Palliative Medicine: the basics

1. Palliative Medicine: the basics Tara Tucker MD FRCPC Lisa Aldridge MD CCFP

3. Objectives • Definition of Palliative Care • The Role of Palliative Medicine • Pain • Constipation • Nausea • Dyspnea • ETHICS

4. Palliative Care "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness." WHO • palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving nausea

5. 1967: Dame Cicely Saunders opens St. Christopher’s Hospice

6. 1995, first stand alone paediatric hospice in N.A., Canuck Place, Vancouver

7. “Dr. Bohen will be out here to talk to you in just a minute – All I can tell you is that your husband’s condition has stabilized!”

8. We will all face death in our lives and in our work. • 10% of us will die suddenly…. but what about the rest?

12. End of Life Care • Most of us in this room will DO and NEED palliative care… • 220 000 Canadians die each year • Process and outcome has tremendous effect on others… “collateral suffering” • Only 5% people receive integrated, multidisciplinary palliative care • Cancer patients (25% deaths) receive 90% palliative care • Pain and symptoms are poorly controlled

13. Medicine’s Shift in Focus Many health care providers feel they have failed if the patient dies… our own fear of death may influence how we approach others

14. To cure sometimes • To relieve often • To comfort always Socrates

15. Where does Palliative Care fit in? Disease-focused care Death Comfort-focused care F/up

16. The Dying Patient:Your Role • Relieve suffering • Provide Comfort and compassion to both the patient and the family

17. Formulate a Plan for the Dying Patient • Pain Control • Maintain human dignity • Avoid isolation of patient • Discuss with patients their wishes or refer to advance directive • Provide emotional and spiritual support

18. Advance Care Planning • Process of making decisions about future medical care with the help of health care providers, family and loved ones • Discuss diagnosis, prognosis, expected course of illness, treatment alternatives, risks, benefits • In context of patients goals, expectations, values, beliefs and fears

19. EOL Decision Making • People need time to reflect on goals, values, beliefs • EOL decision making is a process, not a one time event • Multidisciplinary team to convey info, discuss alternatives, provide emotional and psychological support – avoid mixed messages

20. “What you need, Mr. Terwilliger, is a bit of human caring; a gentle, reassuring touch; a warm smile that shows concern--all of which, I’m afraid, were not a part of my medical training.”

21. Communication • Talk about death – find the words • “Hope for the best, plan for the worst” • Lose the medical jargon • Being, not doing • Compassion/presence and balance • Cultural sensitivity • Collaboration with team members

22. Phrases to Avoid • “It doesn’t look good” • Too vague, be more specific • “Do you want us to do everything?” • “We will not do anything extraordinary, heroic, or aggressive.” • Implies substandard care • There’s nothing more that we can do. • Implies abandonment

23. Language to describe the goals of care… • We want to give the best care possible until the day you die. • We will concentrate on improving the quality of your child’s life. • We want to help you live meaningfully in the time that you have.

24. …language to describe the goals of care • I will focus my efforts on treating your symptoms. • Let’s discuss what we can do to fulfill your wish to stay at home.

25. Withholding or Withdrawing Treatment • What does the pt/family know and understand about life sustaining Rx – ie: risks and benefits • What are the goals of care/ pt’s wishes • Explain how it will be done and what to expect • How will pain/distress be managed • Pertinent religious/cultural issues • Time limited trials for some interventions ie: dialysis

26. “I wish you’d called me sooner, Mrs. Moodie.”

27. When to call on Palliative Medicine Specialist? • Early in the trajectory of life limiting illness – again, find the words to use • When major decisions have to made re: treatment • When symptom management is problematic • …

28. Pain “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage” World Health Organization

29. Pain “a state of distress associated with events that threaten the intactness of a person” Eric J Cassell. The Nature of Suffering and the Goals of Medicine. NEJM 1982; 306: 639-645

30. Pain • Chronic pain serves no physiologic purpose • Under-treated pain may lead to depression and suicide

31. Total Pain Pie physical emotional e.g. arthritis, bowel spasms, headache caused by CVA e.g. depression, anxiety, loss of control social spiritual Loss of role, loss of social contacts - search for meaning Lili/presentations/1999/pie.ppt

32. Causes of Cancer Pain • Direct effects of the disease • Related to disease ie: constipation • Secondary to treatment – 20% • Surgery • Chemotherapy • Radiation

33. Physiological Pain Categories • Nociceptive –localised • Somatic: superficial, deep • Bone mets, cellulitis • Visceral • Infiltration, compression, distension of viscera • Neuropathic – may radiate along dermatome, nerve distribution • TGN, herpes zoster

34. Neuropathic Pain • Sympathetic • Central • Peripheral (non-sympathetic)

35. Neuropathic Pain • Spontaneous pain • Dysesthesia • e.g. burning • Neuralgia • e.g. lancinating, “electric shocks” • Evoked pain • Allodynia • Pain from a non-painful stimulus • Hyperalgesia • Pain more than expected from a mildly painful stimulus • Hyperpathia • Explosive build-up of pain with repetitive stimuli

36. Evaluating Pain • Believe the patient • Initiate discussions • Detailed pain history • Careful physical exam • Investigations • Monitor results of treatment

37. Pain History – the key! • P = provokes and palliates • Q = quality • R = Radiates - location • S = severity • T = time – duration, time of day • O = other ie: red flags • Headache + vomiting

38. Principles of Analgesic Therapy • By the mouth • By the clock • By the ladder • For the individual • Attention to detail

39. The ideal treatment for any pain is to remove the cause.

40. Treating Pain Use a Multidisciplinary approach • Medications • Counselling • Physical Therapy • Nerve block • Surgery

41. WHO Pain Ladder

42. WHO Pain Ladder 3Severe Morphine Hydromorphone Methadone Fentanyl Oxycodone ± Acetaminophen ± NSAIDs ± Adjuvants 2 Moderate Acetaminophen + Codeine Acetaminophen + Oxycodone ± NSAIDs ± Adjuvants 1Mild Acetaminophen NSAIDs ± Adjuvants

43. NSAIDS • Antiinflammatory • Adverse effects • Gastropathy, renal failure, platelet inhibition, cardiac • Risk factors • Age, PUD, cachexia, dehydration, steroids, comorbid conditions

44. Combination medications • Percocet (oxycodone and tylenol) • Tylenol #3 (Codeine and tylenol) • Limited by dose of acetaminophen

45. Opioids:choosing the right drug • Morphine is first line • Morphine metabolites will accumulate in renal failure patients; suggest fentanyl or hydromorphone • Do NOT use meperidine (Demerol) due to metabolites causing adverse effects

46. Opioids – choosing the right drug • Pt’s previous experience with opioids • Compliance • Fears and myths – pt + MD! • Physician comfort + experience

47. Opioids – choosing the right dose • Opioid naïve patient • Morphine 2.5 - 5 – 10 mg po q4h • Hydomorphone 0.5 – 1 mg po q4h • Oxycodone 2.5 - 5 mg po q4h • Percocet • Some references give higher starting doses – CAUTION!

48. Opioids – choosing the right schedule • Immediate Release (IR) • Q4h dosing – straight • Prn q1-2h at 10% of daily dose • Sustained release (the Contins) • Q12h, prn IR 10% daily dose

49. Opioids – adverse events • Common • Constipation is easier to prevent than treat • Softener + laxative • Nausea (tolerance develops) • Maxeran, Haldol • Sedation (tolerance develops) • Dry mouth

50. Opioids - Adverse events • Less common • Urinary retention • Pruritis • Delirium • Myoclonus • Psychotomimetic effects • Postural hypotension • Vertigo