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Palliative Care For Children. General Overview. Mike Harlos MD, CCFP, FCFP. Professor, Faculty of Medicine, University of Manitoba Medical Director, Winnipeg Regional Health Authority Palliative Care Program Co-Chair, Canadian Network of Palliative Care for Children

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Palliative care for children

Palliative Care For Children

General Overview

Mike Harlos MD, CCFP, FCFP

Professor, Faculty of Medicine, University of Manitoba

Medical Director, Winnipeg Regional Health Authority Palliative Care Program

Co-Chair, Canadian Network of Palliative Care for Children

Physician Consultant, Canadian Virtual Hospice


Objectives

  • To consider the definition of pediatric palliative care

  • To consider where pediatric palliative care may fit in the care of seriously ill children

  • To consider similarities/differences with palliative care for adults

  • To review the prevalence and management of symptoms in children living with life-threatening illness


Prognostic uncertainty
Prognostic Uncertainty

Pediatric Palliative Care services providers must acknowledge the uncertainty involved in determining if a specific circumstance or condition is life-limiting / life-threatening


Common Trajectory Of Decline In Progressive Life-Limiting Illness In Children

From presentation by Joanne Wolfe at the 16th International Congress on the Care of The Terminally Ill

Functional

Status

Decline

Crises

(“Scary Dips”)

Death

Time


Prognostic irrelevance
“Prognostic Irrelevance” Illness In Children

  • In the view of patient, family, and/or care team, there may be unwillingness to even consider the possibility of death

  • Service availability should not only accommodate prognostic uncertainty, but should not require acceptance of a threatened life


“What if…? Illness In Children

Palliative Care… The “What If…?” Tour Guides

  • What would things look like?

  • Time frame?

  • Where care might take place

  • What should the patient/family expect (perhaps demand?) regarding care?

  • How might the palliative care team help patient, family, health care team?

Disease-focused Care

(“Aggressive Care”)


Addressing the what ifs silence is not golden
Addressing The “What-Ifs…” Illness In Children Silence Is Not Golden

  • Children (even young children) are very perceptive, and can tell when something serious is happening

  • Even when pursuing cure for their child, parents are often aware in their “heart of hearts” that things may not unfold as hoped for

  • Palliative Care has a role in:

    • helping families navigate through difficult decisions, at times conflicted about which course is best for their child… “path of least regret”

    • ensuring that comfort and quality of life are minimally affected by the impact of illness, tests, and treatments

    • facilitating communication about fears and worries, and open dialogue about what to expect


n = 147 Illness In Children

(34 %)

n = 282

(66 %)

Yes

No

Do you regret not having done so?

Do you regret having done so?

No parents regretted having talked with their children about dying

Yes

No

Identify and facilitate communication

Talking about Death with Children … ctd

Kreicbergs et al NEJM 2004; 351(12):1175-1186.

Did you talk about death with your child at any time?

Overall:

27%

73%

Sensed Child Aware Of Dying:

47%

53%

Did Not Sense Child Aware:

87%

13%



The Measurement Of Symptoms In Children With Cancer Illness In Children Collins JJ, Byrnes ME, Dunkel IJ, Lapin J, Nadel T, Thaler HT et al. J Pain Symptom Manage 2000; 19(5):363-377.

  • n = 160 cancer patients receiving treatment

  • aged 10 – 18 yo

  • 30-item patient-rated instrument (MSAS 10-18)

  • Inpatients averaged 13 symptoms, outpatients 6.5

  • Patients who had recently received chemotherapy had more than double the symptoms of those who had not


Symptoms at the end of life in children with cancer
Symptoms At The End of Life in Children With Cancer Illness In Children

Wolfe J. et al, NEJM 2000; 342(5) p 326-333

80

70

%

60

50

40

30

20

Successfully

Treated

(% Of Affected

Children)

10

27 %

16 %

10 %

Nausea And Vomiting

Dyspnea

Pain


Pain In Advanced Childhood Illness Illness In Children

Symptom Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncol Nurses Forum SurveyGoldman A et al; Pediatrics 2006; 117; 1179-1186

Abstract from the 7th International Symposium on Pediatric Pain

Stenekes S, Hughes A, Grégoire MC, Frager G 2006

Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Adolesc Med 2003; 157(12):1219-1226.

