1. Two Palliative Care Giants Dr Jennifer Vidrine ST4 Palliative Medicine

2. Overview A broad overview of palliative care in relation to general practice Pain Case 1 BREAK Nausea and Vomiting Case 2 Round Up

3. Palliative Care Recognised as distinct entity since 1980s First modern hospice opened 1967 Based on concept of ‘Holistic’ care Palliative care teams Not just for patients with cancer

4. GPs and palliative care

5. “GPs found looking after palliative care patients satisfactory and varied but burdensome” Found barriers on three levels: – Personal – Relational – Organisational

6. Challenges faced… Personal – Knowledge symptom and symptom control – Technical procedures in pts who want to stay at home (ie Catheter) – Small numbers of palliative care patients in a year – Emotional – Time constraints – Lack of psychological support in an autonomous worker

7. Relational – Communication Between pts, carers, other HCPs – ‘Territory’ (GP? SPCT? Hospital team?)

8. Organisational – Bureaucracy – Obtaining medications (Controlled drugs, CSCI etc) – Need to organise care/social work review etc

9. They conclude Barriers exist It is imperative to support GPs as the frontline of service provision Role of specialist palliative care teams in this (both specialist knowledge and emotional support)

11. Common Symptoms Pain Nausea and Vomiting Shortness of Breath Anxiety/Psychological Distress

12. Common Symptoms Pain Nausea and Vomiting Shortness of Breath Anxiety/Psychological Distress

13. Pain

14. Nociceptive vs neuropathic pain

16. Neuropathic pain Disproportionate to stimulation of the nociceptor Leads to: – Hyperalgesia (exaggerated and prolonged pain response to a mildly painful stimulus) – Allodynia (Pain produced by a stimulus that is not normally painful, such as light touch) – Spontaneous pain No protective function Pathological pain

17. Distinguishing the two… History History History Thinking abut possible/likely aetiologies What has the pain responded to thus far?

18. Very often in palliative care it is a combination of both Requires combination treatments (Often one won’t cut it) Often requires some lateral thinking

19. WHO analgesic ladder

20. Correct the Correctable Anticancer treatment (DXT, Chemo) Treat precip factors (cough, constipation, retention) Non-Drug Positioning Modification to way of life, environment Relaxation therapies Surgery (eg bone pinning) Drug Relieve background pain Prescribe rescue Nerve Blockade Spinal Analgesia

21. An approach… Patient specific Tend to start with low dose strong opiate (eg Oramorph 2.5-5mg PRN) If possible also give regular paracetamol Ask patient/relative to write down the following: DateTimeSite PainPain score /10 before What taken Pain Score /10 after Notes/Si de effects

22. Review in a couple of days. Establish if opioid making ANY difference Establish any side effects Calculate what has been taken in last 24 hours (ie 4 doses of 5mg=20mg) Start BD preparation of long acting opiate Explain need to continue with Breakthroughs and ongoing monitoring. Breakthrough is 1/6 total daily opioid dose (except Alfentanil which is 1/10 th )

23. Established on Morphine but still in pain? Would an adjunct help? Steroids (Dexamethasone) TCA (Amitriptyline) Anti-epileptics (Gabapentin/Pregabalin) Very often end up on combination

24. Evidence Base Amitriptiline-OD dosing, syrup available. Gabapentin- syrup available, TDS Pregabablin- ?more tolerable, BD, only tablets Valporate- OD, syrup available, RCT conflicting Clonazepam- Concurrent anxiolytic and muscle relaxant properties, SC Anti-epilepticNNT Carbmazepine3.3 Gabapentin3.5 Lamotrigine4 Sodium valporate 2-2.5?

25. Other things to consider NSAIDs – If no contra-indications – Esp if inflamm element of pain – Useful in bone pain – Ibuprofen used most frequently – Ketorolac useful as can be used subcut (Generally only for short spells/at end of life) Bisphosphonates

26. Particular Challenges Episodic Pain High anxiety element (Total pain) Non-concordance Consider referral/involvement SPCT

27. What might be offered… Methadone Ketamine Spinal Lines (epidural/intrathecal line) Nerve Blocks Cordotomy (Division of lateral spinothalamic tracts in the spine) Involvement of clinical psychology

28. Case 1 Break up into groups of 3-5 Look at the case and start to think about the issues involved for 20 mins Try to approach as holistically as possible Feed back to group.

29. Comfort Break

30. Nausea & Vomiting

31. Nausea & Vomiting-Background Extremely common in cancer patients Deeply distressing Vomiting generally tolerated better than nausea “Last night we went to a Chinese dinner at six and a French dinner at nine, and I can feel the shark’s fins navigating unhappily in the Burgundy” Peter Flemming, Letter from Yunnanfu, March 1938

32. Reality of the situation Often as/more challenging to treat than pain Many patients have multifactorial N&V Absorption of the very stuff we are giving them to make them better May well require more than one anti-emetic Systematic/logical approach….

