PALLIATIVE CARE:PALLIATIVE CARE:WHO Definition

The active total care of patients whose disease is not responsive to curative treatment....

SUFFERINGSUFFERINGEMOTIONALPSYCHOSOCIAL

PHYSICAL

SPIRITUAL

1.1. Adequate knowledge base Adequate knowledge base

2.2. Attitude / Behaviour / Philosophy Attitude / Behaviour / Philosophy

• Active, aggressive management of sufferingActive, aggressive management of suffering

• Team approachTeam approach

• Recognizing death as a natural closure of life Recognizing death as a natural closure of life

• Broadening your concept of “successful” care Broadening your concept of “successful” care

Effective nursing / medical care of the dying Effective nursing / medical care of the dying involves:involves:

Cure/Life-prolongingCure/Life-prolongingIntentIntent

Palliative/Palliative/Comfort IntentComfort Intent

Bereavement

Bereavement

DEATH

“Active Treatment”

PalliativePalliativeCareCare

DEATH

EVOLVING MODEL OF PALLIATIVE CAREEVOLVING MODEL OF PALLIATIVE CARE

SYMPTOMS IN ADVANCED CANCERSYMPTOMS IN ADVANCED CANCER

0 10 20 30 40 50 60 70 80 90

Asthenia

Anorexia

Pain

Nausea

Constipation

Sedation/Confusion

Dyspnea % Patients (n=275)

Ref: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-KetteringRef: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering

PREVALENCE OF CANCER PAINPREVALENCE OF CANCER PAIN

0 10 20 30 40 50 60 70 80 90

All

All: Advanced

Bone

Pancreas

Stomach

Uterus/Cervix

Lung

Breast

Prostate

Colon

Lymphoma

Leukemia% Patients

From Portenoy; From Portenoy; CancerCancer 63:2298, 1989 63:2298, 1989

TYPES OF PAINTYPES OF PAIN

NEUROPATHICNEUROPATHICNOCICEPTIVENOCICEPTIVE

SomaticSomatic VisceralVisceral

DeafferentationDeafferentation Sympathetic Sympathetic MaintainedMaintained

PeripheralPeripheral

Somatic Visceral

Features • Constant• Aching• Well localized

• Constant or crampy• Aching• Poorly localized• Referred

Examples • Bone metastases • Pancreatic CA• Liver tumor• Bowel obstruction

NOCICEPTIVE PAIN

COMPONENT DESCRIPTORS MEDICATIONS

Steady • Burning, Tingling• Constant, Aching• Squeezing, Itching• Allodynia• Hypersthesia

• Gabapentin• Tricyclic antidepressants• Corticosteroids• Mexilitene

Paroxysmal • Stabbing• Shocklike, electric• Shooting

• Gabapentin• Baclofen• Tegretol• Corticosteroids• Mexilitene

FEATURES OF NEUROPATHIC PAINFEATURES OF NEUROPATHIC PAIN

PAIN HISTORYPAIN HISTORY

• Temporal FeaturesTemporal Features

• Daily FrequencyDaily Frequency

• LocationLocation

• SeveritySeverity

• QualityQuality

• Aggravating & Alleviating FactorsAggravating & Alleviating Factors

• Previous HistoryPrevious History

• MeaningMeaning

+/- adjuvant+/- adjuvantNon-opioidNon-opioid

Weak opioidWeak opioid

Strong opioidStrong opioid

Pain persists or increases

Pain persists or increases

By the

Clock

W.H.OW.H.O. ANALGESIC LADDER. ANALGESIC LADDER

+/- adjuvant+/- adjuvant

+/- adjuvant+/- adjuvant

1

2

3

STRONG OPIOIDSSTRONG OPIOIDS

• most commonly use: most commonly use: – morphinemorphine– hydromorphonehydromorphone– transdermal fentanyl (Duragesic®)transdermal fentanyl (Duragesic®)– MethadoneMethadone

• DO NOT use meperidine (DemerolDO NOT use meperidine (Demerol) long-term) long-term– active metabolite active metabolite normeperidinenormeperidine seizuresseizures

