Palliative CarePalliative Care

Dr Philip LeeDr Philip Lee

Palliative Medicine Staff Specialist WSAHSPalliative Medicine Staff Specialist WSAHS

Acting Director Palliative Care WSAHSActing Director Palliative Care WSAHS

Palliative Care DefinitionsPalliative Care Definitions

To cure, occasionallyTo cure, occasionallyTo relieve, oftenTo relieve, oftenTo comfort, alwaysTo comfort, always

Anonymous (16Anonymous (16thth Century) Century)

Death should simply become a Death should simply become a discreet but dignified exit of a discreet but dignified exit of a peaceful person from a helpful peaceful person from a helpful society … without pain or suffering society … without pain or suffering and ultimately without fear.and ultimately without fear.

Philippe Ariès, 1977Philippe Ariès, 1977

The Hour of Our DeathThe Hour of Our Death

Palliative Care provides for all the Palliative Care provides for all the medical and nursing needs of the medical and nursing needs of the

patient for whom cure is not patient for whom cure is not possible and for all the possible and for all the

psychological, social and spiritual psychological, social and spiritual needs of the patient and the needs of the patient and the

family, for the duration of the family, for the duration of the patient’s illness, including patient’s illness, including

bereavement care.bereavement care.

Roger WoodruffRoger Woodruff

Palliative Palliative MedicineMedicine

22ndnd Edition Edition

Palliative CarePalliative Care

Caring for a person with an active, Caring for a person with an active, progressive, far advanced disease progressive, far advanced disease with little or no prospect of cure and with little or no prospect of cure and for whom the primary treatment goal is for whom the primary treatment goal is quality of lifequality of life

PALLIATIVE CARE - PALLIATIVE CARE - WHEN?WHEN?

ACTIVE TREATMENTACTIVE TREATMENTPALLIATIVE CARE

PALLIATIVE CARE BEREAVE-

MENT

BEREAVE-MENT

ACTIVE TREATMENTACTIVE TREATMENT

PALLIATIVE CARE

PALLIATIVE CARE

BEREAVE-MENT

BEREAVE-MENT

PALLIATIVE CARE - WHERE?PALLIATIVE CARE - WHERE?

Palliative Care is a NetworkPalliative Care is a Network Services are provided by TeamsServices are provided by Teams Services are available in:Services are available in:

Community, home and aged care facilitiesCommunity, home and aged care facilities Acute hospitalsAcute hospitals Private HospitalsPrivate Hospitals Specific inpatient units eg St Joseph’s, Mt Druitt, Specific inpatient units eg St Joseph’s, Mt Druitt,

Neringah, Greenwich, Braeside HospitalsNeringah, Greenwich, Braeside Hospitals

PALLIATIVE CARE - COMMUNITYPALLIATIVE CARE - COMMUNITY GP “case manager”GP “case manager” Generalist Community Nurse - GCNGeneralist Community Nurse - GCN Clinical Nurse Specialist - CNSClinical Nurse Specialist - CNS Clinical Nurse Consultant - CNCClinical Nurse Consultant - CNC Palliative Care Medical OfficerPalliative Care Medical Officer Community Palliative Care SpecialistCommunity Palliative Care Specialist

WHAT DOES PALLIATIVE CARE WHAT DOES PALLIATIVE CARE OFFER?OFFER?

Pain controlPain control Other symptom controlOther symptom control Terminal careTerminal care Family supportFamily support Bereavement supportBereavement support

Cancer painCancer pain

30-50% of cancer patients undergoing active 30-50% of cancer patients undergoing active treatmenttreatment

70-90% of cancer patients with advanced 70-90% of cancer patients with advanced diseasedisease

Prospective studies indicate that as many as Prospective studies indicate that as many as 90% of patients could attain adequate pain relief 90% of patients could attain adequate pain relief with simple drug therapies.with simple drug therapies.

