1. Practical symptom management for cancer and beyond

2. St Ann’s Hospice Dr Catriona Barrett-Ayres
Speciality doctor Palliative Medicine
Dr Alison Phippen
Associate Specialist Palliative Medicine

3. Palliative Care What is it? How is it relevant to you now?
How is it relevant to you in the future?
Practical applications for foundation jobs
Quiz
Questions

4. Palliative care (from Latin palliare, to cloak)

5. WHO Definition of Palliative Care
“..an approach that improves the quality of life of patients and their families facing the problem 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.”

6. Palliative care encompasses
holistic care of patients with advanced progressive illness.
Management of pain and other distressing symptoms through early identification and thorough assessments to promote comfort
psychological and emotional, social, spiritual support, care coordination and advance care planning (multidisciplinary approach)
achievement of the best quality of life for patients and their families.
Affirms life and regard dying as a normal process
Neither hastens or postpones death
Offers a support system to help patients and families cope during the patient’s illness and with their own bereavement
Strives for excellent communication with patients and families
Many aspects of palliative care are also applicable earlier in the course of the illness.

7. How is palliative care provided?
Hospital advisory service (Macmillan nurses and specialist palliative care consultants)
Community-GP/ Macmillan nurses/ District nurses/ continuing health care
Nursing homes
Hospice inpatient
Outpatient services
Day care
Carer support through outpatients (NCCC)

8. Symptom control Pain Nausea and vomiting Dry mouth Breathlessness
Bowel obstruction
Lymphoedema/ ascites
Psychological support
Bleeding
Difficult wounds
secretions

9. What is pain?
ƒ. “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”
ƒ“pain is a category of complex experiences, not a single sensation produced by a single
stimulus.”
ƒ “pain is what the experiencing person says it is, existing whenever (s)he says it does.”

10. PAIN Assess what it is! Reverse anything reversible.
What is the aetiology? Does it need urgent investigation?
Is it new and therefore needs further investigation? Is it escalating?
What is the severity?
Visceral?
Neuropathic?
Bone pain?
Incident pain?

11. PAIN in cancer patients
Pain associated with cancer often increases with progression of the disease.
1/3 with cancer report pain, rising to 3/4 in the advanced stages of cancer.
Attempts to control pain and hence improve functional ability and quality of life have been overshadowed in the past by attempts to cure the underlying disease.
Several myths surrounding opiates make patients and Drs wary
Cancer pain has many dimensions including psychological, physical, social and spiritual which must be addressed in order to improve quality of life and functional ability

12. Where to look for help BNF or Palliative care formulary
Symptom control guidelines St. Ann’s Hospice
SIGN guidelines 2008
NICE guideline (in progress)
If in doubt seek help/ advice from senior staff, Macmillan team

13. WHO pain ladder

14. Step 1 Regular paracetamol
NSAID (remember can worsen renal function, bleeding risk)

15. Step 2 Codeine Tramadol cocodamol can reduce tablet burden
Remember side effects- constipation/neuropsychiatric disturbance

16. Step 3
Morphine
Morphine type drugs may be used but this is more specialist and you should seek advice about these.
Oxycodone
Fentanyl
bupenorphine
hydromorphone
Alfentanil
Lozenges/ buccal/ intranasal/ subcutaneous

17. Adjuvants Amitriptyline Gabapentin Ketamine Methadone clonazepam
Benzodiazepines
Antidepressants

18. Amitriptyline Unlicenced for neuropathic pain
Dose range for pain is 10-75mg
TCA
NNT=3
Comes as liquid preparation
Dry mouth, presyncope can limit
Helpful in sleep disorders, depression

19. Gabapentin Anticonvulsant NNT=3
eg 300mg TDS(can be increased gradually to 900mg tds)
Capsules can be opened
Dry mouth, movement disorder, tremor ataxia, dry mouth, drowsiness can limit
Reduce in renal failure
Pregabalin is (an expensive) pro-drug. It is licenced for anxiety. It is indicated if other agents have failed or not been tolerated

