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 controlEffective communicationRehabilitation – maximising independenceContinuity of careCoordination of servicesTerminal careSupport in bereavement

Funding

Differs from the rest of the health service20% inpatient units in UK funded entirely

by NHSVoluntary sectorGoodwill 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 painAngerDepressionAnxiety

All affect patient’s perception of pain.

Needs thorough assessment

90% can be controlled with self-administered oral drugs

Depression

Loss of social positionLoss of job prestige, incomeLoss of role in familyInsomnia and chronic fatigueHelplessnessDisfigurement

Anxiety

Fear of hospital, nursing homeFear of painWorry about family and financesFear of deathSpiritual unrestUncertainty in future

Anger

Delays in diagnosisUnavailable physiciansUncommunicative physiciansFailure of therapyFriends who don’t visitBureaucratic bungling

Treatment options

Analgesic drugsAdjuvant drugsSurgeryRadiotherapyChemotherapySpiritual and emotional support (total pain)

Analgesic drugs

Mainstay of managing cancer painChoice based on severity of pain, not stage

of diseaseStandard doses, regular intervals, stepwise

fashionNon-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

Codeine60mg 4 hourly

Dihydrocodeine30-80mg tds max 240mg daily

Dextropropoxyphene65mg four hourly

Tramadol 50-100mg 6 hourly Prescribing more than the maximum daily dose will

increase s/e without producing further analgesia

Combinations

ConvenientCare 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

MorphineHydromorphoneFentanylDiamorphineBuprenorphine

Morphine

Where possible dose by mouthDose tailored to requirementsRegular intervals – prevent pain from

returningNo arbitrary upper limit (unlike weak

opioids)Fears of patients and familySide effects

Morphine Products

Oramorph 4 hourlySevredol 4 hourlyOramorph RS 12 hourlyZomorph 12 hourlyMST 12 hourlyMXL 24 hourly

Starting Morphine - Dose titration

Start with quick-release formulationPrescribe regular four hourly dose, allow

same size dose PRN in addition for breakthrough pain, as often as necessary

Usual starting dose 5-10mg four hourlyAfter 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 M56y breast cancer with bony metsParacetamol 1g qdsDiclofenac SR 75mg bdMST 60mg bd Taking three doses Oramorph a day for

breakthrough painWhat 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 mouthSubcutaneous infusion commonest

alternative – syringe driverConvert 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 handIn inkName and address patientName of drugForm and strengthTotal quantity, or number of dose units, in

both words and figures

Writing a prescription for opiates

Mary Jones16 High Street, Worcester, WR1 1AAOramorph liquid 20mg/5mlSupply 200ml (two hundred)Take 20mg every 4 hours

Oramorph 10mg/5ml no longer a CD

Side effects of Opiates

Common– Constipation

– N+V

– Sedation

– Dry mouth

Less common– Miosis

– Itching

– Euphoria

– Hallucination

– Myoclonus

– Tolerance

– Respiratory depression

Constipation

Develops in almost all patientsPrescribe PROPHYLACTIC laxativesStart with stimulant AND softener

– Senna TT nocte PLUS– Docusate or lactulose

Also common with weak opioids

Nausea and vomiting

Initially very commonUsually resolve over a few daysEasily controlled if forewarned

– Metoclopramide 10mg 8 hourly– Haloperidol 1.5mg bd or nocte

Sedation

Also common initially and then resolvingBe alert to possibility of recurrence of

sedation or confusion after dose alteration

Dry mouth

Often most troublesome symptomSimple 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– Degree of responsiveness– Prior exposure– Rate of titration– Concomitant medication– Renal function

Opioid toxicity

Subtle agitationShadows at periphery of visual fieldVivid dreamsVisual hallucinationsConfusionMyoclonic jerks

Agitated confusion

Often misinterpreted as patient being in painThus further opioids are prescribedVicious cycle, leads to dehydrationAccumulation of metabolites componds toxicityManagement

– 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

Corticosteroids

Antidepressant/-convulsants

Bisphosphonates

Bone painSoft tissue inflitrationHepatomegaly

Raised ICPSoft tissue infiltrationNerve compressionHepatomegaly

Nerve compressionNerve infiltrationParaneoplastic neuropathy

Bone pain

Bone pain

ParacetamolMorphineNSAIDSRadiotherapyBisphosphonates

Neuropathic pain

Features which suggest neuropathic pain– 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– TENS– Acupuncture– Hypnosis– Aromatherapy– Counselling– Social support

Common mistakes in cancer pain management

Forgetting there is more than one painReluctance to prescribe morphineFailure to use non-drug treatmentsFailure to educate patient about treatmentReducing 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