33. Questions to ask Nausea/vomiting predominant? Timing? What is vomited? (Consistency, volume, colour) Feel better after vomiting? Associated features? Exacerbating/relieving factors Are there are any probable causes? (eg Constipation)

34. Identify specifically treated causes Constipation-Laxatives/PR intervention (Prevention) Gastritis-Would PPI help? Oropharyngeal Candida-Often difficult to treat Hypercalcaemia-IV hydration +/- Bisphosphonate Pain-Optimise analgesia If drug induced how essential is drug? Treat infection

35. Think about non-drug measures Select anti-emetic based on most likely cause Basic principals: – Give regular antiemetics – Need to carefully assess risk of non-absorption and consider alt routes (CSCI) early – If you are relatively sure about cause consider maximising dose rather than switching (esp Metoclopramide)

36. Two ‘broad’ avenues.. 1.Gastric-stasis 2.Chemically mediated (central)

37. 1. Gastric Stasis-presentation Early Satiety Large volume vomits Undigested food Relief after vomiting Hiccoughs/belching Exacerbated by eating/medcations

38. 1.Gastric stasis-causes Slowed gastric emptying ‘Squashed stomach’ due to Hepatomegally Ascites Subacute obstruction (consider specialist input)

39. 1.Gastric Stasis-management Prokinetic eg Metoclopramide Targets peripheral (and central) Dopamine (D2) receptors. Caution in young females CAUTION IN PARKINSON’S DISEASE/SYNDROMES Dose: 10-20mg tds/qds – CSCI 30-120mg/24 hours Domperidone (less side effects but limited routes) OBSERVE FOR INTESTINAL COLIC

40. Vomiting Centre Chemical Medication Biochemical Toxins GI tract Obstruction Gastric stasis Irritation/ hepatic Vestibular Motion sickness Local tumour Medication Central Anxiety Pain Cerebral mets Raised ICP Dopamine Seretonin 3 Dopamine Seretonin 4 Acetylcholine Histamine CTZ Metoclopramide

41. Two ‘broad’ avenues.. 1.Gastric-stasis 2.Chemically mediated (central)

42. 2.Central Causes-presentation Constant nausea No/little relief after vomiting May be able to identify cause Other signs drug toxicity

43. Central-Causes Drugs: Opiates Antidepressants AEDs Electrolyte Imbalance Renal Failure Hypercalcaemia Sepsis Anxiety Pain Raised Intracranial Pressure Ischemic Bowel

44. 2. Central Causes-Management Cyclizine Antihistaminic/Anticholinergic antiemetic acting at ACh M and H 1 receptors Acts centrally to help with vagally mediated nausea. Can give anticholinergic side effects Dose: 25-50mg tds – CSCI: 150mg/24 hour Particularly useful if raised intracerebral pressure

45. Vomiting Centre Chemical Medication Biochemical Toxins GI tract Obstruction Gastric stasis Irritation/ hepatic Vestibular Motion sickness Local tumour Medication Central Anxiety Pain Cerebral mets Raised ICP Dopamine Seretonin 3 Dopamine Seretonin 4 Acetylcholine Histamine CTZ Cyclizine

46. 2. Central Causes-Management Haloperidol Useful for chemical induced nausea (inc Drug induced) Centrally acting anti-emetic acting at D 2 receptor at the CTZ Contraindications Dose: 1.5mg Nocte (0.5-1.5mg bd) – CSCI: 2.5-5mg/24 hours

47. Vomiting Centre Chemical Medication Biochemical Toxins GI tract Obstruction Gastric stasis Irritation/ hepatic Vestibular Motion sickness Local tumour Medication Central Anxiety Pain Cerebral mets Raised ICP Dopamine Seretonin 3 Dopamine Seretonin 4 Acetylcholine Histamine CTZ Haloperidol

48. If at first you don’t succeed Remember often multifactorial Consider increasing dose Consider combinations (that target diff receptors) Dex 4mg will often enhance affect anti-emetic (unknown mech) Levomepromazine

49. Vomiting Centre Chemical Medication Biochemical Toxins GI tract Obstruction Gastric stasis Irritation/ hepatic Vestibular Motion sickness Local tumour Medication Central Anxiety Pain Cerebral mets Raised ICP Dopamine Seretonin 3 Dopamine Seretonin 4 Acetylcholine Histamine CTZ Levomepromazine

50. Chemotherapy Induced N&V Ondansetron often used Best to time limit it’s use Headaches Constipation Has a very specific role Consider anticipatory n&v – Levomepromazine – Lorazapam

51. Case 2 Break up into groups of 3-5 Look at the case and start to think about the issues involved for 20 mins Try to approach as holistically as possible Feed back to group.

52. In summary A whistle stop tour of two pretty meaty subjects The importance of a thorough assessment in managing symptoms The importance of a systematic approach in managing them Make use of community SPCT/hospice advice lines if in doubt.

53. Any questions?

54. Watson, M. Lucas, C. Hoy, A. Wells, J (2010) The Oxford Handbook of palliative care. Oxford university press. Twycross, R. Wilcock, A. Palliative care formulary 4 th Edition (2012) Palliativedrugs.com Groot, M. Vernooij-Dassen, M. Crul, B. Grol, R. (2005) General practitioners (GPs) and palliative care: percieved tasks and barriers in daily practice. J Pall Med. (19)111-118