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Palliative Care

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Title: Palliative Care


1
Palliative Care
  • Nikki Burger
  • GP Registrar
  • November 2005

2
WHO Definition Palliative Care
  • The active total care of patients whose disease
    is not responsive to curative treatment. Control
    of pain, of other symptoms, and of psychological,
    social and spiritual problems is paramount. The
    goal of palliative care is achievement of best
    quality of life for patients and their families.

3
Components of Palliative Care
  • Effective symptom control
  • Effective communication
  • Rehabilitation maximising independence
  • Continuity of care
  • Coordination of services
  • Terminal care
  • Support in bereavement

4
Funding
  • Differs from the rest of the health service
  • 20 inpatient units in UK funded entirely by NHS
  • Voluntary sector
  • Goodwill and fundraising initiatives in local
    communities

5
Funding
  • National charities
  • Macmillan Cancer Relief
  • Marie Curie Cancer Care
  • Sue Ryder Foundation
  • These are the three major providers nationally.

6
Concept of Total Pain
  • Physical pain
  • Anger
  • Depression
  • Anxiety
  • All affect patients perception of pain.
  • Needs thorough assessment
  • 90 can be controlled with self-administered oral
    drugs

7
Depression
  • Loss of social position
  • Loss of job prestige, income
  • Loss of role in family
  • Insomnia and chronic fatigue
  • Helplessness
  • Disfigurement

8
Anxiety
  • Fear of hospital, nursing home
  • Fear of pain
  • Worry about family and finances
  • Fear of death
  • Spiritual unrest
  • Uncertainty in future

9
Anger
  • Delays in diagnosis
  • Unavailable physicians
  • Uncommunicative physicians
  • Failure of therapy
  • Friends who dont visit
  • Bureaucratic bungling

10
Treatment options
  • Analgesic drugs
  • Adjuvant drugs
  • Surgery
  • Radiotherapy
  • Chemotherapy
  • Spiritual and emotional support (total pain)

11
Analgesic drugs
  • Mainstay of managing cancer pain
  • Choice based on severity of pain, not stage of
    disease
  • Standard doses, regular intervals, stepwise
    fashion
  • Non-opiodweak opioidstrong opiod-adjuvant at
    any level (WHO analgesic ladder)

12
Non-opioid drugs
  • Paracetamol
  • 1g 4 hourly
  • NSAIDS
  • Ibuprofen 400mg 4 hourly
  • Aspirin 600mg 4 hourly
  • NB daily maximum doses

13
Weak opioids
  • Codeine
  • 60mg 4 hourly
  • Dihydrocodeine
  • 30-80mg tds max 240mg daily
  • Dextropropoxyphene
  • 65mg four hourly
  • Tramadol 50-100mg 6 hourly
  • Prescribing more than the maximum daily dose will
    increase s/e without producing further analgesia

14
Combinations
  • Convenient
  • Care with dosing
  • Some combinations e.g co-codamol contain
    subtherapeutic doses of weak opioid
  • Co-proxamol only contains 325mg paracetamol
  • Get dosing right before moving on to strong
    opioids

15
Strong Opioids
  • Morphine
  • Hydromorphone
  • Fentanyl
  • Diamorphine
  • Buprenorphine

16
Morphine
  • Where possible dose by mouth
  • Dose tailored to requirements
  • Regular intervals prevent pain from returning
  • No arbitrary upper limit (unlike weak opioids)
  • Fears of patients and family
  • Side effects

17
Morphine Products
  • Oramorph 4 hourly
  • Sevredol 4 hourly
  • Oramorph RS 12 hourly
  • Zomorph 12 hourly
  • MST 12 hourly
  • MXL 24 hourly

18
Starting Morphine - Dose titration
  • Start with quick-release formulation
  • Prescribe regular four hourly dose, allow same
    size dose PRN in addition for breakthrough pain,
    as often as necessary
  • Usual starting dose 5-10mg four hourly
  • After 24-48 hours daily requirements can be
    calculated

19
Dose titration
  • Once total dose required in 24 hours known,
    prescribe it as SR preparation (eg MST) bd
  • Provide additional doses of IR morphine (eg
    Oramorph) for breakthrough pain at 1/6 of total
    daily dose
  • If taking regular top-ups recalculate the total
    daily dose

20
Dose titration
  • Example Mrs M
  • 56y breast cancer with bony mets
  • Paracetamol 1g qds
  • Diclofenac SR 75mg bd
  • MST 60mg bd
  • Taking three doses Oramorph a day for
    breakthrough pain
  • What next?

21
  • Calculate total daily dose
  • 60mg bd MST 120mg
  • (120/6) x3 60mg
  • Total 180mg

22
  • So, prescribe
  • 180/2 MST 90mg bd
  • 180/6 Oramorph 30mg PRN for breakthrough pain.

