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Perinatal Palliative Care Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Adult & Pediatric Palliative Care,

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Presentation on theme: "Perinatal Palliative Care Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Adult & Pediatric Palliative Care,"— Presentation transcript:

1 Perinatal Palliative Care Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Adult & Pediatric Palliative Care, Winnipeg Regional Health Authority Mike Harlos MD, CCFP, FCFP Erin Shepherd RN, MN Clinical Nurse Specialist, WRHA Pediatric Palliative Care

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4 The presenters have no conflicts of interest to disclose

5 Objectives To consider where pediatric palliative care may fit in the care of those with a potentially non-survivable fetal condition To review considerations for the management of symptoms in the newborn with an anticipated non-survivable condition to review Winnipegs experience with intranasal fentanyl in the palliative care of newborns To learn about the overall management of complex clinical scenarios in perinatal palliative care

6 WHO Definition of Palliative Care for Children Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. Health providers must evaluate and alleviate a child's physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited. It can be provided in tertiary care facilities, in community health centres and even in children's homes.

7 Thank you for giving me aliveness Jonathan – 6 yr old boy terminally ill boy Ref: Armfuls of Time; Barbara Sourkes

8 Meet Matthew… Prenatal Dx Trisomy 18 Prenatal palliative care consult May 22, 2008 reviewed potential outcomes and approaches Induced July 14, 2008 on low-risk unit (LDRP) Home within 16 hrs

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11 BACKGROUND neonatal deaths remain a reality in health care, and with prenatal diagnosis a palliative approach to care can often be planned UK Stats: -98% of neonatal deaths occur in an NICU -few are supported to die at home or in hospice -palliative care is only routinely provided for babies and children over 28 days old

12 Potential Palliative Scenarios known lethal fetal anomalies; potential need for aggressive symptom management with noninvasive routes of administration withdrawing life-sustaining treatment withholding / non-escalation of interventions comfort care during terminal phase of irreversible organ failure (e.g.. gut, renal, hepatic)… may be days to weeks

13 Wilkinson D, Thiele P, Watkins A, De Crespigny L. Fatally flawed? A review and ethical analysis of lethal congenital malformations. BJOG. 2012;119:1302-1308.

14 2012 Report On The Ten Most Common Causes of Infant Deaths In U.S.A. In 2009 Kochanek KD, Kirmeyer SE, Martin JA, Strobino DM, Guyer B.Pediatrics. 2012 Feb;129(2):338-48 Significant potential for anticipating palliative needs of newborn

15 WRHA Prenatal and Neonatal Consults

16 Prenatal Consult Diagnoses 2010-2012

17 Neonatal Consult Diagnoses 2010-1012

18 Location of Neonatal Deaths Followed By Palliative Care – 2010-2012

19 Potential Roles For Neonatal Palliative Care Explore potential what-if scenarios and inform the discussion about possible approaches Regardless of the prognostic certainty or the approach taken, ensure vigilance towards: Comfort of the newborn Support of family Support of team Connections – siblings, other relatives Legacy/Memory – footprints, photos, etc Participate in dialogue around difficult ethical considerations On occasion – consolidate information from multiple involved specialists; serve as a steady presence in the context of turnover of attending physicians Participate in exploration of alternate care settings

20 Potential Pitfalls Experienced Through Our Prenatal Involvement Assumptions that pediatrics and/or neonatology does not need to be involved in delivery or in postnatal care if palliative care involved Over-interpreting what the palliative label means about other aspects of care and support for the baby Misconception that families cant change their minds and opt for aggressive care

21 What if…? What would things look like? Time frame? Where care might take place What should the patient/family expect (perhaps demand?) regarding care? How might the palliative care team help patient, family, health care team? What would things look like? Time frame? Where care might take place What should the patient/family expect (perhaps demand?) regarding care? How might the palliative care team help patient, family, health care team? Palliative Care… The What If…? Tour Guides Disease-focused Care (Aggressive Care) Disease-focused Care (Aggressive Care)

22 Elements of Neonatal Palliative Care Best practice guidelines: Palliative care for the newborn in the United Kingdom L. de Rooy, N. Aladangady, E. Aidoo; Early Human Development 88 (2012) 73–77 Assessment: baby's current clinical state, focusing on pain, agitation, dyspnea and other symptoms Communication: verbal/ written communication with parents Review of medications: stop all medications which do not add to the baby's comfort, actively treat all symptoms. Review of interventions: stop all unnecessary interventions and observations, actively consider interventions which can increase comfort, e.g. skin-to-skin contact. Resuscitative care plan: record details of what should, and should not be provided in case of deterioration Provision of hydration/nutrition: provide fluids/feeds through the least invasive route Communication with MDT Review: palliative care is a process not an event, review care plans and adjust as needed Other care options: consider whether the baby may be best cared for in other settings e.g. hospice or home.

