Presentation on theme: "Palliative Care Nikki Burger GP Registrar November 2005."— Presentation transcript:
Palliative Care Nikki Burger GP Registrar November 2005
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.
Components of Palliative Care Effective symptom control Effective communication Rehabilitation – maximising independence Continuity of care Coordination of services Terminal care Support in bereavement
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
Funding National charities –Macmillan Cancer Relief –Marie Curie Cancer Care –Sue Ryder Foundation These are the three major providers nationally.
Concept of Total Pain Physical pain Anger Depression Anxiety All affect patients perception of pain. Needs thorough assessment 90% can be controlled with self-administered oral drugs
Depression Loss of social position Loss of job prestige, income Loss of role in family Insomnia and chronic fatigue Helplessness Disfigurement
Anxiety Fear of hospital, nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest Uncertainty in future
Anger Delays in diagnosis Unavailable physicians Uncommunicative physicians Failure of therapy Friends who dont visit Bureaucratic bungling
Treatment options Analgesic drugs Adjuvant drugs Surgery Radiotherapy Chemotherapy Spiritual and emotional support (total pain)
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)
Non-opioid drugs Paracetamol 1g 4 hourly NSAIDS Ibuprofen 400mg 4 hourly Aspirin 600mg 4 hourly NB daily maximum doses
Weak opioids Codeine 60mg 4 hourly Dihydrocodeine 30-80mg tds max 240mg daily Dextropropoxyphene 65mg four hourly Tramadol mg 6 hourly Prescribing more than the maximum daily dose will increase s/e without producing further analgesia
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
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
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 hours daily requirements can be calculated
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
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?
So, prescribe –180/2 = MST 90mg bd –180/6 = Oramorph 30mg PRN for breakthrough pain.
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
Opioid alternatives to morphine Hydromorphone –7 times more potent than morphine, so care in those with no prior exposure
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
Hydromorphone Palladone and Palladone SR –1.3mg hydromorphone = 10mg morphine
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
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
Side effects of Opiates Common –Constipation –N+V –Sedation –Dry mouth Less common –Miosis –Itching –Euphoria –Hallucination –Myoclonus –Tolerance –Respiratory depression
Constipation Develops in almost all patients Prescribe PROPHYLACTIC laxatives Start with stimulant AND softener –Senna TT noctePLUS –Docusate or lactulose Also common with weak opioids
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
Sedation Also common initially and then resolving Be alert to possibility of recurrence of sedation or confusion after dose alteration
Dry mouth Often most troublesome symptom Simple measures –Frequent sips cold drinks –Sucking boiled sweets –Ice cubes/frozen fruit segments Eg pineapple or melon
Addiction Often feared by inexperienced prescribers and patients and families Escalating requirements are sign of disease progression or possibly tolerance, not addiction
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
Opioid toxicity Subtle agitation Shadows at periphery of visual field Vivid dreams Visual hallucinations Confusion Myoclonic jerks
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
Opioid responsiveness Not all pains respond well –Bone pain –Neuropathic pain Need adjuvants –Drugs –Radiotherapy –Anaesthetic blocks
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
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
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
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?
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