Principles of Palliative Care

Dr. Tony O’Brien

Marymount Hospice &

Cork University Hospital

Wednesday March 9th, 2010

Medicine is about people

Every body has a story to tell. Allow people to tell their own

unique story, in their own way and in their own time.

No two people ever share the same illness.

Definition

Disease – describes a specific pathology affecting an organ, tissue or system in the body

Illness – describes the subjective experience of the disease in the unique context of an individual’s life – past, present and anticipated future

PASTPAST FUTURFUTUREE

BirthBirth DeatDeathh

PASTPAST

BirthBirth DeatDeathh

Palliative Care

.. is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

W.H.O. 2002

Palliative Care

Provides relief from pain and other distressing symptoms

Affirms life, and regards dying as a normal process Intends neither to hasten nor postpone death Integrates the psychological and spiritual aspects of

patient care Offers a support system to help the family cope during

the patient’s illness and in their own bereavement

W.H.O. 2002

Palliative Care

Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated

Will enhance quality of life, and may also positively influence the course of illness;

Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as radiotherapy or chemotherapy, and includes those investigations needed to better understand and manage distressing clinical complications.

W.H.O. 2002

Living

Dying

My world

Hospice

DyingDying

LivingLiving

Dame Cicely Saunders

1918 - 2005

Disease ModifyingDisease Modifying TreatmentsTreatments

EndEndOf Of

Life Life CareCare

‘‘There is nothing There is nothing more to be done’more to be done’

TimeTime

Disease modifying

Symptomatic

Palliative Care / Bereavement

TimeTime

Pain

Pain is an unpleasant sensory and Pain is an unpleasant sensory and EMOTIONAL experience……EMOTIONAL experience……

Pain is always subjectivePain is always subjective Pain is what the patient says hurtsPain is what the patient says hurts Pain is what the patient says it isPain is what the patient says it is

Pain Types

Nociceptive Neuropathic

Peripheral CentralSomatic Visceral

Mixed

Nociceptive Pain

Stimulation of peripheral sensory receptors Neural pathways intact and functioning Somatic pain: well localised Visceral pain: less well localised; may be referred to

cutaneous sites

Neuropathic Pain

Occurs as a result of aberrant somatosensory processing in the nervous system

Central, peripheral or both Diagnosis is based on history Pain in an area with abnormal neurology findings

is typically neuropathic

Breakthrough Cancer Pain

Transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.

Davies, A et al. APM Guidelines,2009

Measurement

No PainNo Pain Worst PainWorst Pain

Visual Analogue ScaleVisual Analogue Scale

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Numerical Rating ScoreNumerical Rating Score

None Mild Moderate Severe ExcruciatingNone Mild Moderate Severe Excruciating

Verbal Descriptor ScaleVerbal Descriptor Scale

Assessment Site Radiation Duration Progression Severity Frequency Significance Effect on mood

Quality Precipitating Factors Aggravating Factors Relieving Factors Effect on activity Effect on sleep

Treatment History

Medication(s) Route Dose Compliance Duration Concerns re meds.

Benefits Adverse effects Non-drug Rx Non-medical Rx Patient’s views Relative’s views

Palliative Interventions

SurgerySurgery Radiology Chemotherapy / Systemic therapy Radiotherapy Anaesthesia Psychiatric / psychological

Surgery

Excision e.g. Breast carcinoma Debulking e.g. Brain metastasis Debridement e.g. Fungating tumour Diverting (Stoma) e.g. Bowel obstruction Stabilisation e.g. Prophylactic pinning of bone

metastasis

Interventional Radiology

Gastrointestinal stents Biliary stents Renal stents Paracentesis Pleural drain Gastrostomy tube Vascular stents / Filters

Systemic therapy

Pain & symptom relief Functional Improvement ? Life Prolonging ? Life enhancing - Balance

Radiation Therapy

Metastatic bone disease SVC obstruction Spinal Cord compression Brain metastases Bleeding Ulcerating / fungating tumours Tumour shrinkage

Anaesthesia

Nerve blocks Plexus blocks Epidural medication Intrathecal medication

Pain Distress

Severity (Visual Analogue Scale / Verbal rating score)

