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Principles of Palliative Care

Principles of Palliative Care. Dr. Tony O’Brien Marymount Hospice & Cork University Hospital Wednesday March 9 th , 2010. Medicine is about people. Every body has a story to tell. Allow people to tell their own unique story, in their own way and in their own time.

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Principles of Palliative Care

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  1. Principles of Palliative Care Dr. Tony O’Brien Marymount Hospice & Cork University Hospital Wednesday March 9th, 2010

  2. Medicine is about people • Every body has a story to tell. • Allow people to tell their own unique story, in their own way and in their own time. • No two people ever share the same illness.

  3. Definition • Disease – describes a specific pathology affecting an organ, tissue or system in the body • Illness – describes the subjective experience of the disease in the unique context of an individual’s life – past, present and anticipated future

  4. Birth Death PAST FUTURE

  5. Birth Death PAST

  6. Palliative Care .. is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. W.H.O. 2002

  7. Palliative Care • Provides relief from pain and other distressing symptoms • Affirms life, and regards dying as a normal process • Intends neither to hasten nor postpone death • Integrates the psychological and spiritual aspects of patient care • Offers a support system to help the family cope during the patient’s illness and in their own bereavement W.H.O. 2002

  8. Palliative Care • Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated • Will enhance quality of life, and may also positively influence the course of illness; • Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as radiotherapy or chemotherapy, and includes those investigations needed to better understand and manage distressing clinical complications. W.H.O. 2002

  9. My world Living Hospice Dying

  10. Living Dying

  11. Dame Cicely Saunders 1918 - 2005

  12. ‘There is nothing more to be done’ Disease Modifying Treatments End Of Life Care Time

  13. Disease modifying Symptomatic Palliative Care / Bereavement Time

  14. Pain • Pain is an unpleasant sensory and EMOTIONAL experience…… • Pain is always subjective • Pain is what the patient says hurts • Pain is what the patient says it is

  15. Pain Types Nociceptive Mixed Neuropathic Somatic Visceral Peripheral Central

  16. Nociceptive Pain • Stimulation of peripheral sensory receptors • Neural pathways intact and functioning • Somatic pain: well localised • Visceral pain: less well localised; may be referred to cutaneous sites

  17. Neuropathic Pain • Occurs as a result of aberrant somatosensory processing in the nervous system • Central, peripheral or both • Diagnosis is based on history • Pain in an area with abnormal neurology findings is typically neuropathic

  18. Breakthrough Cancer Pain • Transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Davies, A et al. APM Guidelines,2009

  19. Measurement Visual Analogue Scale No Pain Worst Pain Numerical Rating Score 0 1 2 3 4 5 6 7 8 9 10 Verbal Descriptor Scale None Mild Moderate Severe Excruciating

  20. Site Radiation Duration Progression Severity Frequency Significance Effect on mood Quality Precipitating Factors Aggravating Factors Relieving Factors Effect on activity Effect on sleep Assessment

  21. Medication(s) Route Dose Compliance Duration Concerns re meds. Benefits Adverse effects Non-drug Rx Non-medical Rx Patient’s views Relative’s views Treatment History

  22. Palliative Interventions • Surgery • Radiology • Chemotherapy / Systemic therapy • Radiotherapy • Anaesthesia • Psychiatric / psychological

  23. Surgery • Excision e.g. Breast carcinoma • Debulking e.g. Brain metastasis • Debridement e.g. Fungating tumour • Diverting (Stoma) e.g. Bowel obstruction • Stabilisation e.g. Prophylactic pinning of bone metastasis

  24. Interventional Radiology • Gastrointestinal stents • Biliary stents • Renal stents • Paracentesis • Pleural drain • Gastrostomy tube • Vascular stents / Filters

  25. Systemic therapy • Pain & symptom relief • Functional Improvement • ? Life Prolonging • ? Life enhancing - Balance

  26. Radiation Therapy • Metastatic bone disease • SVC obstruction • Spinal Cord compression • Brain metastases • Bleeding • Ulcerating / fungating tumours • Tumour shrinkage

