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Nikki Burger GP Registrar November 2005
Palliative Care Nikki Burger GP Registrar November 2005
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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.
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Components of Palliative Care
Effective symptom control Effective communication Rehabilitation – maximising independence Continuity of care Coordination of services Terminal care Support in bereavement
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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
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Funding National charities Macmillan Cancer Relief
Marie Curie Cancer Care Sue Ryder Foundation These are the three major providers nationally.
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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
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Depression Loss of social position Loss of job prestige, income
Loss of role in family Insomnia and chronic fatigue Helplessness Disfigurement
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Anxiety Fear of hospital, nursing home Fear of pain
Worry about family and finances Fear of death Spiritual unrest Uncertainty in future
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Anger Delays in diagnosis Unavailable physicians
Uncommunicative physicians Failure of therapy Friends who don’t visit Bureaucratic bungling
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Treatment options Analgesic drugs Adjuvant drugs Surgery Radiotherapy
Chemotherapy Spiritual and emotional support (total pain)
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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)
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Non-opioid drugs Paracetamol 1g 4 hourly NSAIDS
Ibuprofen 400mg 4 hourly Aspirin 600mg 4 hourly NB daily maximum doses
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Weak opioids Codeine 60mg 4 hourly Dihydrocodeine
30-80mg tds max 240mg daily Dextropropoxyphene 65mg four hourly Tramadol mg 6 hourly Prescribing more than the maximum daily dose will increase s/e without producing further analgesia
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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
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Strong Opioids Morphine Hydromorphone Fentanyl Diamorphine
Buprenorphine
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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
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Morphine Products Oramorph 4 hourly Sevredol 4 hourly
Oramorph RS 12 hourly Zomorph 12 hourly MST 12 hourly MXL hourly
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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 hours daily requirements can be calculated
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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
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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?
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Calculate total daily dose
60mg bd MST = 120mg (120/6) x3 = 60mg Total 180mg
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So, prescribe 180/2 = MST 90mg bd
180/6 = Oramorph 30mg PRN for breakthrough pain.
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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
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Opioid alternatives to morphine
Hydromorphone 7 times more potent than morphine, so care in those with no prior exposure
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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
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Oxycodone OxyContin OxyNorm 10mg oral oxycodone = 20mg oral morphine
Onset 1 hour, 12 hour modified release OxyNorm Liquid and capsules Immediate release 10mg oral oxycodone = 20mg oral morphine
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Hydromorphone Palladone and Palladone SR
1.3mg hydromorphone = 10mg morphine
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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
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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
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Side effects of Opiates
Common Constipation N+V Sedation Dry mouth Less common Miosis Itching Euphoria Hallucination Myoclonus Tolerance Respiratory depression
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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
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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
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Sedation Also common initially and then resolving
Be alert to possibility of recurrence of sedation or confusion after dose alteration
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Dry mouth Often most troublesome symptom Simple measures
Frequent sips cold drinks Sucking boiled sweets Ice cubes/frozen fruit segments Eg pineapple or melon
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Addiction Often feared by inexperienced prescribers and patients and families Escalating requirements are sign of disease progression or possibly tolerance, not addiction
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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
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Opioid toxicity Subtle agitation Shadows at periphery of visual field
Vivid dreams Visual hallucinations Confusion Myoclonic jerks
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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
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Opioid responsiveness
Not all pains respond well Bone pain Neuropathic pain Need adjuvants Drugs Radiotherapy Anaesthetic blocks
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Common adjuvant analgesics
NSAIDS Corticosteroids Antidepressant/-convulsants Bisphosphonates Bone pain Soft tissue inflitration Hepatomegaly Raised ICP Soft tissue infiltration Nerve compression Nerve infiltration Paraneoplastic neuropathy
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Bone pain Paracetamol Morphine NSAIDS Radiotherapy Bisphosphonates
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Neuropathic pain Features which suggest neuropathic pain Burning
Shooting/stabbing Tingling/pins and needles Allodynia Dysaesthesia Dermatomal distribution
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Neuropathic pain Antidepressant Anticonvulsant Steroids
Amitriptyline 50mg nocte Anticonvulsant Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine) Steroids Dexamethasone 12mg daily Antiarrhythmics Mexiletine mg tds (or flecainide or lignocaine) Anaesthetics Ketamine Nerve blocks and spinal anaesthesia
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Neuropathic pain Complementary therapies TENS Acupuncture Hypnosis
Aromatherapy Counselling Social support
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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
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Any questions?
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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
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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”?
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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
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