service these last two weeks. Some interesting and challenging issues came up.  I don’t have time to flesh them out into individual posts.  I would love some feedback from the GeriPal commmunity.

1. I was consulted about a 62 year old woman with an unusual form of memory disorder: she couldn’t form new memories (all cases completely altered to protect patient identity).  She was stuck in a past that existed 8 years ago.  She had end stage renal disease and was on dialysis.  She knew that she needed dialysis to survive, because that was also true 8 years ago, and would agree to start each dialysis session.  Shortly after starting a dialysis run, however, she’d stand up, forgetting why she was there, and try to go for a walk.  The frequent need to re-orient her proved too much for the dialysis providers.  They refused to continue dialysis.  This case raised a number of issues.  First, if she understands the risks and benefits of dialysis, but then can’t sit still for it, what is our obligation?  If we stop the dialysis she will die – and clearly if we talk to this patient about her life, which she believes is her life from 8 years ago, she doesn’t want to die.  Second, the team was considering giving her sedating medications so she could make it through each dialysis run.  This form of chemical restraint might be less repugnant than phyically strapping her down, but it is still a form of restraint that doesn’t seem right.  We (with the help of a formal neuropsychiatric consultation) ultimately decided she doesn’t have capacity to make complex medical decisions.  I don’t know how this case will end.
2. What is up with neuroleptics for hiccups?  Specifically gapabentin.  Is this real or marketing?  I was asked about gabapentin twice in the last week.  There are a few reports (here and here) in the literature that I can find, but I want to know from the “real world” if this works.
3. Why isn’t there a lower dose of long-acting opioid?  I’ve had several instances of patients with chronic pain or COPD for whom very low dose opioids are effective.  But their total daily dose is typically around 8-12mg of oral morphine equivalents – too low for the lowest dose of long acting opioid.  The lowest dose fentanyl patch is 12.5mg, equianalgesic to 25mg of oral morphine; the lowest dose of MS Contin is 15mg twice a day (30mg/day);  the lowest dose of oxycontin is 10mg twice a day, again equianalgesic to 30mg of oral morphine a day.  Having to take medications multiple times a day is a drag for patients, and for those in nursing homes, burdensome on the staff.  Anyone else frustrated by this?

Looking forward to seeing some of you in Boston at the palliative care conference!