TOTALTOTALPAINPAIN

SOMATIC SOURCE

ANGERDEPRESSION

ANXIETY

Symptoms of debility

Side effects of therapy

Non-cancer pathology

Cancer

Bureaucratic bungling

Friends not visiting

Delays in diagnosis

Unavailable doctors

Irritability

Therapeutic failure

Fear of hospitalor nursing home

Worry about family

Fear of death

Spiritual (existential) unrest

Fear of pain

Family finances

Loss of choices

Uncertainty about future

Loss of social position

Loss of job prestigeand income

Loss of role in family

Chronic fatigueand insomnia

Sense of helplessness

Disfigurement

The ContextThe Context

WHO analgesic ladderWHO analgesic ladder

PainPain Pain persistsPain persists Pain persists Pain persists

or increasesor increases or increases or increases

1. Non-opioid ± adjuvant

2. Weak opioid ± non-opioid ± adjuvant

3. Strong opioid ± non-opioid ± adjuvant

Guidelines for opioid useGuidelines for opioid use

Preferably oralPreferably oral Continuous rather than PRNContinuous rather than PRN Commence with immediate releaseCommence with immediate release Once stable convert to slow release + Once stable convert to slow release +

immediate for breakthrough pain reliefimmediate for breakthrough pain relief If more than 2 episodes of breakthrough pain If more than 2 episodes of breakthrough pain

increase regular doseincrease regular dose LaxativesLaxatives

Analgesic ClassesAnalgesic Classes

AspirinAspirin ParacetamolParacetamol NSAIDSNSAIDS OpioidsOpioids

OpioidsOpioids

Weak opioidsWeak opioids CodeineCodeine DextropropoxyphenDextropropoxyphen

ee

Strong opioidsStrong opioids OxycodoneOxycodone MorphineMorphine MethadoneMethadone FentanylFentanyl HydromorphoneHydromorphone PethidinePethidine TramadolTramadol

Opioid receptorsOpioid receptors

All opioids produce analgesia and other All opioids produce analgesia and other effects by mimicking the actions of effects by mimicking the actions of endogenous opioid compounds endogenous opioid compounds (endorphins) at multiple subtypes of the (endorphins) at multiple subtypes of the three major opioid receptors in the brain three major opioid receptors in the brain stem, spinal cord and peripheral tissues.stem, spinal cord and peripheral tissues.

Opioid actionsOpioid actions

The perception of pain is altered both by a The perception of pain is altered both by a direct effect on the spinal cord, direct effect on the spinal cord, modulating peripheral nociceptive input, modulating peripheral nociceptive input, and by activation of the descending and by activation of the descending inhibitory systems from the brain stem inhibitory systems from the brain stem and basal ganglia.and basal ganglia.

Patients’ concerns about Patients’ concerns about narcoticsnarcotics

Addiction & withdrawalAddiction & withdrawal ToleranceTolerance Implications of taking morphineImplications of taking morphine Side effectsSide effects

Side effectsSide effects SedationSedation HallucinationsHallucinations Nausea & vomitingNausea & vomiting ConstipationConstipation Urinary retentionUrinary retention MyoclonusMyoclonus Respiratory depressionRespiratory depression PruritusPruritus

Cognitive impairmentCognitive impairment

Some sedation early in use of morphineSome sedation early in use of morphine Tolerance developsTolerance develops Prior sleep deprivation due to poor pain Prior sleep deprivation due to poor pain

controlcontrol Other causes of cognitive impairment Other causes of cognitive impairment

need to be excludedneed to be excluded

Opioid Dose Duration of ActionOpioid Dose Duration of Action

Morphine (oral) 20 mg 4 hrs

Morphine (parenteral) 10mg 4 hrs

Codeine 130 mg 4-6 hrs

Pethidine (IMI) 80 mg 2-3.5 hrs

Methadone * 2-5 mg 8-12 hrs

Oxycodone 10-20 mg 4 hrs

Tramadol 200 mg 4-6 hrs

Fentanyl 200 mcg 1-2 hrs

Hydromorphone 4 mg 4 hrs

Routes of administration of Routes of administration of morphinemorphine

OralOral SubcutaneousSubcutaneous IVIIVI Epidural & intrathecalEpidural & intrathecal RectalRectal TopicallyTopically

Morphine metabolismMorphine metabolism Primarily metabolised in the liverPrimarily metabolised in the liver Metabolites excreted in urineMetabolites excreted in urine