23
Parenteral opiates
  • Unable to maintain dosing by mouth
  • Subcutaneous infusion commonest alternative
    syringe driver
  • Convert oral dose to equianalgesic sc dose
  • Morphine /2
  • Diamorphine /3
  • Fentanyl patch
  • Less constipation, nausea, sedation

24
Opioid alternatives to morphine
  • Hydromorphone
  • 7 times more potent than morphine, so care in
    those with no prior exposure

25
Opioid alternatives to morphine
  • Fentanyl
  • Self-adhesive patches
  • Changed every 72 hours
  • No IR form so for chronic stable pain, need IR
    morphine for breakthrough
  • 24-48 hours for peak levels to be achieved
  • Useful if side effects with morphine

26
Oxycodone
  • OxyContin
  • Onset 1 hour, 12 hour modified release
  • OxyNorm
  • Liquid and capsules
  • Immediate release
  • 10mg oral oxycodone 20mg oral morphine

27
Hydromorphone
  • Palladone and Palladone SR
  • 1.3mg hydromorphone 10mg morphine

28
Writing a prescription for CDs
  • By hand
  • In ink
  • Name and address patient
  • Name of drug
  • Form and strength
  • Total quantity, or number of dose units, in both
    words and figures

29
Writing a prescription for opiates
  • Mary Jones
  • 16 High Street, Worcester, WR1 1AA
  • Oramorph liquid 20mg/5ml
  • Supply 200ml (two hundred)
  • Take 20mg every 4 hours
  • Oramorph 10mg/5ml no longer a CD

30
Side effects of Opiates
  • Common
  • Constipation
  • NV
  • Sedation
  • Dry mouth
  • Less common
  • Miosis
  • Itching
  • Euphoria
  • Hallucination
  • Myoclonus
  • Tolerance
  • Respiratory depression

31
Constipation
  • Develops in almost all patients
  • Prescribe PROPHYLACTIC laxatives
  • Start with stimulant AND softener
  • Senna TT nocte PLUS
  • Docusate or lactulose
  • Also common with weak opioids

32
Nausea and vomiting
  • Initially very common
  • Usually resolve over a few days
  • Easily controlled if forewarned
  • Metoclopramide 10mg 8 hourly
  • Haloperidol 1.5mg bd or nocte

33
Sedation
  • Also common initially and then resolving
  • Be alert to possibility of recurrence of sedation
    or confusion after dose alteration

34
Dry mouth
  • Often most troublesome symptom
  • Simple measures
  • Frequent sips cold drinks
  • Sucking boiled sweets
  • Ice cubes/frozen fruit segments
  • Eg pineapple or melon

35
Addiction
  • Often feared by inexperienced prescribers and
    patients and families
  • Escalating requirements are sign of disease
    progression or possibly tolerance, not addiction

36
Opioid toxicity
  • Wide variation in toxic doses between individuals
    and over time
  • Depends on
  • Degree of responsiveness
  • Prior exposure
  • Rate of titration
  • Concomitant medication
  • Renal function

37
Opioid toxicity
  • Subtle agitation
  • Shadows at periphery of visual field
  • Vivid dreams
  • Visual hallucinations
  • Confusion
  • Myoclonic jerks

38
Agitated confusion
  • Often misinterpreted as patient being in pain
  • Thus further opioids are prescribed
  • Vicious cycle, leads to dehydration
  • Accumulation of metabolites componds toxicity
  • Management
  • Reduce dose of opioid
  • Haloperidol 1.5-3mg SC/PO hourly as needed for
    agitation
  • Adequate hydration

39
Opioid responsiveness
  • Not all pains respond well
  • Bone pain
  • Neuropathic pain
  • Need adjuvants
  • Drugs
  • Radiotherapy
  • Anaesthetic blocks

40
Common adjuvant analgesics
  • NSAIDS
  • Corticosteroids
  • Antidepressant/-convulsants
  • Bisphosphonates
  • Bone pain
  • Soft tissue inflitration
  • Hepatomegaly
  • Raised ICP
  • Soft tissue infiltration
  • Nerve compression
  • Hepatomegaly
  • Nerve compression
  • Nerve infiltration
  • Paraneoplastic neuropathy
  • Bone pain

41
Bone pain
  • Paracetamol
  • Morphine
  • NSAIDS
  • Radiotherapy
  • Bisphosphonates

42
Neuropathic pain
  • Features which suggest neuropathic pain
  • Burning
  • Shooting/stabbing
  • Tingling/pins and needles
  • Allodynia
  • Dysaesthesia
  • Dermatomal distribution

43
Neuropathic pain
  • Antidepressant
  • Amitriptyline 50mg nocte
  • Anticonvulsant
  • Sodium Valproate 200mg bd (or Gabapentin or
    Carbamazepine)
  • Steroids
  • Dexamethasone 12mg daily
  • Antiarrhythmics
  • Mexiletine 50-300mg tds (or flecainide or
    lignocaine)
  • Anaesthetics
  • Ketamine
  • Nerve blocks and spinal anaesthesia

44
Neuropathic pain
  • Complementary therapies
  • TENS
  • Acupuncture
  • Hypnosis
  • Aromatherapy
  • Counselling
  • Social support

45
Common mistakes in cancer pain management
  • Forgetting there is more than one pain
  • Reluctance to prescribe morphine
  • Failure to use non-drug treatments
  • Failure to educate patient about treatment
  • Reducing interval instead of increasing dose

46
  • Any questions?

47
Reflective Learning
  • Why?
  • Improve your insight into patients illness
  • Improve your relationship with patient or
    identify stumbling blocks
  • Improve your overall management of the whole
    patient
  • Identify gaps in knowledge
  • Fulfill the role of holistic practitioner
    offering care at end of life

48
Reflective Learning
  • How has the diagnosis affected your relationship
    with the patient?
  • Do you feel uncomfortable in your attempts to
    communicate with the patient or family?
  • Have you explored the patients worries about
    their illness?
  • Have you explored their views on their treatment
    so far?
  • Do you feel that you have been of help?
  • Can you identify stages of anticipatory grief?

49
Other areas for future learning
  • Breathlessness and cough
  • Mouth care/skin care/lymphoedema
  • NV and intestinal obstruction
  • Anorexia, cachexia and nutrition
  • Constipation and diarrhoea
  • Non-cancer palliative care
  • Emergencies
  • Children
  • Caring for carers
  • Bereavement
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