Engel JM, Jensen MP, Hoffman AJ, Kartin D. Pain in persons with cerebral palsy: extension and cross validation Arch Phys Med Rehabil 2003; 84(8):1125-1128.


Symptoms in Children with Neurodegenerative Illness Illness In Children

%

Hunt and Burne, 1995


2002 college of physicians and surgeons of manitoba child health standards committee report
2002 College Of Physicians And Surgeons Of Manitoba Child Health Standards Committee Report

2002 Manitoba Deaths

Unlikely role for Palliative Care in symptom management, though potentially in family and staff support

Potential role for Palliative Care in symptom management as well as family and staff support


Palliative in parallel
“Palliative in Parallel” Health Standards Committee Report

  • Palliative care for children should not be exclusive of ongoing cure-focused care

  • Can be involved as a parallel process, with a variable profile depending on goals of care and clinical circumstances

  • It is not unusual for children/families/clinicians to harbour seemingly conflicting thoughts and contradictory goals

  • There are some situations where one could argue that the standard of care should require involvement of a palliative service… eg:

    • Phase One Clinical trials

    • Organ Transplant waiting lists


Various Patterns Of Pediatric Palliative Care Involvement Health Standards Committee Report

Cure-Oriented; Disease-Focused

Palliative


Group 1 Health Standards Committee Report

Group 2

Children with progressive life-limiting/life-threatening conditions who are not expected to survive into adulthood, but whose prognosis is anticipated to exceed one year

Advanced life-limiting condition from which death within 12 months would not be unexpected

Group 1A

Comfort-focused approach has been chosen, or disease-focused interventions not possible

Group 1B

Advanced life-limiting illness with substantial disease and symptom burden for whom cure is nonetheless hoped for, or for whom all aggressive disease-focused and potentially life-sustaining options are being pursued

Patient Groups For Pediatric Palliative Care Services


Pediatricians sense of preparedness for practice
Pediatricians’ Sense Of Preparedness For Practice Health Standards Committee Report

Lieberman L, Hilliard LI; Medical Education 2006; 40: 539–546

n = 239 pediatricians certified in Canadian training programs between1999 and 2003


Keeping the momentum recent developments
Keeping The Momentum – Recent Developments Health Standards Committee Report

  • 2003: Canadian Network of Palliative Care for Children (CNPCC)- see http://cnpcc.ca

  • March 2006- Pediatric Hospice Palliative Care Guiding Principles And Norms Of Practice, through joint work by the CNPCC and CHPCA

  • 2006: 1st major clinical textbook in pediatric palliative care, The Oxford Textbook of Palliative Care for Children.

  • 2006: The Canadian Council on Health Services Accreditation (CCHSA) released in its standards for Hospice and End-of-Life Care

  • The Royal College of Physicians and Surgeons of Canada is exploring core competencies in Pediatric Palliative Care

  • There is increasing interest is there amongst physicians training in Pediatrics


Pain assessment in children
Pain Assessment In Children Health Standards Committee Report

  • Pain can be measured by:

    • self-report (what children say) – “Gold Standard”

    • biological markers (how their bodies react)

    • behaviour (what children do)

  • Biological and behavioural measures tend to habituate over time; parameters may not be specific to pain.

  • May deny pain if the questioner is a stranger, if they believe they are supposed to be brave, if they are fearful, or if they anticipate receiving an injection for pain.

  • Much variability in developmental capacity for children to report and describe pain

  • Questioning should be patient & use words familiar to the child, eg.

    • "Do you have any hurt?"

    • "Is there an ‘owie’ or ‘boo-boo’ in your tummy?"


Pain assessment self reporting and developmental stage
Pain Assessment Health Standards Committee ReportSelf-Reporting and Developmental Stage

  • Children have words for pain by about 18 months if age; may prefer the word hurt rather than pain; may use idiosyncratic, family words

  • Most children > 2 yrs can report presence & location of pain

  • 3 – 4 yrs: cognitive skills to describe pain intensity (eg. “a little”, “a lot”)

  • 4-5 yrs: can use the Poker Chip scale

  • Can test ability to use pain-rating tools with simple test of seriation

  • By about 5 yrs – capacity to provide good qualitative and quantitative information


Pain assessment self reporting and developmental stage ctd
Pain Assessment Health Standards Committee ReportSelf-Reporting and Developmental Stage ctd…

  • 5+ yrs can usually rate and score pain; the Bieri Faces Pain Scale may be used

    • Children point to a face on the scale that matches how they feel.