Morphine-3-glucuronide (M3G)Morphine-3-glucuronide (M3G) Morphine-6-glucuronide (M6G)Morphine-6-glucuronide (M6G)

Caution in renal impairmentCaution in renal impairment M6G potent morphine agonistM6G potent morphine agonist M3G no significant analgesic actionM3G no significant analgesic action Liver disease not reported to alter Liver disease not reported to alter

pharmacokineticspharmacokinetics

MorphineMorphine

ProsPros ““Gold Standard”Gold Standard” Well understoodWell understood Readily availableReadily available Usually well toleratedUsually well tolerated No “ceiling”No “ceiling”

ConsCons Accumulates in renal Accumulates in renal

failurefailure ConstipatingConstipating NauseaNausea SedationSedation MisconceptionsMisconceptions

Morphine PreparationsMorphine Preparations

Morphine mixture (Ordine)

4 hrs 1, 2, 5, 10, 20, 40 mg/ml

Kapanol caps 24 hrs 10, 20, 50, 100 mg/ml

MS Contin tabs 12 hrs 5, 10, 15, 30, 60, 100, 200 mgs

MS Contin susp 12 hrs 30, 60, 100, 200 mgs

MS Mono caps 24 hrs 30, 60, 90, 120 mgs

Morphine sulphate amps

4 hrs 5, 10, 15, 30, 50 mgs/ml

Morphine tartrate amps 4 hrs 120 mgs/1.5 mls, 400mgs/5mls

OxycodoneOxycodone

ProsPros Various dose forms, Various dose forms,

immeadiate & slow immeadiate & slow releaserelease

Neuropathic painNeuropathic pain ““New”New” OK in renal failureOK in renal failure

ConsCons No parenteral formNo parenteral form ConstipatingConstipating NauseaNausea Confusing namesConfusing names

Oxycodone & TramadolOxycodone & Tramadol

Endone Tabs 4 hrs 5 mg

Oxynorm 4 hrs 5, 10, 20 mgs

Oxycontin 12 hrs 10, 20, 40, 80 mgs

Tramadol caps 4-6 hrs 50 mg

Tramadol SR Tabs 12 hrs 100, 150, 200 mgs

Tramadol amps 4-6 hrs 100 mg/2 mls

FentanylFentanyl

ProsPros Less constipationLess constipation Less nauseaLess nausea Less psychotomimetic Less psychotomimetic

effects effects ConvenientConvenient OK in renal failureOK in renal failure

ConsCons Reliant on good fat storesReliant on good fat stores Inflexible dosingInflexible dosing Difficult to titrateDifficult to titrate ExpensiveExpensive Breakthrough medicationsBreakthrough medications

HydromorphoneHydromorphone

ProsPros Less sedatingLess sedating Less constipatingLess constipating Less hallucinationsLess hallucinations Less nauseatingLess nauseating OK in renal failureOK in renal failure

ConsCons AvailabilityAvailability No slow release currently No slow release currently

availableavailable

MethadoneMethadone

ProsPros

Neuropathic painNeuropathic pain

ConsCons

StigmaStigma Difficult dosing scheduleDifficult dosing schedule Variable half-lifeVariable half-life

Fentanyl, Methadone & Fentanyl, Methadone & HydromorphoneHydromorphone

Fentanyl Patches (Durogesic)

72 hrs 25, 50, 75, 100 mcg/hr

Fentanyl sublingual liquid 1-2 hrs 100 mcg/ml

Fentanyl lozenges (ACTIQ) 1-2 hrs 200, 400, 800, 1200, 1600 mcg

Methadone 8-100 hrs 10 mg

Hydromorphone tabs (Dilaudid)

4 hrs 2, 4, 8 mgs

Hydromorphone liquid 4 hrs 1 mg/ml

Hydromorphone amps 4 hrs 2mg/ml, 10mg/ml, 50mg/5mls, 500mg/50mls

PethidinePethidine

Repetitive dosing leads to accumulation of the toxic metabolite norpethidine

Norpethidine accumulation causes CNS hyper-excitability & subtle mood

changes Tremors Multifocal myoclonus Seizures

Common with repeated large doses, eg 250 mg per day