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Palliative Care Dr Philip Lee
03/11/101 Palliative Care Dr Philip Lee Palliative Medicine Staff Specialist WSAHS Acting Director Palliative Care WSAHS 1
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Palliative Care Definitions
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To cure, occasionally To relieve, often To comfort, always
Anonymous (16th Century) Death should simply become a discreet but dignified exit of a peaceful person from a helpful society … without pain or suffering and ultimately without fear. Philippe Ariès, 1977 The Hour of Our Death
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Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patient’s illness, including bereavement care Roger Woodruff Palliative Medicine nd Edition
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Palliative Care Caring for a person with an active, progressive, far advanced disease with little or no prospect of cure and for whom the primary treatment goal is quality of life
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PALLIATIVE CARE - WHEN? DEATH DIAGNOSIS DEATH PALLIATIVE BEREAVE- MENT
ACTIVE TREATMENT DEATH DIAGNOSIS ACTIVE TREATMENT BEREAVE- MENT DEATH PALLIATIVE CARE
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PALLIATIVE CARE - WHERE?
Palliative Care is a Network Services are provided by Teams Services are available in: Community, home and aged care facilities Acute hospitals Private Hospitals Specific inpatient units eg St Joseph’s, Mt Druitt, Neringah, Greenwich, Braeside Hospitals
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PALLIATIVE CARE - COMMUNITY
GP “case manager” Generalist Community Nurse - GCN Clinical Nurse Specialist - CNS Clinical Nurse Consultant - CNC Palliative Care Medical Officer Community Palliative Care Specialist
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WHAT DOES PALLIATIVE CARE OFFER?
Pain control Other symptom control Terminal care Family support Bereavement support
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Cancer pain 30-50% of cancer patients undergoing active treatment
70-90% of cancer patients with advanced disease Prospective studies indicate that as many as 90% of patients could attain adequate pain relief with simple drug therapies.
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The Context SOMATIC SOURCE TOTAL PAIN DEPRESSION ANGER ANXIETY
Symptoms of debility Non-cancer pathology Side effects of therapy Cancer Loss of social position Bureaucratic bungling SOMATIC SOURCE Loss of job prestige and income Friends not visiting TOTAL PAIN Loss of role in family Delays in diagnosis DEPRESSION ANGER Chronic fatigue and insomnia Unavailable doctors Sense of helplessness Irritability ANXIETY Disfigurement Therapeutic failure Fear of hospital or nursing home Fear of pain Family finances Worry about family Loss of choices Fear of death Uncertainty about future Spiritual (existential) unrest
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WHO analgesic ladder or increases or increases
03/11/101 WHO analgesic ladder Pain Pain persists Pain persists or increases or increases Strong opioid ± non-opioid ± adjuvant Weak opioid ± non-opioid ± adjuvant Non-opioid ± adjuvant 9
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Guidelines for opioid use
03/11/101 Guidelines for opioid use Preferably oral Continuous rather than PRN Commence with immediate release Once stable convert to slow release + immediate for breakthrough pain relief If more than 2 episodes of breakthrough pain increase regular dose Laxatives 28
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03/11/101 Analgesic Classes Aspirin Paracetamol NSAIDS Opioids 10
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Opioids Strong opioids Weak opioids Oxycodone Codeine Morphine
03/11/101 Opioids Strong opioids Oxycodone Morphine Methadone Fentanyl Hydromorphone Pethidine Tramadol Weak opioids Codeine Dextropropoxyphene 17
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03/11/101 Opioid receptors All opioids produce analgesia and other effects by mimicking the actions of endogenous opioid compounds (endorphins) at multiple subtypes of the three major opioid receptors in the brain stem, spinal cord and peripheral tissues. 18
