Palliative Care – update for the acute physician Dr Anne Goggin

Pain management – use of opioids Update on LCP

Pain management

Evaluation Location Duration Palliative factors – ‘What makes it better?’ Provocative factors – ’What makes it worse?’ Quality Radiation Severity Timing

Analgesic history What medication at what dose Regularly or prn Duration Effect of current medication on pain Side-effects now or in the past

WHO method for cancer pain relief – is it still valid? Recommendations for correct use of analgesics to optimise effectiveness By the mouth By the clock By the ladder Individual dose titration Use adjuvant drugs Attention to detail

WHO analgesic ladder

Weak Opioids General rules If a weak opioid, given regularly, at maximum recommended dose, is inadequate - change to a strong opioid Do not move sideways from weak opioid to weak opioid

Stepping up from Step 2 to Step 3 In practice this most commonly involves changing from: Codeine 60mg qds to morphine – m/r morphine 10-15mg q 12 hr Tramadol 100mg qds to morphine – m/r morphine30- 40mg q 12 hr Remember to prescribe prn rescue dose of oramorph at 1/6 24 hour dosage of m/r morphine CAVE renal impairment

Switching from strong opioid Opioids differ from each other in part due to receptor affinity These properties can be used in patients who are intolerant of morphine by switching to an alternative opioid Other reasons for alternative opioid: Transdermal route preferable Psychological ‘allergy’ to morphine

Opioid conversion chart

Neuropathic pain Quality Superficial burning / stinging Spontaneous stabbing pain Deep ache Often there is Allodynia Sensory deficit

Neuropathic Pain About 50% of cancer related neuropathic pain respond to the combined use of an NSAID and a strong opioid The rest need adjuvant analgesics Most commonly used Amitriptyline Gabapentin pregabalin

Common reasons for unrelieved pain in advanced cancer Failure to evaluate each pain individually and to plan treatment accordingly Prescription of analgesic to be taken only ‘as needed’ Failure to monitor patients response to prescribed analgesics Changing to an alternative analgesic before optimising the dose & timing of the previous analgesic

Last Days

More care, less pathway Response to substantial criticism of LCP in the media & elsewhere Panel to review its use in England- Chair Baroness Neuberger Independent of Gov & NHS Evidence from many quarters

Background to Liverpool Care Pathway for the Dying Patient (LCP) About half of all deaths currently take place in in hospital, making care of the dying a core duty of hospital trusts. Proportion dying at home will rise but as death rate is rising actual numbers dying in hospital will also increase The LCP is an approach to care of the dying intended to ensure that uniformly good care is given to everyone thought to be dying within hours or 2 or 3 days.

Report findings Principles of the LCPDP - sound When the LCPDP is used by well trained, well- resourced & sensitive clinical teams, it works well Where care is already poor the LCPDP is sometimes used as a tick box exercise Preventable problems of communication – accounted for substantial part of concerns raised

Report findings Problems of definitions & terminology ‘end of life’ – can mean between last year of life to last days or hours of life ‘pathway’ is clearly being misunderstood Diagnosis of dying

Leadership Alliance for the Care of Dying People Statement -20 March 2014 – Focus on what care should be like rather than the delivery of particular protocols – 5 priority areas – LCPDP to be phased out by July 2014 – There will not be a ‘national tool ’to replace the LCP – The priority areas will inform the inspection by CQC of end of life care – & will inform a new NICE Clinical Guideline on the care of dying adults

Next Steps More national guidance to come – late spring/ early summer 2014 Pan – Hampshire group to advise on local care plan

Guidance for last days The possibility that a person may die is recognised & communicated Continue to visit Simplify medication Anticipate a time when the patient will not be able to swallow & prescribe meds that can be given PR or subcut Anticipate symptoms that may arise in dying – pain, excess secretions, delirium.

Contact details Hospital Palliative Care Team Mon- Fri 0830 to 1630 ext 4126 Sat & Sun CNS bleep 1477 Out of Hours CMH doctor on- call