- Describe your topic.
- Among hospitalized palliative care patients with refractory pain, does parenteral infusion of ketamine infusion as compared to non-ketamine approaches, impact outcomes such as immediate and/or long term pain scores, quality of life, anxiety or depression prevalence and/or incidence, survival, and/or length of hospitalization?
- incapable of providing adequate relief,
- are associated with excessive and intolerable acute or chronic morbidity, or
- are unlikely to provide relief within a tolerable time frame.
- Describe why this topic is important.
- Palliative care aims to relieve suffering and to help patients and families with life limiting illness live as actively as possible with good quality of life, neither hastening nor postponing death. Although many palliative care patients experience symptoms, most are well managed when appropriate medications and treatments are used. Pain is a complex subjective phenomenon and is affected by the emotional context in which it is endured (SIGN 2008). Adequate psychological support is critical, as removing the fear of pain in itself will help to optimize pain control. A refractory symptom is one that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness (Cherny 1994). In deciding when a symptom is refractory, the clinician must perceive that further invasive and non-invasive interventions are:
- A trend in the care of individuals admitted to the hospital setting with preexisting chronic pain who have severe acute pain is to administer an IV ketamine infusion in subanesthetic doses to relieve pain that is refractory to first-line analgesics, such as nonopioids, opioids, local anesthetics, and anticonvulsants (https://www.medscape.com/viewarticle/782693_5). The drug is also administered for neuropathic pain, ischemic pain, regional pain syndromes, and cancer (https://www.medscape.com/viewarticle/782693_5). It is listed by the World Health Organization as an essential drug for the treatment of refractory pain in the palliative care setting (https://www.medscape.com/viewarticle/782693_5). Ketamine is also used as an anesthetic on animals and in some cases, on humans, due to low cost and ease of use as an anesthetic in the developing world for decades. However, in many countries ketamine addiction is on the raise. For instance, China recently put forth a motion to the U.N. Commission on Narcotic Drugs calling for ketamine to be added to the list of internationally controlled narcotics (http://www.activebeat.com/health-news/ketamine-the-pros-and-cons-of-a-worldwide-ban-on-the-drug/). For medical use on humans, ketamine is administered for sedation, pain relief, and depression, the last of which has been a main focus of research over the past few years. The results of these studies and others for using Ketamine on people have shown promising results as a form of anesthesia (to put patients to sleep for surgery) as well as a pain reliever during certain medical tests or procedures. However, the benefits of the drug don’t come without dangers and controversy— for instance, ketamine (Special K) is commonly used for recreational purposes in many countries (notably Hong Kong, China, Taiwan, Australia, and Europe) with serious side effects (http://www.activebeat.com/health-news/ketamine-the-pros-and-cons-of-a-worldwide-ban-on-the-drug/).
- Tell us why you are suggesting this topic.
- On the Connect platform of the American Academy of Hospice and Palliative Medicine (AAHPM), members can dialogue, ask questions and offer suggestions to their colleagues on any subject they choose (following the rules of course). Our Chief Medical Officer reviewed the most popular AAHPM Connect Forum topics for the past 12 months and ranked them by thread title and number of contributions – the subject of “Ketamine in Inpatient Palliative Care Unit” included 47 responses (#1 most popular conversation in the past 12 months), prompting our question, “What is the best protocol for using parenteral ketamine for refractory pain or depression in hospice/PC patients?”
- Target Date.
- 2020-01-01
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- Currently, there is no standard protocol for ketamine use for refractory pain in palliative care. 47 responses to the initial question on our Connect platform shows that people are currently either making their own protocols or experimenting with different treatment combinations. The initial question reflects the complexity of the issue: “With the reported national back order of many hospice and palliative care (PC) medications looming, many of us will find it necessary to think outside the box to continue to provide symptom management to the patients we serve. Of most concern, are the parenteral meds-fentanyl, hydromorphone, methadone, morphine. I practice inpatient hospice care in a large IPU. Our team is exploring other options for our patients, such as maximally concentrated oral opiates, compounded opiate suppositories, etc. However, some patients will still need scheduled/PRN/continuous infusion of parenteral opiates for comfort. We are currently exploring Ketamine IV/continuous infusion in the inpatient hospice setting as an alternative for pain management. Does anyone have experience using Ketamine in that context?” Some common answers included, “This is an excellent question and very legitimate concern. I also work in a large IPU and have used ketamine in a limited way in the past to ‘rescue’ patients who were requiring a large opiate burden and still having pain. I look forward to hearing what our colleagues advise.” “I haven't used ketamine as an alternative to other therapies, per se. I do occasionally use intravenous ketamine infusion in the inpatient hospice setting along with standard therapies, for pain that has remained refractory to multi-agent regimens. I've had mixed results, but I really only turn to ketamine when I'm desperate--the worst of the worst pain cases that I see.” “We have a patient with intractable pain and intractable nausea in absence of bowel obstruction. Would appreciate your sharing your ketamine protocol.” “Hello all- as far as oral ketamine, we don't have a protocol. I have just developed my own over the years from listening to various speakers and reading online, and my nurses are well trained in how to use it.” “Thank you to the seventy-yes seventy-clinicians who have reached out regarding ketamine. I haven't posted the ketamine protocol on the listserv because: There's minimal evidence behind this-it's just sorta ‘what I've been trying.’ Putting it out there for all to see may lend it more heft than it deserves, and perhaps inspire less caution/scrutiny than ketamine requires. For anyone considering it, I also want to add anecdotal insights, which probably shouldn't be ‘published.’” Ideally, an AHRQ evidence review, or even a randomized controlled trial, would help our members know whether ketamine infusion as compared to non-ketamine approaches, impact outcomes such as immediate and/or long term pain scores, quality of life, anxiety or depression prevalence and/or incidence, survival, and/or length of hospitalization?
- How will you or your group use the information from a new evidence report?
- The American Academy of Hospice and Palliative Medicine (AAHPM) will use the information from this new evidence report to help inform guidelines for best practices for palliative care.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- The American Academy of Hospice and Palliative Medicine (AAHPM) would disseminate this information to our members through newsletters and educational meetings. We would also disseminate this information to important stakeholders such including government and private payers of hospice care.
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- The Centers for Medicare and Medicaid Services and other payers of hospice services could use this evidence report to inform policies regarding reimbursement for care for palliative care patients.
- Information About You: (optional)
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- Provide a description of your role or perspective.
- Staff at physician medical specialty society
- If you are you making a suggestion on behalf of an organization, please state the name of the organization.
- American Academy of Hospice & Palliative Medicine
- Please tell us how you heard about the Effective Health Care Program.
- Email from AHRQ
