Principles of palliative care
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Principles of Palliative Care. Dr. Tony O’Brien Marymount Hospice & Cork University Hospital Wednesday March 9 th , 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.

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Principles of palliative care

Principles of Palliative Care

Dr. Tony O’Brien

Marymount Hospice &

Cork University Hospital

Wednesday March 9th, 2010


Medicine is about people

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

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


Principles of palliative care

Birth

Death

PAST

FUTURE


Principles of palliative care

Birth

Death

PAST


Palliative care

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 care1

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 care2

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


Principles of palliative care

My world

Living

Hospice

Dying


Principles of palliative care

Living

Dying


Principles of palliative care

Dame Cicely Saunders

1918 - 2005


Principles of palliative care

‘There is nothing

more to be done’

Disease Modifying

Treatments

End

Of

Life

Care

Time


Principles of palliative care

Disease modifying

Symptomatic

Palliative Care / Bereavement

Time


Principles of palliative care

Pain

  • Pain is an unpleasant sensory and EMOTIONAL experience……

  • Pain is always subjective

  • Pain is what the patient says hurts

  • Pain is what the patient says it is


Pain types

Pain Types

Nociceptive

Mixed

Neuropathic

Somatic Visceral

Peripheral

Central


Nociceptive pain

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

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

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

Measurement

Visual Analogue Scale

No Pain

Worst Pain

Numerical Rating Score

0 1 2 3 4 5 6 7 8 9 10

Verbal Descriptor Scale

None Mild Moderate Severe Excruciating


Assessment

Site

Radiation

Duration

Progression

Severity

Frequency

Significance

Effect on mood

Quality

Precipitating Factors

Aggravating Factors

Relieving Factors

Effect on activity

Effect on sleep

Assessment


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

Treatment History


Palliative interventions

Palliative Interventions

  • Surgery

  • Radiology

  • Chemotherapy / Systemic therapy

  • Radiotherapy

  • Anaesthesia

  • Psychiatric / psychological


Surgery

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

Interventional Radiology

  • Gastrointestinal stents

  • Biliary stents

  • Renal stents

  • Paracentesis

  • Pleural drain

  • Gastrostomy tube

  • Vascular stents / Filters


Systemic therapy

Systemic therapy

  • Pain & symptom relief

  • Functional Improvement

  • ? Life Prolonging

  • ? Life enhancing - Balance


Radiation therapy

Radiation Therapy

  • Metastatic bone disease

  • SVC obstruction

  • Spinal Cord compression

  • Brain metastases

  • Bleeding

  • Ulcerating / fungating tumours

  • Tumour shrinkage


Anaesthesia

Anaesthesia

  • Nerve blocks

  • Plexus blocks

  • Epidural medication

  • Intrathecal medication


Pain distress

Pain Distress

  • Severity (Visual Analogue Scale / Verbal rating score)

  • Previous pain experience

  • Mood (Pain tolerance threshold)

  • SIGNIFICANCE


Pain control essentials

Pain Control - Essentials

  • Believe, do not doubt!

  • Detailed assessment of EACH pain

  • Understand common pain types

  • Understand treatment modalities

  • Total pain concept


Total pain

Total Pain

Physical

Emotional

Spiritual

Pain

Social


W h o analgesic ladder

W.H.O. Analgesic Ladder

Strong Opioids

Weak Opioids

+/-Adjuvants

+/- Adjuvants

Non-Opioids


Adjuvant drugs

Adjuvant Drugs

  • Non-steroidal anti-inflammatory drugs

  • Corticosteroids

  • Anti-convulsants

  • Anti-depressants

  • Anti-spasmodics

  • Anxiolytics

  • Local anaesthetic agents

  • NMDA receptor antagonists


Strong opioids

Strong Opioids

Oxycodone

Hydromorphone

Fentanyl

MORPHINE

Diamorphine

Methadone

Buprenorphine


Analgesic drugs

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

Dose – limiting toxicity

  • Central nervous system*

  • Gastrointestinal system*

  • Endocrine system

  • Immune system

  • Others

* hypercalcaemia


Opioid induced cns toxicity

Opioid induced CNS toxicity

  • Sleepiness, drowsiness

  • Confusion

  • Visual hallucinations

  • Myoclonus

  • Pruritus

  • Distorted sound of voice


Constipation

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

Constipation associated features


Opioid induced bowel dysfunction

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 / 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 pain1

Total Pain

Physical

Emotional

Spiritual

Pain

Social


Uncontrolled pain

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

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

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

Family tree

7


Spiritual anguish

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


Principles of palliative care

Birth

Death

PAST


Expressions of spiritual pain

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

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!!!


Principles of palliative care

Pain

SUFFERING


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