What is New in Palliative Care
MaryseMaryse BouvetteBouvette, B.Sc.N., , B.Sc.N., MEdMEd., CON(C), CHPCN(C)., CON(C), CHPCN(C)
Advance Practice NurseAdvance Practice Nurse
Palliative Pain and Symptom Management Consultation ServicePalliative Pain and Symptom Management Consultation Service
SCO Health ServiceSCO Health Service
May 7th, 2008
Objectives
� Review the concept of palliative care, of suffering & of total pain
� Share standardized assessment tools
� Discuss the new approaches in the management for neuropathic pain
� Share other new technologies and upcoming new medications to manage certain symptoms ( if we have time…..)
Your Objectives?
�
�
�
What is Palliative Care?What is Palliative Care?
What is Palliative Care?What is Palliative Care?
�� It aims to It aims to relieve sufferingrelieve suffering and improve the and improve the
quality of livingquality of living and and dyingdying of patients living with of patients living with
a life threatening illness and their family a life threatening illness and their family
�� It address physical, psychological, social, It address physical, psychological, social,
spiritual and practical issues associated with spiritual and practical issues associated with
expectations, needs, hopes and fearsexpectations, needs, hopes and fears
�� It constitutes active careIt constitutes active care
�� It applies to all agesIt applies to all agesCHPCA 2002CHPCA 2002
Loss, Grief
Loss
Grief
Bereavement planning
Mourning
Loss, Grief
Loss
Grief
Bereavement planning
Mourning
Spiritual
Meaning
Existential, transcendental
Values
Spiritual advisors, rites
Symbols, icons
Spiritual
Meaning
Existential, transcendental
Values
Spiritual advisors, rites
Symbols, icons
Practical
Activities of daily living
Dependents, pets
Telephone access,
transportation
Practical
Activities of daily living
Dependents, pets
Telephone access,
transportation
End of Life Care
Life closure
Gift giving, legacy creation
Preparation for expected
death
Physiological changes
Rites, rituals
Perideath care of family
Funerals, celebrations
End of Life Care
Life closure
Gift giving, legacy creation
Preparation for expected
death
Physiological changes
Rites, rituals
Perideath care of family
Funerals, celebrations
Disease
Management
Primary diagnosis
Secondary diagnoses
Co-morbidities
Adverse events
Allergies
Disease
Management
Primary diagnosis
Secondary diagnoses
Co-morbidities
Adverse events
Allergies
PhysicalPain and other symptoms
Cognition
Function
Nutrition
Wounds
Habits
PhysicalPain and other symptoms
Cognition
Function
Nutrition
Wounds
Habits
Psychological
Personality
Depression
Emotions, fears
Control
Conflict
Self-image
Psychological
Personality
Depression
Emotions, fears
Control
Conflict
Self-image
Social
Cultural values
Relationships
Environment
Routines, rituals
Financial resources
Family caregiver protection
Guardianship, custody issues
Social
Cultural values
Relationships
Environment
Routines, rituals
Financial resources
Family caregiver protection
Guardianship, custody issues
Patient and Family
Characteristics
Demographics
Culture
Personal values
Developmental state
Disabilities
National Hospice Palliative Care NormsNational Hospice Palliative Care Norms
Canadian Hospice Palliative Care Association, 2002
What is Palliative Care?
Use Use ofof standardizedstandardized
AsssessmentAsssessment toolstools
PPS: Palliative Performance Scale
ESAS: Edmonton SymptomAssessment Scale
PPSv2PPSv2
�� Measurement of performance status in Measurement of performance status in
palliative carepalliative care
�� Assessment of patient needAssessment of patient need
�� Progression of conditionProgression of condition
�� Monitoring of progressive declineMonitoring of progressive decline
Palliative Performance Scale (PPSv2)Palliative Performance Scale (PPSv2)
�� Phases of disease progressionPhases of disease progression
��7070--100% PPS 100% PPS = = stablestable phasephase
��4040--60% PPS 60% PPS = = transitionaltransitional phasephase
��00--30% PPS 30% PPS = = end of lifeend of life phasephase
CHPCA 2002
When does palliative care start?