23 Approach To Prenatal Palliative Care Consult Explore parents understanding of condition and potential outcomes, options for care If needed, develop an approach to discussing with siblings Discuss care setting and expectations RE delivery plan for potential threats to comfort (almost always dyspnea) Consider pre-drawn medications (fentanyl) for nasal/buccal administration for possible pain, resp distress, restlessness Home as a possible care setting if baby survives long enough Autopsy/coroner/tissue donation Bereavement follow-up

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25 Live Birth Approach to comfort in first few minutes Next 1 – 2 hours Try feedingTry feeding Connections & legacyConnections & legacy Next 3 – 4 hours Feeding/hydration decisions if not feeding By 12 – 24 hours Explore options for care setting e.g. palliative care at home?

26 Patient/Family Understanding and Expectations Health Care Teams Assessment and Expectations What if…?

27 Life-And-Death Decisions? In situations where death will be an inescapable outcome, family may nonetheless feel that their choices about care are life-and-death decisions (treating infections, hydrating, tube feeding, etc.) It may be helpful to say something such as: I know that youre being asked to make some very difficult choices about care, and it must feel that youre having to make life-and-death decisions. You must remember that this is not a survivable condition, and none of the choices that you make can change that outcome. We know that because of her illness, she is on a path towards dying. We are asking you to help us choose the smoothest path, causing least distress for your baby

28 Fentanyl highly potent opioid – small volumes needed lipophilic – absorbed readily through transmucosal membranes and blood-brain barrier expanding pediatric and adult literature on intranasal use of the injectable preparation for pain and dyspnea management

29 Intranasal Fentanyl T MAX 5 – 15 min. -compare with T MAX of 138 minutes for buccal morphine therapeutic levels reported as short as 2 minutes bioavailability 71 – 89% not irritating to the nasal mucosa

30 Intranasal Meds DrugT max (min)Bioavailability (%) Midazolam 1,2 11 – 14*55 – 83 Fentanyl 3,7 571 – 89 Sufentanil 3 1078 Hydromorphone 4 20 – 2555 Ketamine 6 2045 1.P. D.Knoester ; Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers ; Br J Clin Pharmacol. 2002 May;53(5):501-7 2.Rey E. et al; Pharmacokinetics of midazolam in children: comparative study of intranasal and intravenous administration ; Eur J Clin Pharmacol 41(4) 1991; 355-357 3.Dale O, Hjortkjaer R, Kharasch ED; Nasal administration of opioids for pain management in adults ; Acta Anaesthesiol Scand. 2002 Aug;46(7):759-70 4.Coda BA, Rudy AC, Archer SM, Wermeling DP; Pharmacokinetics and bioavailability of single-dose intranasal hydromorphone hydrochloride in healthy volunteers ; Anesth Analg. 2003 Jul;97(1):117-23 5.Fisgin T et al; Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study ; J Child Neurol. 2002 Feb;17(2):123-6 6.Yanagihara Y et al; Plasma concentration profiles of ketamine and norketamine after administration of various ketamine preparations to healthy Japanese volunteers; Biopharm Drug Dispos. 2003 Jan;24(1):37-43. 7.Foster D, Upton R, Christrup L, Popper L. Pharmacokinetics and pharmacodynamics of intranasal versus intravenous fentanyl in patients with pain after oral surgery. Ann Pharmacother 2008;42: 1380e1387 * Available to the cerebral cortex 2 – 5 min. after nasal use 5 Reasonable to start with recommended mg/kg for IV dosing and adjust empirically

31 MAD300® Device Syringe is filled with an extra 0.1 ml medication to accommodate for device dead space our practice is to reuse the device multiple times with the same patient device is cleared with air to restore dead space prior to next dose

32 first (and still the only) publication describing the use of intranasal fentanyl in < 6 months old

33 retrospective chart review examining intranasal (IN) fentanyl use 58 consecutive referrals of < 6 months old from Nov. 2006 – July 2010 described 11 palliative children for whom intranasal fentanyl was used… all to relieve respiratory distress

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35 Patient Age at Death

36 no adverse effects noted (drug-related apnea, chest wall rigidity)

37 1 mcg/dose =0.1 ml of 10 mcg/ml =2 mcg/kg for 500 gm neonate and 1 mcg/kg for 1000 gm neonate 1 mcg/dose =0.1 ml of 10 mcg/ml =2 mcg/kg for 500 gm neonate and 1 mcg/kg for 1000 gm neonate 2.5 mcg/dose =0.1 ml of 25 mcg/ml =2 mcg/kg for 1250 gm neonate and 1 mcg/kg for 2500 gm neonate 2.5 mcg/dose =0.1 ml of 25 mcg/ml =2 mcg/kg for 1250 gm neonate and 1 mcg/kg for 2500 gm neonate 500 – 1000 gm Based on Fetal Assessment or gestational age < 27 weeks 500 – 1000 gm Based on Fetal Assessment or gestational age < 27 weeks > 1000 gm Based on Fetal Assessment or gestational age > 27 weeks > 1000 gm Based on Fetal Assessment or gestational age > 27 weeks Intranasal Fentanyl Preparation Prior To Delivery Based on Estimated Birth Weight Intranasal Fentanyl Preparation Prior To Delivery Based on Estimated Birth Weight administered q 10 min prn, up to 3 doses within a 30 min period