OPIOIDS andOPIOIDS andINCOMPLETE CROSS-TOLERANCEINCOMPLETE CROSS-TOLERANCE

• conversion tables assume full cross-toleranceconversion tables assume full cross-tolerance

• cross-tolerance unpredictable, especially in:cross-tolerance unpredictable, especially in:– high doseshigh doses– long-term uselong-term use

• divide calculated dose in ½ and titratedivide calculated dose in ½ and titrate

CONVERTING OPIOIDSCONVERTING OPIOIDS

Medication Approx. Equiv. Oral Dose (mg)

Morphine 10

Hydromorphone 2

Methadone 1

Codeine 60

NB: Does not consider incomplete cross-tolerance

TITRATING OPIOIDSTITRATING OPIOIDS

• dose increase depends on the situationdose increase depends on the situation• dose dose by by 25 - 100%25 - 100%

EXAMPLE: (doses in mg q4h)EXAMPLE: (doses in mg q4h)

Morphine 5 10 15 20 25 30 40 50 60

Hydromorphone 1 2 3 4 5 6 8 10 12

Using Opioids for Breakthrough PainUsing Opioids for Breakthrough Pain

• Patient must feel in control, empowered• Use aggressive dose and interval

Patient Taking Short-Acting Opioids:• 50 - 100% of the q4h dose given q1h prn

Patient Taking Long-Acting Opioids:• 10 - 20% of total daily dose given q1h prn with short-acting opioid preparation

TOLERANCETOLERANCE

PHYSICAL PHYSICAL DEPENDENCEDEPENDENCE

PSYCHOLOGICALPSYCHOLOGICALDEPENDENCE /DEPENDENCE /

ADDICTIONADDICTION

TOLERANCE

A normal physiological phenomenon in which

increasing doses are required to produce the same effect

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

PHYSICAL DEPENDENCE

A normal physiological phenomenon

in which a withdrawal syndrome occurs

when an opioid is abruptly discontinued

or an opioid antagonist is administered

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

PSYCHOLOGICAL DEPENDENCEand ADDICTION

A pattern of drug use characterized by a continued craving for an opioid

which is manifest as compulsive drug-seeking behaviour leading to an

overwhelming involvement in the use and procurement of the drug

Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

In In chronicchronic opioid dosing: opioid dosing:

po / sublingual / rectal routespo / sublingual / rectal routes

sq / iv / IM routessq / iv / IM routes

reduce by ½

ADJUVANT DRUGSADJUVANT DRUGS

• primary indication usually other than painprimary indication usually other than pain• analgesic in some painful conditionsanalgesic in some painful conditions• enhance analgesia of opioidsenhance analgesia of opioids• other roles:other roles:

– treat opioid side effectstreat opioid side effects– treat symptoms associated with paintreat symptoms associated with pain

ANTI-ANTI-CHOLINERGICCHOLINERGIC

EFFECTSEFFECTS

AmitriptylineAmitriptyline

NortriptylineNortriptyline

DesipramineDesipramine

inflammationinflammationedemaedema

spontaneous nerve depolarization spontaneous nerve depolarization

tumor tumor mass effectsmass effects

CORTICOSTEROIDS AS ADJUVANTSCORTICOSTEROIDS AS ADJUVANTS

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IMMEDIATE LONG-TERM

• Psychiatric• Hyperglycemia risk of GI bleed

gastritis aggravation of existing lesion (ulcer, tumor)

• Immunosuppression

• Proximal myopathy

** often < 15 days **• Cushing’s syndrome• Osteoporosis• Aseptic / avascular necrosis of bone

CORTICOSTEROIDS: ADVERSE EFFECTS CORTICOSTEROIDS: ADVERSE EFFECTS

DEXAMETHASONE: DOSING DEXAMETHASONE: DOSING

• minimal mineralcorticoid effects– po/iv/sq/?sublingual routes

• can be given once/day; often given bid – qid to facilitate titration

• typically administer as follows:» 4 mg qid x 7 days then» 4 mg tid x 1 day then» 4 mg bid x 1 day then» 4 mg once/day x 1 day then D/C