Potpourri from Clinical Work III

Interesting issues and questions from my recent stint on the inpatient hospice and palliative care service.

1. Hospices are not supposed to discriminate against patients based on code status.  Yet I think in practice some do. Some do not take patients who are DNR.  Others ask them to sign a DNR form on enrollment.   Other people’s experiences with this?  Is anyone concerned?
2. We cared for a patient with Complex Regional Pain Syndrome (former name Reflex Sympathetic Dystrophy).  This patient has a chronic painful condition but no terminal illness, and pushes on the boundaries of what constitutes a “palliative care” patient.  In some sense all hospitalized patients can benefit from palliative care.  The question is, how far do our boundaries extend in caring for these patients?  Sure we can help everyone, at least a little bit.  But at some point the costs outweigh the benefits.  Where is that line, and how much should be determined on a local basis versus a national  mission and vision for palliative care?  AAHPM says palliative medicine providers should care for patients with “serious” conditions.  Is CRPS serious?  How about sickle cell crisis?  Chronic back pain?  Late life disability?
3. We had a patient who was told he had a prognosis of weeks to months.  He said he didn’t believe it; he thought his prognosis was years.  The medicine attending recommended we reiterate that his prognosis was weeks to months until he “got it.”  What do you think about this?  On the one hand, this seems like battery of some sort.  On the other hand, while we didn’t reiterate his prognosis on a daily basis, we did point out the multitude of ways his body was failing.  He eventually accepted his prognosis and transitioned to hospice. 
4. When treating opioid related nausea that is not well treated with the initial dose of an anti-emetic, do you generally push the dose of one medication or add another agent until you achieve satisfactory effect?  I usually start with metoclopramide (5mg TID scheduled before meals) because of it’s anti-dopaminergic and promotility properties, and push the dose before switching to another agent.  Curious what others have done.
5. Now that ondansetron (Zofran) is generic, people are prescribing it like water.  The teaching when I trained was that it was first line for nausea due to chemotherapy, radiation, and anesthesia.  I don’t actually think it has been studied and found effective for other causes of nausea.  What are other people’s clinical experience?  I recommended against routine use when lecturing to a bunch of Emergency Medicine residents and was absolutely slammed – “but it works better!”  Trying to keep an open mind here…maybe it does work better?

by: Alex Smith