38 lowest starting dose was 0.24 mcg/kg – o extremely low birth weight triplet at a time that our program was just becoming familiar with IN fentanyl and was somewhat conservative in prescribing. highest starting dose was 3.8 mcg/kg – o opioid-tolerant patient on fentanyl 3 mcg/kg/h IV o venous access was lost at the time of withdrawal of ventilatory support. mean initial dose was 1.3 mcg/kg; median was 1 mcg/kg.

39 avg: 4.5 range: 1 – 17 median: 3 mode: 1 the newborn who received 17 doses had a diagnosis of Potter's Syndrome and over 21h of life experienced episodes of resp distress, for which clusters of repeated fentanyl doses were administered with good effect Avg. time from last fentanyl dose until death was 61 min # Doses

40 Example Extremely premature infant with NEC and sepsis, intubated and ventilated Seen by palliative care team in NICU 6 days prior to death, plan for withdrawal of life sustaining treatment IJ line had been running Morphine continuous infusion for one month, switched to Fentanyl infusion 2 days prior to extubation. Lost IJ line immediately prior to planned extubation. Given 4 doses of intranasal fentanyl. Two doses prior to extubation (32 min and 14 min prior). Two doses given after extubation at 3 min and then 26 min post-extubation (this last dose was given 81 minutes prior to death). One dose of Midazolam intranasally prior to extubation. Died at 44 days of age in NICU (2 hr + 26 min after extubation) Effective in managing respiratory distress – well sedated and comfortable and Looks settled

41 in our experience, resp. distress accompanying progressive resp. compromise is the predominant threat to comfort in the dying newborn no dyspnea assessment tools for newborns… we use: 1.signs of increased work of breathing: tachypnea, nasal flaring, grunting, use of accessory muscles, chest wall retractions and 2.evidence of distress: restlessness, irritability, crying Article reviewer comments: the combination of respiratory rate, accessory muscle use, nasal flaring, retractions, and subjective evidence of distress are perfectly reasonable tools to assess respiratory distress and its resolution in the neonatal period

42 Common Concerns About Aggressive Use of Opioids at End-Of-Life How do you know that the aggressive use of opioids for dyspnea doesn't actually bring about or speed up the patient's death? I gave the last dose of morphine and he died a few minutes later… did the medication cause the death?

43 1.Literature: the literature supports that opioids administered in doses proportionate to the degree of distress do not hasten death and may in fact delay death 2.Clinical context: breathing patterns usually seen in progression towards dying (clusters with apnea, irreg. pattern) vs. opioid effects (progressive slowing, regular breathing; pinpoint pupils) 3.Medication history: usually the last dose is the same as those given throughout recent hours/days, and was well tolerated

44 Analgesia For Dying Infants Whose Life Support Is Withdrawn Or Withheld Partridge JC, Wall SN; Pediatrics 99(1) 1997; 76-79 n = 121 deaths in the context of withdrawing life-sustaining treatment

45 aliphatic phenothiazine non-opioid analgesic properties – about ½ as potent as morphine no resp depressant effects alone, but conflicting reports when administered with opioids broad-spectrum antinauseant, with antagonistic effects at D 2, H 1, muscarinic cholinergic, and 5HT 2 receptors effect on dyspnea inferred from beneficial effects found in research into chlorpromazine potential adverse effects include dystonic reactions, sedation, QT prolongation, postural hypotension, lower seizure threshold Methotrimeprazine

46 no literature to guide dosing specifically in neonates Oxford Textbook of Palliative Care or Children (2012) recommends: o 0.1 mg/kg starting intermittent dose recommended for nausea in children 2-12 y.o. o up to 0.4 mg/kg/day by continuous infusion for nausea in children 1 month – 12 yrs o up to 3 mg/kg/day by continuous infusion for sedation in palliative children 1-12 y.o. van der Zwaan S, et al, Additional use of methotrimeprazine for treating refractory agitation in pediatric patients. Intensive Care Med. 2012; 38:175-6 o describes using 0.15 mg/kg qid in a palliative 8 month old with pulmonary hypertension Methotrimeprazine ctd

47 Palliative Care in the Community What needs to be considered? –Family awareness and desire to take child home Who is involved? –Pediatrician / Family Physician –Specialists –Home Care –Palliative Care Team What is involved? –Develop a care plan Letter of Anticipated Home Death Advance care plan with DNAR discussion of autopsy/tissue donation anticipate symptoms and evaluate routes of medication administration –Preparation of family –Ensure responsiveness and availability at all times


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