Palliative Care

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Palliative Care

• Nikki Burger
• GP Registrar
• November 2005

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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

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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

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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)

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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)

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Non-opioid drugs

• Paracetamol
• 1g 4 hourly
• NSAIDS
• Ibuprofen 400mg 4 hourly
• Aspirin 600mg 4 hourly
• NB daily maximum doses

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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

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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

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Strong Opioids

• Morphine
• Hydromorphone
• Fentanyl
• Diamorphine
• Buprenorphine

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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

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Morphine Products

• Oramorph 4 hourly
• Sevredol 4 hourly
• Oramorph RS 12 hourly
• Zomorph 12 hourly
• MST 12 hourly
• MXL 24 hourly

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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

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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

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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?

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

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

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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

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Opioid alternatives to morphine

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

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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

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Oxycodone

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

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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

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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

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Side effects of Opiates

• Common
• Constipation
• NV
• Sedation
• Dry mouth

• Less common
• Miosis
• Itching
• Euphoria
• Hallucination
• Myoclonus
• Tolerance
• Respiratory depression

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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

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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

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Sedation

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

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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

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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

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Opioid toxicity

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

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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

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Opioid responsiveness

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

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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

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Bone pain

• Paracetamol
• Morphine
• NSAIDS
• Radiotherapy
• Bisphosphonates

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Neuropathic pain

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

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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

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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

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• Any questions?

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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

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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?

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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