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Palliative Care Issues in End Stage Renal Disease

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Title: Palliative Care Issues in End Stage Renal Disease


1
Palliative Care Issues in End Stage Renal Disease
  • Mike Harlos MD, CCFP, FCFP
  • Medical Director, WRHA Palliative Care
  • Medical Director, St. Boniface Hospital
    Palliative Care

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http//palliative.info
5
http//virtualhospice.ca
6
PALLIATIVE CARE World Health Organization
Definition
Palliative care is an approach that improves the
quality of life of patients and their families
facing the problem associated with
life-threatening illness, through the prevention
and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
7
PHYSICAL
SUFFERING
PSYCHOSOCIAL
EMOTIONAL
SPIRITUAL
8
Specific Issues
  • Where does RRT fit in Palliative Care?
  • Where does Palliative Care fit in RRT?
  • What are some of the unique symptom control
    challenges in ESRD
  • Communication issues

9
EVOLVING MODEL OF PALLIATIVE CARE
Active Treatment
Palliative Care
Cure/Life-prolonging Intent
Palliative/ Comfort Intent
Bereavement
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11
Pain Control
  • Variety of pain etiologies in ESRD
  • Neuropathic (diabetic neuropathy)
  • Ischemic (causes nociceptive, visceral, and
    neuropathic pains)
  • Renal insufficiency has significant implications
    for opioid choice morphine and hydromorphone
    have active metabolites which accumulate

12
TYPES OF PAIN
NOCICEPTIVE
NEUROPATHIC
Somatic
Visceral
Deafferentation
Sympathetic Maintained
Peripheral
13
FEATURES OF NEUROPATHIC PAIN
14
Morphine and HydromorphoneActive Metabolite
Accumulation in Renal Failure
15
Vicious Cycle of Opioid-Induced Neurotoxicity
16
Codeine
  • Metabolized to C-6-G, norcodeine, and morphine
  • Guay et al 1987 found accumulation of codeine
    in hemodialysis patients (t1/2 19 hrs) relative
    to healthy volunteers (t1/2 4 hrs)
  • Dose reduction suggested in renal failure
  • Clcr 10-50 ml/min Administer 75 of dose
  • Clcr lt10 ml/min Administer 50 of dose
  • Morphine metabolites will also accumulate

17
Methadone
  • NMDA receptor antagonist unique role in
    neuropathic pain, preventing tolerance and
    neurotoxicity
  • Becoming a preferred opioid in renal
    insufficiency
  • Inactive metabolites
  • Approx. 20 excreted unchanged in urine, the
    remainder of the parent drug and metabolites
    excreted through feces
  • As renal function deteriorates, there is
    increased elimination through feces without
    increased plasma concentrations
  • Nonetheless, start low and go slow

18
Fentanyl
  • Inactive metabolites
  • No dosage modification needed when administered
    as a bolus, but accumulation occurs with chronic
    dosing
  • Koehntop DE, Rodman JH. Fentanyl pharmacokinetics
    in patients undergoing renal transplantation.
    Pharmacotherapy 1997
  • Marked decreases in fentanyl clearance, related
    to degree of azotemia
  • Chronic dosing empirically titrated to effect

19
Oxycodone
  • Kirvela et al, The Pharmacokinetics of Oxycodone
    in Uremic Patients Undergoing Renal
    Transplantation, J Clin Anesth 1996
  • Mean elimination half-life was prolonged in
    uremic patients due to increased volume of
    distribution and reduced clearance.
  • Conclusions Elimination of oxycodone is impaired
    in end-stage renal failure
  • start low and go slow approach, with empirical
    titration to effect

20
Meperidine (Demerol)
  • Neurotoxic metabolite normeperidine, which
    accumulates in renal insuff.
  • May cause seizures, death
  • Should not be used in chronic dosing, regardless
    of renal function

21
Delirium at End of Life
  • Common 80 90 in last few weeks
  • Almost always multifactorial illness,
    medications
  • May rapidly worsen, with paranoia and agitation
  • Very distressing for all involved
  • Not likely to be reversible in last few days of
    life, such as after D/C dialysis
  • Main intervention is effective sedation