    • The child should be trained by asking how he or she would feel following some minor pain. The child is asked about how much a more serious pain would hurt.

  • 7+ yrs: children can rate pain on a 0 (no pain) – 10 (worst possible pain) scale

  • 8+ yrs are able to describe the quality of the pain experience

  • Describing how pain affects emotions requires more abstract concepts

  • Adolescents are quite capable of using scales that use adjectives to describe both affect and sensory intensity


Faces Pain Scale – Revised Health Standards Committee Report

Children Beginning At 3-4 yo

  • Avoid affective descriptors (eg. “Point to the face that shows how you are feeling”)

  • May be misinterpreted as “are you happy/sad?”


General Principles For The Prevention And Management Of Pain In Newborns

  • Pain often unrecognized and undertreated. Neonates do feel pain, and analgesia should be prescribed when indicated during their medical care.

  • If something hurts adults, it will hurt newborns, even if they are preterm.

  • Compared with older age groups, newborns may experience a greater sensitivity to pain and are more susceptible to the long-term effects of painful stimulation.

  • Adequate treatment of pain may be associated with ↓complications and ↓ mortality.

  • The appropriate use of environmental, behavioral, and pharmacological interventions can prevent, reduce, or eliminate neonatal pain in many clinical situations.

  • Sedation does not provide pain relief and may mask the neonate's response to pain.

  • Health care professionals have the responsibility for assessment, prevention, and management of pain in neonates.

  • Clinical units providing health care to newborns should develop written guidelines and protocols for the management of neonatal pain.

Anand KJ. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001; 155(2):173-180.


Approach to analgesia use in pediatric palliative care
Approach To Analgesia Use In Pediatric Palliative Care In Newborns

  • The oral (enteral) route preferred for most children, most of the time

  • However… many alternate routes available if needed:

    • IV (peripheral and central)

    • Subcutaneous

    • Transmucosal (nasal, buccal, sublingual)

    • Transdermal / transcutaneous

    • Spinal (epidural, intrathecal)

    • Rectal (usually not well tolerated)

  • Use adjuvants as appropriate

  • The W.H.O. ladder is a good template on which to base analgesic use

  • Virtually always prescribe laxatives with opioid Rx


Weak opioids used in pediatric palliative care
Weak Opioids Used In Pediatric Palliative Care In Newborns

  • Codeine remains the most commonly prescribed weak opioid, however there are considerations:

    • Codeine is a pro-drug of morphine, from which its analgesic effect is derived

    • Up to 10% of the Caucasian population lack the enzyme necessary for transformation of codeine to morphine; perhaps up to 47% of those < 12 yrs old

    • If 1 mg/kg codeine ineffective, switch to morphine or alternative

  • Oxycodone:

    • has some κ receptor agonist activity as well as μ

    • No ceiling dose – can potentially be continued throughout course of illness


STRONG OPIOIDS In Newborns

  • Children > 3 months are probably at no greater risk of signif. resp depression than adults; younger infants may have ↑ risk due to metabolic immaturity affecting pharmacokinetics

  • Morphine elimination t ½ (h):

    • Preterm infants: 9 – 10

    • Term Infants: 7

    • Children: 3 – 4(Saaranmaa E, Huttunen P, Leppaluoto J, Meretoja O, Fellman V. Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial. J Pediatrics 134[2], 144-150. 1999)


STRONG OPIOIDS In Newbornsctd

  • most commonly use:

    • morphine

    • hydromorphone (Dilaudid ®)

    • fentanyl (IV infusions)

    • oxycodone

    • methadone

  • DO NOT use meperidine (Demerol®) long-term

    • active metabolite normeperidine→ seizures


Using Opioids for Breakthrough Pain In Newborns

  • Patient/Family must feel in control, empowered

  • Use aggressive dose and interval

  • There should be confidence in the effectiveness of the breakthrough dose; empirically and reliably effective

  • Patient Taking Short-Acting Enteral Opioids:

    • 50 - 100% of the q4h dose given q1h prn

  • Patient Taking Long-Acting Enteral Opioids:

    • 10 - 20% of total daily dose given q1h prn using short-acting opioid preparation

