Transcript Palliative Care Nikki Burger GP Registrar November 2005

Palliative Care
Nikki Burger
GP Registrar
November 2005
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.
Components of Palliative Care
Effective symptom control
Effective communication
Rehabilitation – maximising independence
Continuity of care
Coordination of services
Terminal care
Support in bereavement
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
Funding
National charities
– Macmillan Cancer Relief
– Marie Curie Cancer Care
– Sue Ryder Foundation
These are the three major providers nationally.
Concept of Total Pain
 Physical pain
 Anger
 Depression
 Anxiety
All affect patient’s perception of pain.
Needs thorough assessment
90% can be controlled with self-administered oral
drugs
Depression
Loss of social position
Loss of job prestige, income
Loss of role in family
Insomnia and chronic fatigue
Helplessness
Disfigurement
Anxiety
Fear of hospital, nursing home
Fear of pain
Worry about family and finances
Fear of death
Spiritual unrest
Uncertainty in future
Anger
Delays in diagnosis
Unavailable physicians
Uncommunicative physicians
Failure of therapy
Friends who don’t visit
Bureaucratic bungling
Treatment options
Analgesic drugs
Adjuvant drugs
Surgery
Radiotherapy
Chemotherapy
Spiritual and emotional support (total pain)
Analgesic drugs
Mainstay of managing cancer pain
Choice based on severity of pain, not stage
of disease
Standard doses, regular intervals, stepwise
fashion
Non-opiod…weak opioid…strong
opiod…+-adjuvant at any level (WHO
analgesic ladder)
Non-opioid drugs
Paracetamol
1g 4 hourly
NSAIDS
Ibuprofen 400mg 4 hourly
Aspirin 600mg 4 hourly
NB daily maximum doses
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
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
Strong Opioids
Morphine
Hydromorphone
Fentanyl
Diamorphine
Buprenorphine
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
Morphine Products
Oramorph
Sevredol
Oramorph RS
Zomorph
MST
MXL
4 hourly
4 hourly
12 hourly
12 hourly
12 hourly
24 hourly
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
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
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?
Calculate total daily dose
– 60mg bd MST = 120mg
– (120/6) x3 = 60mg
– Total 180mg
So, prescribe
– 180/2 = MST 90mg bd
– 180/6 = Oramorph 30mg PRN for
breakthrough pain.
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
Opioid alternatives to morphine
Hydromorphone
– 7 times more potent than morphine, so care in
those with no prior exposure
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
Oxycodone
OxyContin
– Onset 1 hour, 12 hour modified release
OxyNorm
– Liquid and capsules
– Immediate release
10mg oral oxycodone = 20mg oral
morphine
Hydromorphone
Palladone and Palladone SR
– 1.3mg hydromorphone = 10mg morphine
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
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
Side effects of Opiates
 Common
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Constipation
N+V
Sedation
Dry mouth
 Less common
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Miosis
Itching
Euphoria
Hallucination
Myoclonus
Tolerance
Respiratory depression
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
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
Sedation
Also common initially and then resolving
Be alert to possibility of recurrence of
sedation or confusion after dose alteration
Dry mouth
Often most troublesome symptom
Simple measures
– Frequent sips cold drinks
– Sucking boiled sweets
– Ice cubes/frozen fruit segments
• Eg pineapple or melon
Addiction
Often feared by inexperienced prescribers
and patients and families
Escalating requirements are sign of disease
progression or possibly tolerance, not
addiction
Opioid toxicity
Wide variation in toxic doses between
individuals and over time
Depends on
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Degree of responsiveness
Prior exposure
Rate of titration
Concomitant medication
Renal function
Opioid toxicity
Subtle agitation
Shadows at periphery of visual field
Vivid dreams
Visual hallucinations
Confusion
Myoclonic jerks
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
Opioid responsiveness
Not all pains respond well
– Bone pain
– Neuropathic pain
Need adjuvants
– Drugs
– Radiotherapy
– Anaesthetic blocks
Common adjuvant analgesics
NSAIDS
Bone pain
Soft tissue inflitration
Hepatomegaly
Corticosteroids
Raised ICP
Soft tissue infiltration
Nerve compression
Hepatomegaly
Antidepressant/-convulsants
Nerve compression
Nerve infiltration
Paraneoplastic neuropathy
Bisphosphonates
Bone pain
Bone pain
Paracetamol
Morphine
NSAIDS
Radiotherapy
Bisphosphonates
Neuropathic pain
Features which suggest neuropathic pain
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Burning
Shooting/stabbing
Tingling/pins and needles
Allodynia
Dysaesthesia
Dermatomal distribution
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
Neuropathic pain
Complementary therapies
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TENS
Acupuncture
Hypnosis
Aromatherapy
Counselling
Social support
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
Any questions?
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
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”?
Other areas for future learning
 Breathlessness and cough
 Mouth care/skin care/lymphoedema
 N+V and intestinal obstruction
 Anorexia, cachexia and nutrition
 Constipation and diarrhoea
 Non-cancer palliative care
 Emergencies
 Children
 Caring for carers
 Bereavement