22
Common Medications for Sedation in Terminal
Delirium
Nozinan (methotrimeprazine)
  • Phenothiazine neuroleptic
  • Dopamine antagonist, with histamine and
    muscarinic receptor antagonism as well (effective
    general antinauseant)
  • Oral, sublingual, subcutaneous routes

Versed (midazolam)
  • benzodiazepine
  • Subcutaneous route about 1/3 as potent as IV
    route
  • Can mix with methotrimeprazine in same syringe

23
Communication Issues in Sedation for Delirium at
End of Life (e.g. Dialysis Withdrawal)
  • Delirium not reversible ongoing physiologic
    decline
  • Once effectively sedated, will not likely awaken
    again
  • Medications not hastening process, but ensuring
    comfort
  • Encourage ongoing communication by family,
    including private time alone with patient
  • Be cautious in presenting non-choices as
    choices there no other realistic options but
    aggressive sedation in trying to settle a
    restless, agitated, delirious person who is
    imminently dying

24
Dyspnea
  • In prospective studies approaches 80 in final
    days
  • Effectively controlled in lt 50 in studies
  • Multifactorial
  • Pneumonia is a common final event
  • Treatment requires urgency
  • often rapid progression
  • severe distress
  • often only hours before dying

25
Dyspnea Management
  • Non-Pharmacological
  • Calm reassurance
  • Fan
  • Open window
  • Sitting upright
  • Pharmacological
  • Oxygen
  • Opioids may need aggressive titration with IV
    boluses q10 min with escalating dose
  • Sedatives Neuroleptics (methotrimeprazine) or
    Benzodiazepines
  • Antisecretory agents scopolamine, glycopyrrolate

26
Pruritus
  • Common in ESRD prevalence 50 90
  • Various etiologies suggested - e.g.
  • inadequate dialysis
  • secondary hyperparathyroidism
  • dry skin
  • divalent ion accumulation and precipitation in
    skin
  • mast cell dysregulation
  • abnormal cutaneous innervation
  • aluminum toxicity
  • elevated serum histamine
  • elevated serum serotonin
  • substance P
  • altered immune function
  • others

27
Potential Treatments For Uremic Pruritus
  • optimizing dialysate concentrations of magnesium
    and other divalent ions
  • emollients and moisturizers
  • ultraviolet B light
  • Naltrexone (opioid antagonist) conflicting
    results in randomized crossover trials dont use
    if needs opioids
  • Thalidomide effective in gt 50 of patients
    Note fetal malformations use appropriate
    caution in women
  • Capsaicin cream may help in localized itch
  • Mirtazapine antidepressant H1 , 5HT2 , and
    5HT3 receptor blocker

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29
Potential Treatments For Uremic Pruritus ctd
  • H1 antihistamines ineffective
  • Ondansetron recently found to be no more
    effective than placebo in randomized double-blind
    trial

30
Withdrawal of Dialysis
Catalano C et al, Withdrawal of renal
replacement therapy in Newcastle upon Tyne
1964-1993. Nephrol Dial Transplant. 1996
Jan11(1)133-9.
n 88 Median survival 8 days
31
Withdrawal of Dialysis Palliative Issues in
Ensuring Comfort
  • Communication
  • Anticipating symptoms, aggressive response
  • Pain (generally only if a pre-existing problem)
  • Nausea
  • Restlessness, confusion
  • Dyspnea fluid balance, pneumonia
  • Pruritus
  • Myoclonus, twitching
  • Communication
  • Anticipating need for non-oral medication routes
  • Communication

32
Common Communication Issues
  • Treatment decisions - Would you prefer the
    rock, or the hard place?
  • Food and fluids
  • Withdrawing or withholding treatment seen as
    euthanasia
  • Sedation is seen as euthanasia
  • You wouldnt let an animal die this way
  • Everyone would be better off if Id just die
  • How long have I got?
  • How will I die? (rarely asked, always worried
    about)
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