ESASESAS
�� A validated, reliable instrument A validated, reliable instrument
�� Measures 9 different symptoms Measures 9 different symptoms
�� ONLY ONLY a screening toola screening tool
�� Is Is one one partpart of a holistic clinical assessmentof a holistic clinical assessment
Nine(9) Common SymptomsNine(9) Common Symptoms
Anxiety**Anxiety**Depression**Depression**Shortness Shortness
of Breathof Breath
WellbeingWellbeing
****AppetiteAppetiteNauseaNausea
TirednessTiredness
****drowsinessdrowsinessPainPain
Those symptoms with an asterisk are subjective and can only be assessed
by the person. The remainder of symptoms can be assessed by the
caregiver or nurse as objectively as possible.
How to make it work?How to make it work?
�� ESAS = a ESAS = a screeningscreening tool only tool only
�� Further assessment needed Further assessment needed --
symptom algorithmssymptom algorithms
AlgorithmsAlgorithms
�� A step by step procedure to solving a A step by step procedure to solving a
problem and accomplishing the problem and accomplishing the
appropriate outcomeappropriate outcome
�� To initiate a care plan according to To initiate a care plan according to
the results of ESAS or other validated the results of ESAS or other validated
toolstools
WredeWrede--Seaman, L. (1999). Seaman, L. (1999).
AlgorithmsAlgorithms
�� Standard format (bilingual) Standard format (bilingual)
�� 6 symptom algorithms 6 symptom algorithms developeddeveloped
�� PainPain
�� Nausea /vomitingNausea /vomiting
�� Appetite/Anorexia/CachexiaAppetite/Anorexia/Cachexia
�� DyspneaDyspnea
�� DrowsinessDrowsiness
�� Delirium *Delirium *
14
PALLIUM
Suffering
� Suffering occurs when there is a perceived threat to the integrity or continuing existence of the person
� It is individual in its origins and expressions
� It is intensely privateCassell E.J. NEJM 1984
16
PALLIUM
Total SufferingHow do we recognize it?
� Patients use the terms “suffering” or “anguished”
� Symptoms that do not respond to usually successful treatments
� Sense of emptiness, hopelessness, meaninglessness
Michael Kearney. Mortally Wounded
PHYSICAL
EMOTIONAL
Total pain =Total pain =
(Kearney 1994)
SOCIAL
SPIRITUAL
Presentation/rush
Suffering
physical emotional
social spiritual
Total Pain Total Pain == Suffering
physical emotional
social spiritual
Total Pain Total Pain == Suffering
Disease management
Physical
Psychological
Loss/Grief
Social
Practical
Spiritual
End of life issues
Spiritual Pain
�� Combination of:Combination of:
�� Awareness of deathAwareness of death
�� Loss of relationshipLoss of relationship
�� Loss of selfLoss of self
�� Loss of purpose + Loss of controlLoss of purpose + Loss of control� Life affirming and transcending purpose, internal sense of control
Millspaugh 2005
15
PALLIUM
“Soul Pain”
Soul pain is the experience of an individual who has become disconnected and alienated from the deepest and most fundamental aspects of himself or herself.
Michael Kearney. Mortally Wounded
Pain: Pain:
A Multidimensional ExperienceA Multidimensional Experience
Pain is whatever the experiencing personPain is whatever the experiencing person
says it is, says it is,
existing whenever he (or she) existing whenever he (or she)
says it does.” says it does.”
Margo Margo McCafferyMcCaffery
Specificity Theory of PainSpecificity Theory of Pain
Stimulation of pain receptors/nerve endings Stimulation of pain receptors/nerve endings
(e.g. with injury/tissue damage) causes pain (e.g. with injury/tissue damage) causes pain
messages to be sent to the brain via the messages to be sent to the brain via the
spinal cordspinal cord
Does this fully explain pain???Does this fully explain pain???
Pain is a subjective experience. Pain is a subjective experience.