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03/11/101 Opioid actions The perception of pain is altered both by a direct effect on the spinal cord, modulating peripheral nociceptive input, and by activation of the descending inhibitory systems from the brain stem and basal ganglia. 19
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Patients’ concerns about narcotics
03/11/101 Patients’ concerns about narcotics Addiction & withdrawal Tolerance Implications of taking morphine Side effects 26
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Side effects Sedation Hallucinations Nausea & vomiting Constipation
03/11/101 Side effects Sedation Hallucinations Nausea & vomiting Constipation Urinary retention Myoclonus Respiratory depression Pruritus 27
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Cognitive impairment Some sedation early in use of morphine
03/11/101 Cognitive impairment Some sedation early in use of morphine Tolerance develops Prior sleep deprivation due to poor pain control Other causes of cognitive impairment need to be excluded 29
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Opioid Dose Duration of Action
Morphine (oral) 20 mg 4 hrs Morphine (parenteral) 10mg Codeine 130 mg 4-6 hrs Pethidine (IMI) 80 mg 2-3.5 hrs Methadone * 2-5 mg 8-12 hrs Oxycodone 10-20 mg Tramadol 200 mg Fentanyl 200 mcg 1-2 hrs Hydromorphone 4 mg
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Routes of administration of morphine
03/11/101 Routes of administration of morphine Oral Subcutaneous IVI Epidural & intrathecal Rectal Topically 30
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Morphine metabolism Primarily metabolised in the liver
03/11/101 Morphine metabolism Primarily metabolised in the liver Metabolites excreted in urine Morphine-3-glucuronide (M3G) Morphine-6-glucuronide (M6G) Caution in renal impairment M6G potent morphine agonist M3G no significant analgesic action Liver disease not reported to alter pharmacokinetics 31
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Morphine Pros Cons “Gold Standard” Well understood Readily available
Usually well tolerated No “ceiling” Cons Accumulates in renal failure Constipating Nausea Sedation Misconceptions
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Morphine Preparations
Morphine mixture (Ordine) 4 hrs 1, 2, 5, 10, 20, 40 mg/ml Kapanol caps 24 hrs 10, 20, 50, 100 mg/ml MS Contin tabs 12 hrs 5, 10, 15, 30, 60, 100, 200 mgs MS Contin susp 30, 60, 100, 200 mgs MS Mono caps 30, 60, 90, 120 mgs Morphine sulphate amps 5, 10, 15, 30, 50 mgs/ml Morphine tartrate amps 120 mgs/1.5 mls, 400mgs/5mls
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Oxycodone Pros Cons Various dose forms, immeadiate & slow release
Neuropathic pain “New” OK in renal failure Cons No parenteral form Constipating Nausea Confusing names
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Oxycodone & Tramadol Endone Tabs 4 hrs 5 mg Oxynorm 5, 10, 20 mgs
Oxycontin 12 hrs 10, 20, 40, 80 mgs Tramadol caps 4-6 hrs 50 mg Tramadol SR Tabs 100, 150, 200 mgs Tramadol amps 100 mg/2 mls
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Fentanyl Pros Cons Less constipation Less nausea
Less psychotomimetic effects Convenient OK in renal failure Cons Reliant on good fat stores Inflexible dosing Difficult to titrate Expensive Breakthrough medications
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Hydromorphone Pros Cons Less sedating Less constipating
Less hallucinations Less nauseating OK in renal failure Cons Availability No slow release currently available
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Methadone Pros Cons Neuropathic pain Stigma Difficult dosing schedule
Variable half-life
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Fentanyl, Methadone & Hydromorphone
Fentanyl Patches (Durogesic) 72 hrs 25, 50, 75, 100 mcg/hr Fentanyl sublingual liquid 1-2 hrs 100 mcg/ml Fentanyl lozenges (ACTIQ) 200, 400, 800, 1200, 1600 mcg Methadone 8-100 hrs 10 mg Hydromorphone tabs (Dilaudid) 4 hrs 2, 4, 8 mgs Hydromorphone liquid 1 mg/ml Hydromorphone amps 2mg/ml, 10mg/ml, 50mg/5mls, 500mg/50mls
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03/11/101 Pethidine Repetitive dosing leads to accumulation of the toxic metabolite norpethidine Norpethidine accumulation causes CNS hyper-excitability & subtle mood changes Tremors Multifocal myoclonus Seizures Common with repeated large doses, eg 250 mg per day 25
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