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Palliative Care. Dr Philip Lee Senior Staff Specialist Palliative Medicine Westmead Hospital. Palliative Care Definitions. To cure, occasionally To relieve, often To comfort, always Anonymous (16 th Century)

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palliative care

Palliative Care

Dr Philip Lee

Senior Staff Specialist

Palliative Medicine

Westmead Hospital

slide3
To cure, occasionally

To relieve, often

To comfort, always

Anonymous (16th Century)

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

Philippe Ariès, 1977

The Hour of Our Death

slide4

Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patient’s illness, including bereavement care.Roger Woodruff Palliative Medicine 2nd Edition

palliative care1
Palliative Care

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

palliative care when
PALLIATIVE CARE - WHEN?

PALLIATIVE

CARE

BEREAVE-MENT

ACTIVETREATMENT

DEATH

DIAGNOSIS

ACTIVETREATMENT

BEREAVE-MENT

DEATH

PALLIATIVE

CARE

palliative care where
PALLIATIVE CARE - WHERE?
  • Palliative Care is a Network
  • Services are provided by Teams
  • Services are available in:
    • Community, home and aged care facilities
    • Acute hospitals
    • Private Hospitals
    • Specific inpatient units eg St Joseph’s, Mt Druitt, Neringah, Greenwich, Braeside Hospitals
palliative care community
PALLIATIVE CARE - COMMUNITY
  • GP “case manager”
  • Generalist Community Nurse - GCN
  • Clinical Nurse Specialist - CNS
  • Clinical Nurse Consultant - CNC
  • Palliative Care Medical Officer
  • Community Palliative Care Specialist
what does palliative care offer
WHAT DOES PALLIATIVE CARE OFFER?
  • Pain control
  • Other symptom control
  • Terminal care
  • Family support
  • Bereavement support
cancer pain
Cancer pain
  • 30-50% of cancer patients undergoing active treatment
  • 70-90% of cancer patients with advanced disease
  • Prospective studies indicate that as many as 90% of patients could attain adequate pain relief with simple drug therapies.
the context
The Context

Symptoms of debility

Non-cancer pathology

Side effects of therapy

Cancer

Loss of social position

Bureaucratic bungling

SOMATIC SOURCE

Loss of job prestige

and income

Friends not visiting

TOTAL

PAIN

Loss of role in family

Delays in diagnosis

DEPRESSION

ANGER

Chronic fatigue

and insomnia

Unavailable doctors

Sense of helplessness

Irritability

ANXIETY

Disfigurement

Therapeutic failure

Fear of pain

Fear of hospital

or nursing home

Family finances

Worry about family

Loss of choices

Fear of death

Uncertainty about future

Spiritual (existential) unrest

who analgesic ladder
WHO analgesic ladder

PainPain persists Pain persists

or increases or increases

3. Strong opioid

± non-opioid

± adjuvant

2. Weak opioid

± non-opioid

± adjuvant

1. Non-opioid

± adjuvant

guidelines for opioid use
Guidelines for opioid use
  • Preferably oral
  • Continuous rather than PRN
  • Commence with immediate release
  • Once stable convert to slow release + immediate for breakthrough pain relief
  • If more than 2 episodes of breakthrough pain increase regular dose
  • Laxatives
analgesic classes
Analgesic Classes
  • Aspirin
  • Paracetamol
  • NSAIDS
  • Opioids
opioids
Weak opioids

Codeine

Dextropropoxyphene

Tramadol

Strong opioids

Oxycodone

Morphine

Methadone

Fentanyl

Hydromorphone

Opioids
opioid receptors
Opioid receptors

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

opioid actions
Opioid actions

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

patients concerns about narcotics
Patients’ concerns about narcotics
  • Addiction & withdrawal
  • Tolerance
  • Implications of taking morphine
  • Side effects
side effects
Side effects
  • Sedation
  • Hallucinations
  • Nausea & vomiting
  • Constipation
  • Urinary retention
  • Myoclonus
  • Respiratory depression
  • Pruritus
cognitive impairment
Cognitive impairment
  • Some sedation early in use of morphine
  • Tolerance develops
  • Prior sleep deprivation due to poor pain control
  • Other causes of cognitive impairment need to be excluded
routes of administration of morphine
Routes of administration of morphine
  • Oral
  • Subcutaneous
  • IVI
  • Epidural & intrathecal
  • Rectal
  • Topically
morphine metabolism
Morphine metabolism
  • Primarily metabolised in the liver
  • Metabolites excreted in urine
    • Morphine-3-glucuronide (M3G)
    • Morphine-6-glucuronide (M6G)
  • Caution in renal impairment
  • M6G potent morphine agonist
  • M3G no significant analgesic action
  • Liver disease not reported to alter pharmacokinetics
morphine
Pros

“Gold Standard”

Well understood

Readily available

Usually well tolerated

No “ceiling”

Cons

Accumulates in renal failure

Constipating

Nausea

Sedation

Misconceptions

Morphine
oxycodone
Pros

Various dose forms, immeadiate & slow release

Neuropathic pain

“New”

OK in renal failure

Cons

Constipating

Nausea

Confusing names

Oxycodone
fentanyl
Pros

Less constipation

Less nausea

Less psychotomimetic effects

Convenient

OK in renal failure

Cons

Reliant on good fat stores

Inflexible dosing

Difficult to titrate

Expensive

Breakthrough medications

Fentanyl
hydromorphone
Pros

Less sedating

Less constipating

Less hallucinations

Less nauseating

OK in renal failure

Cons

Availability

Hydromorphone
methadone
Pros

Neuropathic pain

Cons

Stigma

Difficult dosing schedule

Variable half-life

Methadone
pethidine
Pethidine
  • 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
ad