It is an unpleasant sensation, It is an unpleasant sensation,
experienced both experienced both physicallyphysically, and , and
emotionallyemotionally. It may be triggered by a . It may be triggered by a
physical stimulus physical stimulus
but the but the pain experienced is pain experienced is
modulated by a variety of factorsmodulated by a variety of factors..
Pain DefinitionPain Definition
MacDonald 2005
Pain control is possible in 80% ofpatients by applying simple methods of assessment and
management using the World Health
Organization's approach
1 MildNon-Opioid
2 Moderate“Weak” Opioid
3 Severe“Strong” Opioid
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
±±±± Acetaminophen±±±± NSAIDs±±±± Adjuvants
Acetaminophen +
Codeine
Acetaminophen +
Oxycodone
Tramadol
±±±± NSAIDs±±±± Adjuvants
Acetaminophen
ASA
NSAIDs/ COXIB
±±±± Adjuvants
WHO Pain Ladder (2008)
NociceptiveNociceptive PainPain
�� Transmission along normal nervesTransmission along normal nerves
�� Direct stimulation of intact Direct stimulation of intact nociceptorsnociceptors
�� Examples:Examples:
�� Somatic: bone, muscle,soft tissueSomatic: bone, muscle,soft tissue
�� VisceralVisceral
NeuropathicNeuropathic PainPain
‘‘Pain caused by a lesion of the peripheral or Pain caused by a lesion of the peripheral or
central nervous system (or both) central nervous system (or both)
manifesting with sensory symptoms & manifesting with sensory symptoms &
signs”signs”
-- BackonjaBackonja 20032003
caused by injury or compression, or infiltration of a nerve
(chemical or mechanical lesions)
E.g. post herpetic neuralgia or sciatic pain
Significance of NP in Significance of NP in
Cancer PatientsCancer Patients
�� 2nd 2nd commonestcommonest pain syndromepain syndrome
�� Pain Pain often precedes neurological deficitoften precedes neurological deficit
�� Commonest ‘Commonest ‘uncontrolleduncontrolled’ pain’ pain
Causes of NP in Cancer Causes of NP in Cancer
PatientsPatients
Study N=593 (Study N=593 (GrondGrond 1999)1999)
�� 72% 72% TumourTumour
�� 12% Treatment12% Treatment
�� 4% 4% ParaneoplasticParaneoplastic
�� 9% not cancer related9% not cancer related
�� 3% unknown3% unknown
Pain Assessment is Pain Assessment is
essentialessential
New New PharmacologicalPharmacological
AprroachesAprroaches//MethodsMethods for for
thethe Management Management ofof
NeuropathicNeuropathic PainPain
- Methadone
- Ketamine
- Lidocaine
- Epidural access
MethadoneMethadone
� A synthetic agent that is 10 timesmore potent than morphine
� µ receptor agonist
� NMDA antagonist (N-Methyl-D-Aspartate)
� Known efficiency
� No active metabolites
� Good alternative for true allergies
MethadoneMethadone
� Oral bioavailability is 84%
� ½ life = 10- 72 hours
� Duration of analgesia: 6 –12 heures
� Proteinic binding: 60-90%
MD require a special license
MethadoneMethadone pharmacokineticpharmacokinetic
�� Dose Dose administeredadministered
Med eliminatedMed. in blood
stream
analgesia
Med.
being
stocked
A
B
A –med to tissus
B –med available for
analgesia
MethadoneMethadone pharmacokineticpharmacokinetic
Dose Dose administeredadministered
Med. eliminated
Med. in
blood stream
analgesia
Med.
being
stocked
C
DC- full reservoir
D-�dose for analgesia
E – steady state –acts as
sustained release
E
KetamineKetamine
Indications:
- neuropathic pain, resistant to regular approaches
or intolerant to side effects
Should only be initiated by a
Consultant in Palliative Medicine
KetamineKetamine
Properties:
- General anesthetic agent
- NMDA antagonist (N-Methyl-D-Aspartate)
- Sub-cutaneously via continuous infusion at sub anaesthetic doses or orally
- Reduces the opioid requirement and
increases the analgesia
KetamineKetamine
Adverse effects
- Vivid dreams, hallucinations, excessive salivation/secretions,
sedation, psychosis ( rare)
Contraindications
- Intracranial hypertension and seizures ( absolute)
- Hypertension, cardiac failure and previous CVA (relative)