  • Patient On Continuous Parenteral Infusion (non-PCA):

    • 1 – 2 hrs worth of opioid, given q15 minutes prn


PCA Opioids In Newborns

Ref: Pain In Infants, Children, And Adolescents 2nd Ed, 2003; Schechter, Berde, and Yaster Editors

  • Allows patients to self administer small amounts of opioids when needed

  • Usually IV or SQ

  • Most commonly morphine or hydromorphone

  • May have a continuous background opioid infusion in addition to PCA boluses

  • A child able to play a video game can also operate a PCA pump (5 – 6 yo)

  • Varying policies on whether nurse or parent are allowed to initiate a bolus – doing so will lose the inherent safety of being too drowsy to self-overdose


Recommended Opioid Analgesic Doses (> 6 Months Age)* In Newborns

* For infants < 6 months start with ¼ of the pediatric starting dose and titrate


Opioid side effects
Opioid Side Effects In Newborns

  • Constipation – need proactive laxative use

  • Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol)

  • Urinary retention

  • Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success

  • Dry mouth

  • Respiratory depression – uncommon when titrated in response to symptom

  • Drug interactions

  • Neurotoxicity (OIN):delirium, myoclonus ® seizures


Opioid induced pruritus
Opioid-Induced Pruritus In Newborns

  • Not rare; up to 23% in children > 12 yo in one study of long-acting morphine (Zernickow B, Lindena G; Medical and Pediatric Oncology 36:451±458 (2001))

  • Pathophysiology unclear

    • opioid m receptors are relevant to the modulation of pain and itch in the central nervous system.

    • Opioid peptides may also have a peripheral action potentiating itch due to other agents

  • Consider switching opioids; may have less pruritus with fentanyl, methadone, oxycodone

  • Try antihistamines (diphenhydramine, Atarax, trimeprazine)

  • Naloxone 1 – 2 micrograms/kg/hour as an infusion


Adjuvants used in palliative care
Adjuvants Used In Palliative Care In Newborns

  • General / Non-specific

    • corticosteroids

  • Bone Pain

    • NSAIDs

    • bisphosphonates

    • (calcitonin)

  • Neuropathic Pain

    • gabapentin

    • antidepressants

    • ketamine

    • topiramate

    • clonidine

    • cannabinoids (not yet commonly used for pain)


Gabapentin for neuropathic pain
Gabapentin For Neuropathic Pain In Newborns

  • Common Starting Regimen:

    • 5 mg/kg hs days 1-3, then

    • 5 mg/kg bid days 4-6, then

    • 5 mg/kg tid and slowly titrate up

    • Usual effective range: 8 – 35 mg/kg/day

  • Sedation is usual limiting factor.

  • Doses may need to be rounded of due to the capsule strengths


Reasonable to start with recommended mg/kg In Newborns

for IV dosing and adjust empirically

Intranasal Meds

* Available to the cerebral cortex 2 – 5 min. after nasal use5

  • P. D.Knoester ; Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers; Br J Clin Pharmacol. 2002 May;53(5):501-7

  • Rey E. et al; Pharmacokinetics of midazolam in children: comparative study of intranasal and intravenous administration; Eur J Clin Pharmacol 41(4) 1991; 355-357

  • Dale O, Hjortkjaer R, Kharasch ED; Nasal administration of opioids for pain management in adults; Acta Anaesthesiol Scand. 2002 Aug;46(7):759-70

  • Coda BA, Rudy AC, Archer SM, Wermeling DP; Pharmacokinetics and bioavailability of single-dose intranasal hydromorphone hydrochloride in healthy volunteers; Anesth Analg. 2003 Jul;97(1):117-23

  • Fisgin T et al; Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study; J Child Neurol. 2002 Feb;17(2):123-6



Management of
Management Of: In Newborns

  • Nausea And Vomiting

  • Dyspnea

  • Secretions

In Pediatric Palliative Care


Cortex In Newborns

CTZ

GI

VOMITING

CENTRE

Vestibular


Managing Nausea & Vomiting in Palliative Care In Newborns

Some Differences in Children vs. Adults

  • Assessment, communication challenges

  • Higher risk of extrapyramidal reactions, akathisia, and somnolence with dopamine antagonists in children than adults

    • Metoclopramide (Maxeran®)

    • Prochlorperazine (Stemetil®)

    • Haloperidol (Haldol®)

    • Chlorpromazine

  • If using dopamine antagonists, consider slow administration (45-60 min.), as well as concomitant use of diphenhydramine (Benadryl®) 0.5 – 1 mg/kg q4-6h po/IV continued for additional 24hrs after dopamine antagonist stopped.


