Palliative Care

1. Palliative Care Nikki Burger GP Registrar November 2005

2. 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.

3. Components of Palliative Care Effective symptom control Effective communication Rehabilitation � maximising independence Continuity of care Coordination of services Terminal care Support in bereavement

4. 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

5. Funding National charities Macmillan Cancer Relief Marie Curie Cancer Care Sue Ryder Foundation These are the three major providers nationally.

6. 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

7. Depression Loss of social position Loss of job prestige, income Loss of role in family Insomnia and chronic fatigue Helplessness Disfigurement

8. Anxiety Fear of hospital, nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest Uncertainty in future

9. Anger Delays in diagnosis Unavailable physicians Uncommunicative physicians Failure of therapy Friends who don�t visit Bureaucratic bungling

10. Treatment options Analgesic drugs Adjuvant drugs Surgery Radiotherapy Chemotherapy Spiritual and emotional support (total pain)

11. 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)

12. Non-opioid drugs Paracetamol 1g 4 hourly NSAIDS Ibuprofen 400mg 4 hourly Aspirin 600mg 4 hourly NB daily maximum doses

13. Weak opioids Codeine 60mg 4 hourly Dihydrocodeine 30-80mg tds max 240mg daily Dextropropoxyphene 65mg four hourly Tramadol 50-100mg 6 hourly Prescribing more than the maximum daily dose will increase s/e without producing further analgesia

14. 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

15. Strong Opioids Morphine Hydromorphone Fentanyl Diamorphine Buprenorphine

16. 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

17. Morphine Products Oramorph 4 hourly Sevredol 4 hourly Oramorph RS 12 hourly Zomorph 12 hourly MST 12 hourly MXL 24 hourly

18. 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 24-48 hours daily requirements can be calculated

19. 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

20. 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?

21. Calculate total daily dose 60mg bd MST = 120mg (120/6) x3 = 60mg Total 180mg

22. So, prescribe 180/2 = MST 90mg bd 180/6 = Oramorph 30mg PRN for breakthrough pain.

23. 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

24. Opioid alternatives to morphine Hydromorphone 7 times more potent than morphine, so care in those with no prior exposure

25. 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

26. Oxycodone OxyContin Onset 1 hour, 12 hour modified release OxyNorm Liquid and capsules Immediate release 10mg oral oxycodone = 20mg oral morphine

27. Hydromorphone Palladone and Palladone SR 1.3mg hydromorphone = 10mg morphine

28. 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

29. 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

30. Side effects of Opiates Common Constipation N+V Sedation Dry mouth Less common Miosis Itching Euphoria Hallucination Myoclonus Tolerance Respiratory depression

31. 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

32. 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

33. Sedation Also common initially and then resolving Be alert to possibility of recurrence of sedation or confusion after dose alteration

34. Dry mouth Often most troublesome symptom Simple measures Frequent sips cold drinks Sucking boiled sweets Ice cubes/frozen fruit segments Eg pineapple or melon

35. Addiction Often feared by inexperienced prescribers and patients and families Escalating requirements are sign of disease progression or possibly tolerance, not addiction

36. 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

37. Opioid toxicity Subtle agitation Shadows at periphery of visual field Vivid dreams Visual hallucinations Confusion Myoclonic jerks

38. 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

39. Opioid responsiveness Not all pains respond well Bone pain Neuropathic pain Need adjuvants Drugs Radiotherapy Anaesthetic blocks

40. Common adjuvant analgesics NSAIDS Corticosteroids Antidepressant/-convulsants Bisphosphonates Bone pain Soft tissue inflitration Hepatomegaly Raised ICP Soft tissue infiltration Nerve compression Hepatomegaly Nerve compression Nerve infiltration Paraneoplastic neuropathy Bone pain

41. Bone pain Paracetamol Morphine NSAIDS Radiotherapy Bisphosphonates

42. Neuropathic pain Features which suggest neuropathic pain Burning Shooting/stabbing Tingling/pins and needles Allodynia Dysaesthesia Dermatomal distribution

43. Neuropathic pain Antidepressant Amitriptyline 50mg nocte Anticonvulsant Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine) Steroids Dexamethasone 12mg daily Antiarrhythmics Mexiletine 50-300mg tds (or flecainide or lignocaine) Anaesthetics Ketamine Nerve blocks and spinal anaesthesia

44. Neuropathic pain Complementary therapies TENS Acupuncture Hypnosis Aromatherapy Counselling Social support

45. 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

46. Any questions?

47. 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

48. 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�?

49. 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