Ketamine is commonly given with midazolam or
haloperidol to reduce these effects
KetamineKetamine
Nursing implications
1. Qshift/day check on infusion for turbidity (clouding).
2. Qshift/day check the needle site for inflammation.
3. Qshift/day check vital signs.
4. Qshif/dayt pain assessment (ESAS).
5. Qshift/day check for side effects .
Lidocaine Infusions Lidocaine Infusions
�� Na Channel blockerNa Channel blocker
�� Reduces the response from irritable nervesReduces the response from irritable nerves
�� Used in the treatment of Used in the treatment of neuropathicneuropathic painpain
�� Continuous intravenous infusion thru a pumpContinuous intravenous infusion thru a pump
Nursing Assessment Nursing Assessment
Assess every shift Assess every shift
�� Numbness and tinglingNumbness and tingling in the fingers and toes in the fingers and toes
�� NumbnessNumbness or unusual sensations around the or unusual sensations around the
mouth areamouth area
�� Sudden Sudden ringingringing in the earsin the ears
�� Any new onset of Any new onset of dizzinessdizziness
�� Any new onset of Any new onset of tremorstremors
�� Any new onset of Any new onset of nausea and vomitingnausea and vomiting
Nursing AssessmentNursing Assessment
�� Blood pressure, pulse and respiratory rate Blood pressure, pulse and respiratory rate
q shift/dayq shift/day
�� Vital signs are to be taken q 4h if Vital signs are to be taken q 4h if
symptomatic or there is any increase in symptomatic or there is any increase in
lidocaine doselidocaine dose
Notify physician Notify physician
�� RR less than 10 per minuteRR less than 10 per minute
�� Pulse less than 40 per minutePulse less than 40 per minute
�� Increased drowsinessIncreased drowsiness
�� New onset of confusionNew onset of confusion
�� New onset of twitching New onset of twitching
MethodMethod/Route /Route ofof
administrationadministration
Epidural lines
EpiduralsEpidurals
�� An intraspinal/epidural catheter lies within An intraspinal/epidural catheter lies within
the the epidural spaceepidural space which is between the which is between the
dura matter and the vertebral column. dura matter and the vertebral column.
�� It is used for the continuous infusion of It is used for the continuous infusion of
medications for pain controlmedications for pain control
Epidural LinesEpidural Lines
�� Why?Why?
�� Significant reduction in the opioid dose Significant reduction in the opioid dose
requirementrequirement
Nursing Assessment Nursing Assessment
Assess every 4 hours for:Assess every 4 hours for:
�� DrainageDrainage from insertion site (palpate insertion from insertion site (palpate insertion site)site)
�� Condition of insertionCondition of insertion sitesite
�� Catheter is Catheter is anchoredanchored, ,
�� CADDCADD is infusing properlyis infusing properly
�� Verify that Verify that connections are secureconnections are secure
�� Observe for signs of Observe for signs of infectionsinfections or catheter or catheter dislodgementdislodgement
DrugsDrugs
�� 0.1250.125––0.25% bupivacaine, has been 0.25% bupivacaine, has been
demonstrated to increase analgesic effect demonstrated to increase analgesic effect
without increasing toxicity.without increasing toxicity.