20. Opiates In use since 4th century Brompton cocktail – 1920’s
Queen Victoria used laudanum
Patients often think they mean euthanasia

21. Opiate Problems
•Problems- addiction/ tolerence ( 1000 opiate related deaths in England and Wales in 2004, 327,500 problem users in 2005)
•Respiratory depression/OD } think trainspotting!
•Withdrawal }
• Recent death in media- opiate naïve patient given diamorphine high dose
• Side effects- confusion, nausea, constipation
• No set dose- metabolism and requirements differ

22. Communicate Explain possible side effects
Arrange frequent review of the patient to monitor progress and adjustments
Titrate up according to need, increase if ineffective, review if pain is sensitive
Reduce if toxicity
Write down/ look at prn doses
Involve carer

23. Concurrent prescribing
Regular laxatives eg senna
Antiemetics for 1-2 weeks- eg metoclopramide (avoid if bowel obstruction/colic)
30% started on opiates get nausea

24. How to start morphine
Check opiates are appropriate-not in chronic pain.
Is pain opiate sensitive?
Are they at step 3 WHO ladder?
Would a neuropathic agent be better?
Opiate naïve? 2.5-5mg 4 hourly PRN oramorph . May need to be offered 4 hourly regularly plus PRN if pain is still problematic.
Convert total in 24h to Modified Release equivalent twice daily once dose established.
Breakthrough instant release dose is 1/6 total
Review every 48 hours and Increase according to extra PRN’s used but only by 30-50% total dose. Caution with rapid dose escalation

25. Initiating Opiates Already on step 2 weak opiates?
Codeine in 24h/10 to convert to morphine (eg 60mg qds=240mg/10= 24mg morphine= 10mg zomorph twice daily)
Tramadol in 24h/10 (eg 100mg qds= 400/10 = 40mg morphine ie 20mg zomorph twice daily)
Refer to symptom control guidelines/ conversion tables
Elderly/ renal failure? 1.25mg 4-6 hourly PRN oramorph.
Reduce the dose if toxicity occurs (30-50%)
Consider alternative opiate. Get advice. .

26. Opiate toxicity Drowsiness Pin point pupils Twitching (myoclonus)
Hallucinations
Nausea
Slow cognition
Confusion
Respiratory depression- rr<8 omit, consider naloxone, seek advice

27. Other things that may help
Addressing total pain
Antidepressants for low mood/ anxiety
What does the pain mean?
Which route of administration do they need?
Interventional anaethsetic blocks
Bisphosphonates
Lignocaine plaster/ capsaisin cream
Local heat or cooling
Surgical intervention
Complementary therapy

28. Sore mouth Any triggers- recent chemoradiotherapy? Is it dry?
Is the patient dehydrated?
Do their dentures fit?
Is it coated?
Are they immunocompromised? diabetes etc
Is there infection- viral, fungal or bacterial?
Look for thrush and treat if present

29. Dry mouth (xerostomia)
Tongue is dry and fissured
Add gravy and sauces
Saliva replacements – tablets, spray or gel
Mints and sweets or gum(sugar free)
Melon, avoid citrus
Ice chips/ water/ frozen drinks (G&T!)
Pilocarpine drops
Do they have salivary reserve or not?
Do they have their own teeth?
Do they object to animal products?
Is it iatrogenic? O2 or drugs

30. Simple things can make a big difference to comfort

31. Oral candida Treat with topical or systemic treatments
Is there a short prognosis?
Can they swallow?
Are they on any medications that could interact with antifungals?
Do their dentures need to be treated?
In resistant cases consider a swab

32. Treatments Fluconazole 150mg stat dose
Fluconazole 50mg once daily for 1 week
Daktarin oral gel to mucous membranes and angles of mouth
Nystatin drops to tongue
Milton solution for dentures

35. Rx stomatitis Good dental hygiene Mouthwashes Coating agents
Topical anaethetics
Systemic anagesia
IV fluids
Nutritional drinks

37. Coated Tongue
Gentle Brushing Mouthwashes- chlorhexidine (dilute with water) Pineapple Chunks