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Palliative Care

Palliative Care. Dr Philip Lee Senior Staff Specialist Palliative Medicine Westmead Hospital. Palliative Care Definitions. To cure, occasionally To relieve, often To comfort, always Anonymous (16 th Century)

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Palliative Care

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  1. Palliative Care Dr Philip Lee Senior Staff Specialist Palliative Medicine Westmead Hospital

  2. Palliative Care Definitions

  3. 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

  4. 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 2nd Edition

  5. 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

  6. PALLIATIVE CARE - WHEN? PALLIATIVE CARE BEREAVE-MENT ACTIVETREATMENT DEATH DIAGNOSIS ACTIVETREATMENT BEREAVE-MENT DEATH PALLIATIVE CARE

  7. 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

  8. 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

  9. WHAT DOES PALLIATIVE CARE OFFER? • Pain control • Other symptom control • Terminal care • Family support • Bereavement support

  10. 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.

  11. The Context 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 pain Fear of hospital or nursing home Family finances Worry about family Loss of choices Fear of death Uncertainty about future Spiritual (existential) unrest

  12. WHO analgesic ladder PainPain persists Pain persists or increases or increases 3. Strong opioid ± non-opioid ± adjuvant 2. Weak opioid ± non-opioid ± adjuvant 1. Non-opioid ± adjuvant

  13. 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

  14. Analgesic Classes • Aspirin • Paracetamol • NSAIDS • Opioids

  15. Weak opioids Codeine Dextropropoxyphene Tramadol Strong opioids Oxycodone Morphine Methadone Fentanyl Hydromorphone Opioids

  16. 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.

  17. 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.

  18. Patients’ concerns about narcotics • Addiction & withdrawal • Tolerance • Implications of taking morphine • Side effects

  19. Side effects • Sedation • Hallucinations • Nausea & vomiting • Constipation • Urinary retention • Myoclonus • Respiratory depression • Pruritus

  20. 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

  21. Opioid Dose Duration of Action

  22. Routes of administration of morphine • Oral • Subcutaneous • IVI • Epidural & intrathecal • Rectal • Topically

  23. 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

  24. Pros “Gold Standard” Well understood Readily available Usually well tolerated No “ceiling” Cons Accumulates in renal failure Constipating Nausea Sedation Misconceptions Morphine

  25. Morphine Preparations

  26. Pros Various dose forms, immeadiate & slow release Neuropathic pain “New” OK in renal failure Cons Constipating Nausea Confusing names Oxycodone

  27. Oxycodone & Tramadol

  28. Pros 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 Fentanyl

  29. Pros Less sedating Less constipating Less hallucinations Less nauseating OK in renal failure Cons Availability Hydromorphone

  30. Pros Neuropathic pain Cons Stigma Difficult dosing schedule Variable half-life Methadone

  31. Fentanyl, Methadone & Hydromorphone

  32. 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

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