�� HydromorphoneHydromorphone
�� MorphineMorphine
New New ProcedureProcedure for for thethe
Management Management ofof certain certain
SymptomsSymptoms
PleurX catheter
Pleurex Pleurex
�� Used in the treatment of Used in the treatment of malignant pleural malignant pleural
effusioneffusion
�� MPE is an indicator of advanced disease MPE is an indicator of advanced disease
and poor prognosisand poor prognosis
�� 50%50% of lung cancer pts have MPEof lung cancer pts have MPE
�� 40%40% of breast cancer pts have MPEof breast cancer pts have MPE
PleurexPleurex
�� Indwelling pleural catheterIndwelling pleural catheter
�� 15.5 F fenestrated silicone catheter15.5 F fenestrated silicone catheter
�� Polyester cuffPolyester cuff
�� Safety valveSafety valve
�� Inserted as an outpatientInserted as an outpatient
�� Intermittent drainage Intermittent drainage at homeat home is possibleis possible
Treatment Options for MPETreatment Options for MPE
�� Symptomatic managementSymptomatic management
�� Chest tube insertion & drainageChest tube insertion & drainage
�� ThoracentesisThoracentesis
�� Chemical pleurodesisChemical pleurodesis
�� Indwelling Indwelling PleurXPleurX CatheterCatheter
�� PleuroperitonealPleuroperitoneal shuntshunt
�� PleurectomyPleurectomy
PleurodesisPleurodesis: The Issues: The Issues
�� ComplicationsComplications
�� EmpyemaEmpyema
�� PainPain
�� Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
�� Cardiac eventsCardiac events
�� HospitalizationHospitalization
�� Required for insertion of chest tube & Required for insertion of chest tube & pleurodesispleurodesis
�� Done by specialty services (Done by specialty services (thoracicsthoracics / / respirologyrespirology))
�� Lengthy hospitalizationLengthy hospitalization for:for:�� Immune suppressed population Immune suppressed population
�� Patients with a limited life span Patients with a limited life span
The The PleurXPleurX CatheterCatheter
�� Catheter designed for long term Catheter designed for long term drainage of MPEdrainage of MPE
�� Fluid drained intermittently by an Fluid drained intermittently by an RN via a vacuum bottle and RN via a vacuum bottle and drainage set drainage set
Expected OutcomesExpected Outcomes
�� Patient managed at home Patient managed at home
�� �� in symptomsin symptoms
�� �� in drainage over timein drainage over time
�� If < 50 ml on 3 consecutive drains home care If < 50 ml on 3 consecutive drains home care RN to notify program RN to notify program
�� Patient booked for follow up for catheter Patient booked for follow up for catheter removalremoval
�� �� hospitalization timehospitalization time
�� �� patient / family satisfactionpatient / family satisfaction
�� �� health care provider satisfactionhealth care provider satisfaction
Nursing AlertsNursing Alerts
�� The product contains natural rubber latex that The product contains natural rubber latex that
may cause may cause allergic reactionsallergic reactions
�� Sterile techniqueSterile technique should be used for drainage should be used for drainage
and changing the dressingand changing the dressing
�� Use Use rubber shod instrumentsrubber shod instruments when handling the when handling the
cathetercatheter
�� An upper limit on the volume of fluid to be An upper limit on the volume of fluid to be
drained should be determined by the physiciandrained should be determined by the physician
Nursing AssessmentNursing Assessment
�� Complete Complete chest assessmentchest assessment
�� Physical statusPhysical status
�� Pain assessment Pain assessment priorprior, , duringduring, and , and postpost
drainagedrainage
�� Frequency of drainage is based on the Frequency of drainage is based on the
individual and may occur 3 times a weekindividual and may occur 3 times a week
(as per (as per medical order)medical order)
Nursing AssessmentNursing Assessment
�� Assess site q shift for Assess site q shift for redness, tenderness redness, tenderness
or an increased temperatureor an increased temperature
�� Assess Assess vital signsvital signs pre and post drainage pre and post drainage
especially BP for possible hypotensionespecially BP for possible hypotension
�� Assess for excessive coughAssess for excessive cough--possible possible
pulmonary edemapulmonary edema
In the light of the scientificevolution, we must make sure thatwe do NOT let technology drive ourpractice!
Let ’s keep in mind our drivingPRINCIPLES and VALUESPRINCIPLES and VALUES
Let’s not forget about theHUMANITY…
Traditional Management of Traditional Management of
MPEMPE
�� ThoracentesisThoracentesis
�� First step in managementFirst step in management�� Relieves immediate symptomsRelieves immediate symptoms
�� Fluid sent for cytology to confirm MPEFluid sent for cytology to confirm MPE
�� Only temporary as usually recurs within several daysOnly temporary as usually recurs within several days
�� Repeated Repeated thoracentesesthoracenteses result in increased morbidity result in increased morbidity
�� PneumothoraxPneumothorax
�� InfectionInfection
�� LoculationLoculation
�� Must be done by a physicianMust be done by a physician
�� Usually done for those who will respond to Usually done for those who will respond to chemotherapy or radiation therapychemotherapy or radiation therapy
Management of MPE Management of MPE
Cont’d..Cont’d..
