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Palliative Care
Nikki Burger
GP Registrar
November 2005
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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.
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Components of Palliative Care
Effective symptom controlEffective communicationRehabilitation – maximising independenceContinuity of careCoordination of servicesTerminal careSupport in bereavement
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Funding
Differs from the rest of the health service20% inpatient units in UK funded entirely
by NHSVoluntary sectorGoodwill and fundraising initiatives in
local communities
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Funding
National charities– Macmillan Cancer Relief– Marie Curie Cancer Care– Sue Ryder Foundation
These are the three major providers nationally.
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Concept of Total Pain
Physical painAngerDepressionAnxiety
All affect patient’s perception of pain.
Needs thorough assessment
90% can be controlled with self-administered oral drugs
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Depression
Loss of social positionLoss of job prestige, incomeLoss of role in familyInsomnia and chronic fatigueHelplessnessDisfigurement
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Anxiety
Fear of hospital, nursing homeFear of painWorry about family and financesFear of deathSpiritual unrestUncertainty in future
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Anger
Delays in diagnosisUnavailable physiciansUncommunicative physiciansFailure of therapyFriends who don’t visitBureaucratic bungling
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Treatment options
Analgesic drugsAdjuvant drugsSurgeryRadiotherapyChemotherapySpiritual and emotional support (total pain)
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Analgesic drugs
Mainstay of managing cancer painChoice based on severity of pain, not stage
of diseaseStandard doses, regular intervals, stepwise
fashionNon-opiod…weak opioid…strong opiod…
+-adjuvant at any level (WHO analgesic ladder)
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Non-opioid drugs
Paracetamol
1g 4 hourly
NSAIDS
Ibuprofen 400mg 4 hourly
Aspirin 600mg 4 hourly
NB daily maximum doses
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Weak opioids
Codeine60mg 4 hourly
Dihydrocodeine30-80mg tds max 240mg daily
Dextropropoxyphene65mg four hourly
Tramadol 50-100mg 6 hourly Prescribing more than the maximum daily dose will
increase s/e without producing further analgesia
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Combinations
ConvenientCare 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
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Strong Opioids
MorphineHydromorphoneFentanylDiamorphineBuprenorphine
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Morphine
Where possible dose by mouthDose tailored to requirementsRegular intervals – prevent pain from
returningNo arbitrary upper limit (unlike weak
opioids)Fears of patients and familySide effects
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Morphine Products
Oramorph 4 hourlySevredol 4 hourlyOramorph RS 12 hourlyZomorph 12 hourlyMST 12 hourlyMXL 24 hourly
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Starting Morphine - Dose titration
Start with quick-release formulationPrescribe regular four hourly dose, allow
same size dose PRN in addition for breakthrough pain, as often as necessary
Usual starting dose 5-10mg four hourlyAfter 24-48 hours daily requirements can
be calculated
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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
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Dose titration
Example – Mrs M56y breast cancer with bony metsParacetamol 1g qdsDiclofenac SR 75mg bdMST 60mg bd Taking three doses Oramorph a day for
breakthrough painWhat next?
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Calculate total daily dose– 60mg bd MST = 120mg– (120/6) x3 = 60mg– Total 180mg
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So, prescribe– 180/2 = MST 90mg bd– 180/6 = Oramorph 30mg PRN for
breakthrough pain.
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Parenteral opiates
Unable to maintain dosing by mouthSubcutaneous infusion commonest
alternative – syringe driverConvert oral dose to equianalgesic sc dose
– Morphine /2– Diamorphine /3
Fentanyl patch – Less constipation, nausea, sedation
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Opioid alternatives to morphine
Hydromorphone– 7 times more potent than morphine, so care in
those with no prior exposure
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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
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Oxycodone
OxyContin– Onset 1 hour, 12 hour modified release
OxyNorm– Liquid and capsules– Immediate release
10mg oral oxycodone = 20mg oral morphine
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Hydromorphone
Palladone and Palladone SR– 1.3mg hydromorphone = 10mg morphine
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Writing a prescription for CDs
By handIn inkName and address patientName of drugForm and strengthTotal quantity, or number of dose units, in
both words and figures
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Writing a prescription for opiates
Mary Jones16 High Street, Worcester, WR1 1AAOramorph liquid 20mg/5mlSupply 200ml (two hundred)Take 20mg every 4 hours
Oramorph 10mg/5ml no longer a CD
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Side effects of Opiates
Common– Constipation
– N+V
– Sedation
– Dry mouth
Less common– Miosis
– Itching
– Euphoria
– Hallucination
– Myoclonus
– Tolerance
– Respiratory depression
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Constipation
Develops in almost all patientsPrescribe PROPHYLACTIC laxativesStart with stimulant AND softener
– Senna TT nocte PLUS– Docusate or lactulose
Also common with weak opioids
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Nausea and vomiting
Initially very commonUsually resolve over a few daysEasily controlled if forewarned
– Metoclopramide 10mg 8 hourly– Haloperidol 1.5mg bd or nocte
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Sedation
Also common initially and then resolvingBe alert to possibility of recurrence of
sedation or confusion after dose alteration
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Dry mouth
Often most troublesome symptomSimple measures
– Frequent sips cold drinks– Sucking boiled sweets– Ice cubes/frozen fruit segments
• Eg pineapple or melon
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Addiction
Often feared by inexperienced prescribers and patients and families
Escalating requirements are sign of disease progression or possibly tolerance, not addiction
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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
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Opioid toxicity
Subtle agitationShadows at periphery of visual fieldVivid dreamsVisual hallucinationsConfusionMyoclonic jerks
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Agitated confusion
Often misinterpreted as patient being in painThus further opioids are prescribedVicious cycle, leads to dehydrationAccumulation of metabolites componds toxicityManagement
– Reduce dose of opioid– Haloperidol 1.5-3mg SC/PO hourly as needed for
agitation– Adequate hydration
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Opioid responsiveness
Not all pains respond well– Bone pain– Neuropathic pain
Need adjuvants– Drugs– Radiotherapy– Anaesthetic blocks
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Common adjuvant analgesics
NSAIDS
Corticosteroids
Antidepressant/-convulsants
Bisphosphonates
Bone painSoft tissue inflitrationHepatomegaly
Raised ICPSoft tissue infiltrationNerve compressionHepatomegaly
Nerve compressionNerve infiltrationParaneoplastic neuropathy
Bone pain
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Bone pain
ParacetamolMorphineNSAIDSRadiotherapyBisphosphonates
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Neuropathic pain
Features which suggest neuropathic pain– Burning– Shooting/stabbing– Tingling/pins and needles– Allodynia– Dysaesthesia– Dermatomal distribution
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Neuropathic pain
Antidepressant– Amitriptyline 50mg nocte
Anticonvulsant– Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine)
Steroids– Dexamethasone 12mg daily
Antiarrhythmics– Mexiletine 50-300mg tds (or flecainide or lignocaine)
Anaesthetics– Ketamine– Nerve blocks and spinal anaesthesia
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Neuropathic pain
Complementary therapies– TENS– Acupuncture– Hypnosis– Aromatherapy– Counselling– Social support
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Common mistakes in cancer pain management
Forgetting there is more than one painReluctance to prescribe morphineFailure to use non-drug treatmentsFailure to educate patient about treatmentReducing interval instead of increasing
dose
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Any questions?
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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
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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”?
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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