1. Palliative care of Head and neck Oncology patients Magdy Amin Riad Professor of Otolaryngology. Ain Shams University Senior Lecturer in Otolaryngology. University of Dundee

2. Symptom management Breaking difficult news. Pain control. Hydration and feeding. Nausea and vomiting. Confusion, withdrawal, anxiety or anger. Unexpected deterioration.

3. Breaking difficult news Setting Corridors are not appropriate Time and place privacy Understanding Language Hearing Anxiety

4. Breaking difficult news What do they know Most people have already guessed the seriousness Denial Knowing more Check before volunteering

5. Breaking difficult news Warn – pause – check We found something abnormal Pause to see response Check if patient want to know more Repeat with every statement

6. Breaking difficult news More help Difficult questions have to be answered immediately Acknowledge the importance of the question Check why the question is being asked Being honest about uncertainty is acceptable

7. Diagnosing pain At rest. Related to movement. Persisting pain

8. Pain at rest On inspiration? Exclude pleurisy = NSAID Intercostal block for pain localised to 1-3 dermatomes Exclude rib metastases =Consider radiotherapy Nerve block,.

9. Pain at rest Periodic? Exclude colic from bowel, bladder or ureter. =Buscopan 10-20 mg SC +/- NSAID (diclofenac ) 75 mg IM or 100 mg PR

10. Pain at rest Related to eating? Exclude dental,pharyngeal or peptic diseases. Dental = appropriate dental care. Oropharyngeal ulcers =Difflam or antiseptic mouthwash Peptic = ranitidine or omeprazole

11. Pain at rest Localised to dermatome ? Exclude nerve compression. = opioid Exclude skeletal instability (e.g. vertebral collapse) = immobilise Exclude bone metastases = dexamethasone 8 mg /day + opioid

12. Pain related to movement Active movement only? Muscle strain or spasm = inject trigger point with 3-5ml bupivacaine

13. Pain related to movement Slightest passive movement? Exclude a fracture =immobilise

14. Pain related to movement By bone strain or pressure? Exclude bone metastases = dexamethasone 8 mg/ daily or nerve block

15. Persisting pain Analgesic inappropriate. Analgesic incorrectly administered. Poor compliance. Depression. Unresolved fear or anger.

16. Pain Scales Number Scale Describe your pain using a number from 0 to 10: 0= No Pain and 10= The worst pain you've ever had. Word Scale Describe the pain using the words that best tell us how much you hurt: No pain; Mild; Moderate; Severe; Very severe; or Worst possible pain. Faces Scale Place an X or point to the face that shows how much you hurt

18. Some pain medications commonly used include: Acetaminophen - Commonly known by its brand name, Tylenol. It takes care of mild to moderate pain. It usually has very few side effects. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Aspirin and ibuprofen (Motrin), are some NSAIDs you may know. They are commonly used to reduce or prevent swelling. Some NSAIDs are available only by prescription. Others can be purchased over the counter. NSAIDs may not be the best choice for everyone because of some of their side effects. Narcotic Analgesics - Also called opiates. These include morphine, hydromorphone, meperidine, codeine, and oxycodone. Some narcotics are commonly combined with acetaminophen. These include Tylenol #3, Percocet, and Lortab. Narcotics are available only by prescription. Side effects may include drowsiness, stomach upset, nausea, itching, and constipation. Stool softeners or laxatives may be given if narcotics are used for more than a few days. Don't drink alcoholic beverages while taking narcotics.

19. How are pain medications given? Pain medications are given several ways. They may be given by mouth, or through the nose or rectum. Some may be given by injection or infusion. In some cases., Patient Controlled Analgesia (PCA) may be used. With the use of PCA, you control a pump that gives you a small dose of medication every 10-15 minutes. When pain medications are given by epidural route, medication is given through a very small tube into the spinal column. Finally, pain relief may be provided by administering local anesthetics through a very small tube next to a nerve bundle, into a joint or directly into the surgical incision

20. Pain killers in advanced disease WHO analgesic staircase Paracitamol Codeine or dihydrocodiene Oral morphine Start by 10mg/day up to 600 mg /day,median 120mg Titrate opioids. 50% increase every third day.

21. Hydration and feeding Anxiety and depression. Swallowing problems. Orientation, confusion. Constipation. Nausea and vomiting Drugs causing nausea, gastric stasis

22. Hydration and feeding IV Infusions 1-3 litres day, for few days Nasogastric tubes. 1-3 weeks PEG tubes. Long term feeding

23. Nausea and vomiting Regurgitation. Inappropriate tube feeding Pharyng-oesphageal obstruction Delayed gastric emptying. Metoclopramide10-20 mg /8 hours Raised intracranial pressure. Cyclizine 50 mg/8hours

24. Nausea and vomiting Chemical causes. Hypercalcaemia Morphine Bowel obstruction. Treat obstruction if possible If inoperable start cyclizine 150 mg/day SC infusion

25. Agitation Do not leave patient unattended. Ensure environment is safe. Do not use opioids to treat agitation. Hypoxia should be excluded.100% Oxygen via facemask Midazolam 2-10 mg IV or 5mg IM until settled

26. Confusion Memory failure Dementia Cerebral tumour Change in alertness. Drugs Hypercalcaemia Cardiac Pulmonary Subdural

27. Confusion Hallucinations. Altered behaviour

28. The withdrawn patient Usual behaviour Refusing help Confusion Fears,guilt or shame. Clinical depression. Organic cause

29. The withdrawn patient Usual behaviour Offer tome to establish trust Refusing help Their right Acknowledge refusal and offer help in future Confusion

30. The withdrawn patient Fears,guilt or shame. Clinical depression. Persistent low mood for>4weeks, for>50% of time 4 other depressive symptoms (early morning rise, diurnal variation, hopelessness..) Lofepramine 70 mg at night up to 140 mg

31. The withdrawn patient Organic cause Parkinson’s Severe fatigue Drugs causing Parkinson’s like symptoms

32. The angry patient Appropriateness of anger. Escalating anger. Depression Persisting anger.

33. The angry patient Appropriateness of anger. Explore cause Show understanding without being defensive Apologise if it is your fault Do not apologise for others

34. The angry patient Escalating anger If anger is not defusing or worsening : Position yourself near exit door Set limits If patient cannot accept limits =pathological anger Stop interview and leave immediately

35. The angry patient Depression Anger can be a feature Persisting anger. Consider specialist help

36. Unexpected deterioration Drugs are the cause. Uncertainty about treatment. Comfort only.

37. Unexpected deterioration Drugs are the cause. Check medications Check any recent additions Reduce dose

38. Unexpected deterioration Uncertainty about treatment. Review plans Hour by hour deterioration review every 3 hours Day by day deterioration review every 3 days Further deterioration consider treatment for comfort only

39. Unexpected deterioration Comfort only Rapid deterioration Irreversible cause Very short prognosis Patient refusing treatment Sedation if agitated Analgesia if in pain Support patient and family +/-staff

40. End-of-life Care Just as Important as Cures Being able to have a peaceful death with dignity can be among the positive milestones in the cycle of life Studies show that up to 88 percent of people in our country want to die at home surrounded by their loved ones. Yet the reality is that only about one in four people have a peaceful death at home or in a hospice setting