�� ThoracostomyThoracostomy
�� Chest tube insertionChest tube insertion�� Pigtail or large bore Pigtail or large bore
�� Drainage until < 100 ml of fluidDrainage until < 100 ml of fluid
�� PleurodesisPleurodesis
�� Instillation of Instillation of sclerosingsclerosing agentagent�� Talc or Talc or doxycyclinedoxycycline
�� Drainage of Drainage of sclerosingsclerosing agentagent
�� Removal of chest tubeRemoval of chest tube
�� Approximation of the visceral & parietal pleuraApproximation of the visceral & parietal pleura
�� Expected patient outcomeExpected patient outcome�� pleural effusion is resolved & will not recurpleural effusion is resolved & will not recur
Treatment: Chemical PleurodesisTreatment: Chemical Pleurodesis
�� Several agents availableSeveral agents available
�� DoxycyclineDoxycycline, talc, , talc, bleomycinbleomycin, , mitoxantronemitoxantrone, silver nitrate, TGF, silver nitrate, TGF--ßß
�� Most commonly used agent is Most commonly used agent is
�� TalcTalc�� InsufflatedInsufflated
�� SlurrySlurry
PleurXPleurX vsvs PleurodesisPleurodesis::
Impact on CostImpact on Cost
Putnam et al, Putnam et al, Ann Ann ThoracThorac SurgSurg 2000; 69:369 2000; 69:369 ––375375
�� Retrospective review Retrospective review
�� Compared 68 inpatients with chest tube and Compared 68 inpatients with chest tube and pleurodesispleurodesis to 100 to 100 PleurxPleurx patientspatients
�� 60 out60 out--patient, and 40 inpatient, and 40 in--patientpatient
�� OutOut--patient patient PleurxPleurx patients had significantly patients had significantly lower health care costslower health care costs
$3,391 vs. $7,830 (p < 0.001).$3,391 vs. $7,830 (p < 0.001).
- 67% of cancer patients experience pain
–33% of cancer patients may have 3 or
more causes of pain
(Robert Twycross)
- 95-97% of patients with Stage 4 HIV
experience pain
–AIDS patients may have up to 7 different causes of pain
(Debbie Norval)
Prevalence of pain
Pain HistoryPain History
�� Site/DistributionSite/Distribution
�� Spontaneous or EvokedSpontaneous or Evoked
�� CharacterCharacter
�� PatternPattern
�� Superficial Superficial vsvs deepdeep
�� IntensityIntensity
Pain HistoryPain History
�� Aggravating & relieving factorsAggravating & relieving factors
�� Associated motor deficitsAssociated motor deficits
�� Recent history of pain progressionRecent history of pain progression
�� Efficacy of current treatment planEfficacy of current treatment plan
NeuropathicNeuropathic pain:pain:
�� Sensory loss +/Sensory loss +/--
�� Altered sensation to Altered sensation to cutaneouscutaneous stimulistimuli
�� AllodyniaAllodynia (pain from non(pain from non--painful stimuli)painful stimuli)
�� HyperalgesiaHyperalgesia (excess pain)(excess pain)
⇓⇓ sensitivitysensitivity to to opioidsopioids
-- WithWith thethe permission permission
ofof permission de permission de
ll ’auteur’auteur--
De: De: MechanismMechanism ofof
hyperalgesiahyperalgesia andand morphine morphine
tolerancetolerance::
a a currentcurrent viewview ofof theirtheir
possible interactionspossible interactions
((J.maoJ.mao et et alal) Pain 62(95) ) Pain 62(95)
259259--7474
NMDA antagonist ( N-Methyl-D-Aspartate)
