Questioning methadone split-dosing for analgesia among hospitalized patients with opioid use disorder

Methadone is hypothesized to provide greater analgesic coverage when split into two or more divided doses. However, empirical data are lacking, and our anecdotal experience at a safety-net hospital among patients with opioid use disorder suggests that it may not be straightforward. Guidelines and clinicians should exercise appropriate caution when recommending this strategy.

Colorado Palliative Care and Hospice Crisis Standards: Moving Beyond Critical Care Planning

Palliative care (PC) and hospice services have experienced shortages before 2020, and during the initial phases of the current pandemic, more critical gaps are expected with future surges, much as scarcity in intensive care unit services may recur during the COVID-19 pandemic. Although ethical allocation of ventilators and intensive care unit care is the subject of important discussions during this pandemic, caring for those at the end of life and those not desiring or qualifying for critical interventions must not be neglected, as critical care and comfort-focused care are intertwined. We review state and regional gaps already recognized in planning for scarcity in PC and hospice services during this pandemic and describe the planning initiatives Colorado has developed to address potential scarcities for this vulnerable and diverse group of people. We hope to encourage other state and regional groups to anticipate needs in the coming surges of this pandemic or in public health crises to come. Such planning is key to avoid the degradation of care that may result if it is necessary to invoke crisis standards of care and ration these essential services to our communities.

Palliative Volume Resuscitation in a Patient with Cancer and Hypercalcemia: Why Bother?

Hypercalcemia of malignancy affects 2%-2.8% of cancer patients and is associated with an increased risk of mortality and other symptom-related complications. Standard treatment consists of fluid resuscitation, intravenous bisphosphonates, and calcitonin. Little is known, however, about the benefits of treatment of malignant hypercalcemia in patients with late-stage terminal cancer. We present a case of a hospice patient with squamous cell lung cancer brought to our hospital with newly altered mental status who was found to have hypercalcemia of malignancy. Our discussion centers on the diagnostic dilemma of deciding which patients seeking comfort-focused care may benefit from fluid resuscitation for symptoms of hypercalcemia of malignancy while maintaining the unambiguous goal of comfort care.