  27. Anaesthesia • Nerve blocks • Plexus blocks • Epidural medication • Intrathecal medication

  28. Pain Distress • Severity (Visual Analogue Scale / Verbal rating score) • Previous pain experience • Mood (Pain tolerance threshold) • SIGNIFICANCE

  29. Pain Control - Essentials • Believe, do not doubt! • Detailed assessment of EACH pain • Understand common pain types • Understand treatment modalities • Total pain concept

  30. Total Pain Physical Emotional Spiritual Pain Social

  31. W.H.O. Analgesic Ladder Strong Opioids Weak Opioids +/-Adjuvants +/- Adjuvants Non-Opioids

  32. Adjuvant Drugs • Non-steroidal anti-inflammatory drugs • Corticosteroids • Anti-convulsants • Anti-depressants • Anti-spasmodics • Anxiolytics • Local anaesthetic agents • NMDA receptor antagonists

  33. Strong Opioids Oxycodone Hydromorphone Fentanyl MORPHINE Diamorphine Methadone Buprenorphine

  34. Analgesic drugs • Drug & Dose • Route & Dose interval • Breakthrough pain • Titration • Side-effect prophylaxis • Sequential trial / Opioid Switch • Adjuvant drugs Levy MH. NEJM, 1996. 335:10

  35. Dose – limiting toxicity • Central nervous system* • Gastrointestinal system* • Endocrine system • Immune system • Others * hypercalcaemia

  36. Opioid induced CNS toxicity • Sleepiness, drowsiness • Confusion • Visual hallucinations • Myoclonus • Pruritus • Distorted sound of voice

  37. Constipation • Not just related to bowel frequency • Opioid induced bowel dysfunction • Primary feature of dose limiting toxicity • Patients may select pain over bowel complications • Tolerance does NOT develop

  38. Anorexia Nausea / vomiting Reflux Pain / cramps Distension Diarrhoea Borborygmi Obstruction Perforation Peritonitis Incomplete evacuation Haemorrhoids Fissures Confusion Urinary retention Constipation associated features

  39. Opioid induced bowel dysfunction • Mediated by mu opioid receptors • Reduced and in-coordinated gut motility • Decreased secretions (including pancreatic and biliary juice) • Increased sphincter tone • Resulting in OIBD

  40. OIBD / Mechanism Based Therapy • OIBD mediated by action of opioid on GUT mu receptors • Selective blockade of peripheral receptors • Maintain centrally mediated analgesia • Avoid risk of opioid withdrawal

  41. Total Pain Physical Emotional Spiritual Pain Social

  42. Uncontrolled pain ‘the greatest reason for uncontrolled pain is the failure by doctors and nurses to appreciate fully that pain is NOT just a physical sensation…. … there is ALWAYS more to analgesia than analgesics!’ Dr. Robert Twycross

  43. Spiritual Pain • Failure to find any meaning • The ‘why’ question? • Anger, resentment, confusion, bewilderment • Infrequently recognised by patients, families or health care professionals • May aggravate physical symptoms

  44. Case study • 37 year old married lady • Previously healthy • February 2011: Fatigue, back pain, nausea • Investigated: • Carcinoma gastro-oesophageal junction • Carcinomatosis peritonei • Obstructive uropathy / bilateral stents • Duodenal obstruction • Biliary obstruction / mass at head of pancreas • Rapidly progressive disease

  45. Family tree 7

  46. Spiritual anguish • I don’t ask ‘why me’? I used to but not now. • I just have to fight this, get better • I can’t give up. I have too much to live for. • I feel angry all the time. I can’t sleep • What did he ever do to deserve this. He’s only 7, he never harmed anyone. • Why is he being punished? • I just hope the chemotherapy can get rid of it

  47. Birth Death PAST

  48. Expressions of Spiritual Pain • She never smoked and only took a drink at Christmas • It doesn’t make any sense • What did she ever do to deserve this? • What’s the point of all this? • She never harmed anybody • It’s just not fair

  49. Responding to Spiritual Pain • Not about providing answers or solutions • Avoid pious platitudes • Staying with the questions • Staying with the pain • Staying with the uncertainty • Staying with the person • Being there!!!

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