Previous pain experience Mood (Pain tolerance threshold) SIGNIFICANCE

Pain Control - Essentials

Believe, do not doubt! Detailed assessment of EACH pain Understand common pain types Understand treatment modalities Total pain concept

Total Pain

PainPain

PhysicalPhysical

EmotionalEmotional

SocialSocial

SpiritualSpiritual

W.H.O. Analgesic Ladder

Non-OpioidsNon-Opioids

Weak Weak OpioidsOpioids

Strong Strong OpioidsOpioids

+/- +/- AdjuvantsAdjuvants

+/-+/-AdjuvantsAdjuvants

Adjuvant Drugs

Non-steroidal anti-inflammatory drugs Corticosteroids Anti-convulsants Anti-depressants Anti-spasmodics Anxiolytics Local anaesthetic agents NMDA receptor antagonists

Strong Opioids

MORPHINEMORPHINE

OxycodoneOxycodone

BuprenorphineBuprenorphine

FentanylFentanyl

DiamorphineDiamorphine MethadoneMethadone

HydromorphoneHydromorphone

Analgesic drugs

Drug & Dose Route & Dose interval Breakthrough pain Titration Side-effect prophylaxis Sequential trial / Opioid Switch Adjuvant drugs

Levy MH. NEJM, 1996. 335:10

Dose – limiting toxicity

Central nervous system* Gastrointestinal system* Endocrine system Immune system Others

* hypercalcaemia

Opioid induced CNS toxicity

Sleepiness, drowsiness Confusion Visual hallucinations Myoclonus Pruritus Distorted sound of voice

Constipation

Not just related to bowel frequency Opioid induced bowel dysfunction Primary feature of dose limiting toxicity Patients may select pain over bowel

complications Tolerance does NOT develop

Constipation associated features

Anorexia Nausea / vomiting Reflux Pain / cramps Distension Diarrhoea Borborygmi Obstruction

Perforation Peritonitis Incomplete evacuation Haemorrhoids Fissures Confusion Urinary retention

Opioid induced bowel dysfunction

Mediated by mu opioid receptors Reduced and in-coordinated gut motility Decreased secretions (including pancreatic

and biliary juice) Increased sphincter tone Resulting in OIBD

OIBD / Mechanism Based Therapy

OIBD mediated by action of opioid on GUT mu receptors

Selective blockade of peripheral receptors Maintain centrally mediated analgesia Avoid risk of opioid withdrawal

Total Pain

PainPain

PhysicalPhysical

EmotionalEmotional

SocialSocial

SpiritualSpiritual

Uncontrolled pain

‘the greatest reason for uncontrolled pain is the failure by doctors and nurses to appreciate fully that pain is NOT just a physical sensation….

… there is ALWAYS more to analgesia than analgesics!’

Dr. Robert Twycross

Spiritual Pain

Failure to find any meaning The ‘why’ question? Anger, resentment, confusion, bewilderment Infrequently recognised by patients, families

or health care professionals May aggravate physical symptoms

Case study

37 year old married lady Previously healthy February 2011: Fatigue, back pain, nausea Investigated:

Carcinoma gastro-oesophageal junction Carcinomatosis peritonei Obstructive uropathy / bilateral stents Duodenal obstruction Biliary obstruction / mass at head of pancreas Rapidly progressive disease

Family tree

7

Spiritual anguish

I don’t ask ‘why me’? I used to but not now. I just have to fight this, get better I can’t give up. I have too much to live for. I feel angry all the time. I can’t sleep What did he ever do to deserve this. He’s

only 7, he never harmed anyone. Why is he being punished? I just hope the chemotherapy can get rid of it

PASTPAST

BirthBirth DeatDeathh

Expressions of Spiritual Pain

She never smoked and only took a drink at Christmas

It doesn’t make any sense What did she ever do to deserve this? What’s the point of all this? She never harmed anybody It’s just not fair

Responding to Spiritual Pain

Not about providing answers or solutions Avoid pious platitudes Staying with the questions Staying with the pain Staying with the uncertainty Staying with the person Being there!!!

SUFFERINGSUFFERING

PainPain