D In Newborns

D

D

5HT

5HT

5HT

5HT

2

2

2

M

M

M

VOMITING

CENTRE

H1

H1

CB1

H1

Effector

Organs

H1

CB1

Muscarinic

Cannabinoid

Dopamine

Serotonin

Histamine


Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice

From:

Arch. Dis. Child.2004;89;877-880

E S Antonarakis and R D W Hain


Antinauseants / Antiemetics drug management in theory and in practice

1 Komada Y et al. A randomised dose-comparison trial of granisetron in preventing emesis in children with leukaemia receiving emetogenic chemotherapy. Eur J Cancer 1999; 35(7):1095-1101.

2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack


Palliative management of secretions
Palliative Management of Secretions drug management in theory and in practice


Secretions - Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum SurveyGoldman A et al; Pediatrics 2006; 117; 1179-1186


Managing secretions in palliative patients

Suctioning Life

Increased

Secretions

Mucosal

Trauma

Managing Secretions in Palliative Patients

  • Factors influencing approach management:

    • Oral secretions vs. lower respiratory

    • Level of alertness and expectations thereof

    • Proximity of expected death

  • “Death Rattle” – up to 50% in final hours of life

  • At times the issue is more one of creating an environment less upsetting to visiting family/friends

  • Suctioning: “If you can see it, you can suction it”


Atropine eye drops for palliative management of secretions
Atropine Eye Drops LifeFor Palliative Management Of Secretions

  • Atropine 1% ophthalmic preparation

  • Local oral effect for excessive salivation/drooling

  • Dose is usually 1 – 2 drops SL or buccal q6h prn

  • There may be systemic absorption… watch for tachycardia, flushing


Glycopyrrolate for palliative management of secretions
Glycopyrrolate LifeFor Palliative Management Of Secretions

  • Less sedating than scopolamine (doesn’t cross the blood-brain barrier), longer acting, however not as effective

  • Useful where patient is still alert; scopolamine will cause sedation and delirium in awake patients

Enteral: 40 – 100 micrograms/kg 3 – 4 times daily

  • 2006 British National Formulary For Children

  • IWK Health Centre (Halifax) Formulary

Refs:

Parenteral: 4 – 10 micrograms/kg 3 – 4 times daily (10x the enteral dose)

Ref:

IWK Health Centre (Halifax) Formulary


Scopolamine for palliative management of secretions
Scopolamine LifeFor Palliative Management Of Secretions

Ref: 2006 British National Formulary For Children

Intermittent SQ/IV: 10 micrograms/kg (max. 600 micrograms) q 4h

Continuous SQ/IV: 40-60 microgram/kg/day (1.67 – 2.5 microgram/kg/h)

Ref:

2006 Rainbow Hospice Guidelines


Dyspnea in pediatric palliative care
Dyspnea LifeInPediatric Palliative Care


DYSPNEA Life

  • An uncomfortable awareness of breathing

  • Not the same as tachypnea, which is a fast rate of breathing

  • “...the most common severe symptom in the last days of life” (Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 – 98)

  • Increasing incidence as death nears (approx. 80 %); pneumonia at the end of life


TREAT THE CAUSE OF DYSPNEA - Life

IF POSSIBLE AND APPROPRIATE

  • Anti-tumor: chemo/radTx, hormone, laser

  • Infection

  • Anemia

  • CHF

  • SVCO

  • Pleural effusion

  • Pulmonary embolism

  • Airway obstruction


Opioids in dyspnea
Opioids in Dyspnea Life

  • Uncertain mechanism

  • Comfort achieved before resp compromise; rate often unchanged

  • Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration

  • Dosage should be titrated empirically; may easily reach doses commonly seen in adults

  • May need rapid dose escalation in order to keep up with rapidly progressing distress


Recommended Opioid And Sedative Doses For Dyspnea (> 6 Months Age)*

* For infants < 6 months start with ¼ of the pediatric starting dose and titrate


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