Palliative Care for Patients Living with HIV/AIDS

1. Palliative Care for Patients Living with HIV/AIDS HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Explain what palliative care is and why it is important • Describe how to evaluate pain • Explain how to treat nociceptive and neuropathic pain • Describe what end of life care is and why it is important

3. What is Palliative Care? (1) “Palliative care is a combination of measures to relieve suffering and improve the quality of life of patients through the prevention, early detection, and treatment of pain and other physical and psychosocial problems that the patient and family are encountering.” Source: Vietnam MOH: Guidelines on Palliative Care for Cancer and AIDS patients

4. What is Palliative Care? (2) The two major goals of palliative care are: 1) To relieve suffering, and 2) To improve the quality of life of the patient

5. PAINOver 50% of AIDS patients in Vietnam suffer from pain – the majority of which is undiagnosed and untreated.

6. Pain: Definition “the feeling of discomfort of a patient because of current or potential tissue damage or, it is an actual injury that the patient is suffering from”

7. Etiologies of Pain in HIV/AIDS Pain is exacerbated by psychological and social stress

8. Pain Assessments • Based on patient’s own report • Always use same pain assessment scale to best monitor and compare the progress of pain control • Most common pain assessments include: • Pain Intensity Scale • Wong-Baker Faces Pain Rating Scale

9. What are Some Things to Look for When Assessing Pain? • Location • Type or quality of pain: sharp, dull, constant, intermittent • Grade of pain • Pain Scale • Ability to sleep • Good indicator of comfort level • Effect on functioning: • Ability to eat, swallow • Can walk with or without assistance • Response to treatment • Pain medications • Non-pharmacological treatment • Heat, cold • Acupuncture • Massage

10. Role Play: Assessing Pain

11. Treating Pain

12. Principles to Follow in Pain Treatment • Deliver pain relief interventions in a timely, coordinated and logical manner • After pain has been treated, assess if intervention worked • If not, may need to increase dose or try another therapy • Pain assessments and interventions should be documented in patient’s chart so other doctors know what does and does not work

13. Categories of Therapeutics Nociceptive pain • Responds well to opioids and non-opioids Neuropathic pain • Responds better to adjuvant medications (antidepressants, anticonvulsants) than opioids or non-opioids

14. Easing Pain (1)

15. Easing Pain (2) WHO three-step “analgesic ladder” Pain Relief Pain persisting or increasing Strong Opioid +/- Non-opioid +/- Adjuvant 3 SEVERE PAIN Pain persisting or increasing 2 MODERATE PAIN Weak Opioid +/- Non-opioid +/- Adjuvant 1 MILD PAIN Non-opioid +/- Adjuvant Adapted from World Health Organization. Cancer Pain Relief. Geneva: WHO, 1990.

16. Dosing Analgesics Analgesics like all other drugs have side effects, dose carefully to attain useful effect

17. Difference Between Oral and Intravenous Opioids • Oral, immediate release opioids have a 30 minute onset of action • Immediate release opioids last 3-7 hours in the blood • IV opioids have a 5 – 10 minute onset of action

18. What’s Wrong with the Way this Analgesic is Being Given? Pain • Doses are not being given frequently enough • Analgesic wears off, and patient feels pain until next dose is given

19. Give Opioids at Right Frequency to Prevent Breakthrough Pain • Most short-acting opioids are given every 3-4 hours to maintain pain relief effect

20. What if Correct Interval but Patient Still Has Pain? Breakthrough pain • To treat break through pain give 10% of daily dose of opioids: • every 1 – 2 hours for immediate release oral opioids OR • every 30 – 60 minutes for subcutaneous or intravenous opioids • Should NOT be substituted for opioid already • being given every 3 – 4 hours

21. Example: Calculating Breakthrough Pain Dosages • A patient is receiving oral morphine 10mg, every 4 hours • What is her total daily dose? • Total daily dose is 10 mg x 6 = 60 mg • What is her breakthrough dose? • Breakthrough dose: 10% x 60mg = 6 mg every 2 – 4 hours as needed

22. Tolerance to Opioids • Tolerance develops with time in most patients requiring dosage increases • Unlike NSAIDS and most adjuvants, there is no maximum dosage for opioids.

23. Equianalgesic Dosing of Opioids • Sometimes side effects, lack of effectiveness or tolerance requires a change from one opioid to another • When changing to a different opioid one must refer to an opioid table to determine the appropriate dose to start with • This is called the “equianalgesic dose”

24. Non-Pharmacologic Pain Treatments • Acupuncture • Heat or cold packs • Massage • Deep breathing exercises Gets patients and families involved in helping with pain control

25. Case Study: Thuy (1) • Your patient, a 37 year-old female named Thuy, is HIV positive and has been on ART for the last 6 months with nearly perfect adherence • She presents with aching right hip pain which worsens at night • no history of trauma or accident • Examination revealed tenderness over the right proximal femur

26. Case Study: Thuy (2) • What kind of pain is Thuy having? • She is having nociceptive pain as she describes it as aching pain • What steps would you take to further evaluate and treat her? • Treatment would be a nonsteroidal anti-inflammatory drug (i.e. ibuprofen, diclofenac)

27. Case Study: Thuy (3) • 6 months later, Thuy returns with burning and shooting pain in both legs • Pain is intermittent, examination of lower extremities was not remarkable • She takes D4T 40 mg plus 3TC/EFV • She is also on the continuation phase of TB treatment • Her weight is 55kg

28. Case Study: Thuy (3) • What do you think could be going on with Thuy? • What kind of pain is she having? • What are the possible causes of her pain? • What steps would you take to further evaluate her? • Do you think paracetamol would help?

29. HIV-Related Symptoms Other than Pain

30. Prevalence of Symptoms in Patients with AIDS* * Based on several published descriptive studies of patients with AIDS, predominantly in patients with late-stage disease, Europe and North America, 1990-2002.

31. Addressing HIV-Related Symptoms • Treatments can be: • disease-specific (e.g. ARV) and/or • symptom-specific (e.g. anti-emetics, anti-histamines) • Effective treatment of these symptoms: • Reduces suffering • Improves quality of life • Improves ARV adherence • Improves clinical outcomes

32. Symptoms Addressed in 2006 Palliative Care Guidelines • Nausea / vomiting • Diarrhea • Constipation • Odynophagia • Dyspnea • Cough • Weakness / fatigue • Fever • Insomnia • Agitation / delirium • Depression • Anxiety • Pruritus • Bed sores

33. End of Life Care

34. Overview of End of Life Care • What is End of Life Care? • Provision of care during the final days and hours of life • How is it Different from Palliative Care? • End of life care is only given at the very end of a patient’s life with the goal of helping the patient reach death with dignity and with as little pain as possible

35. Ways to Provide Support at the End of a Patient’s Life • Provide emotional and spiritual support • Encourage patients to discuss feelings • Listen attentively, be empathetic • Respect patients’ decisions • Provide grief and bereavement support • Once patient dies, family will need support • Provide bereavement counseling

36. Key Points • The two major goals of palliative care are to relieve suffering and to improve patient quality of life • Assess pain based on patient’s own report and standard pain assessment • Important to understand pain in order to know how to treat effectively • Emotional and spiritual support are important parts of palliative care

37. Thank you! Questions?