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Two Palliative Care Giants. Dr Jennifer Vidrine ST4 Palliative Medicine. Overview. A broad overview of palliative care in relation to general practice Pain Case 1 BREAK Nausea and Vomiting Case 2 Round Up. Palliative Care. Recognised as distinct entity since 1980s

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two palliative care giants

Two Palliative Care Giants

Dr Jennifer Vidrine

ST4 Palliative Medicine

overview
Overview
  • A broad overview of palliative care in relation to general practice
  • Pain
  • Case 1
  • BREAK
  • Nausea and Vomiting
  • Case 2
  • Round Up
palliative care
Palliative Care
  • Recognised as distinct entity since 1980s
  • First modern hospice opened 1967
  • Based on concept of ‘Holistic’ care
  • Palliative care teams
  • Not just for patients with cancer
slide5

“GPs found looking after palliative care patients satisfactory and varied but burdensome”

  • Found barriers on three levels:
    • Personal
    • Relational
    • Organisational
challenges faced
Challenges faced…
  • Personal
    • Knowledge symptom and symptom control
    • Technical procedures in pts who want to stay at home (ie Catheter)
    • Small numbers of palliative care patients in a year
    • Emotional
    • Time constraints
    • Lack of psychological support in an autonomous worker
slide7

Relational

    • Communication
      • Between pts, carers, other HCPs
    • ‘Territory’ (GP? SPCT? Hospital team?)
slide8

Organisational

    • Bureaucracy
    • Obtaining medications (Controlled drugs, CSCI etc)
    • Need to organise care/social work review etc
they conclude
They conclude
  • Barriers exist
  • It is imperative to support GPs as the frontline of service provision
  • Role of specialist palliative care teams in this (both specialist knowledge and emotional support)
common symptoms
Common Symptoms
  • Pain
  • Nausea and Vomiting
  • Shortness of Breath
  • Anxiety/Psychological Distress
common symptoms1
Common Symptoms
  • Pain
  • Nausea and Vomiting
  • Shortness of Breath
  • Anxiety/Psychological Distress
neuropathic pain
Neuropathic pain
  • Disproportionate to stimulation of the nociceptor
  • Leads to:
    • Hyperalgesia

(exaggerated and prolonged pain response to a mildly painful stimulus)

    • Allodynia

(Pain produced by a stimulus that is not normally painful, such as light touch)

    • Spontaneous pain
  • No protective function
  • Pathological pain
distinguishing the two
Distinguishing the two…
  • History History History
  • Thinking abut possible/likely aetiologies
  • What has the pain responded to thus far?
slide18

Very often in palliative care it is a combination of both

  • Requires combination treatments (Often one won’t cut it)
  • Often requires some lateral thinking
an approach
An approach…
  • Patient specific
  • Tend to start with low dose strong opiate

(egOramorph 2.5-5mg PRN)

  • If possible also give regular paracetamol
  • Ask patient/relative to write down the following:
slide22

Review in a couple of days.

  • Establish if opioid making ANY difference
  • Establish any side effects
  • Calculate what has been taken in last 24 hours (ie 4 doses of 5mg=20mg)
  • Start BD preparation of long acting opiate
  • Explain need to continue with Breakthroughs and ongoing monitoring.
  • Breakthrough is 1/6 total daily opioid dose (except Alfentanil which is 1/10th)
established on morphine but still in pain
Established on Morphine but still in pain?
  • Would an adjunct help?

Steroids (Dexamethasone)

TCA (Amitriptyline)

Anti-epileptics (Gabapentin/Pregabalin)

    • Very often end up on combination
evidence base
Evidence Base
  • Amitriptiline-OD dosing, syrup available.
  • Gabapentin- syrup available, TDS
  • Pregabablin- ?more tolerable, BD, only tablets
  • Valporate- OD, syrup available, RCT conflicting
  • Clonazepam- Concurrent anxiolytic and muscle relaxant properties, SC
other things to consider
Other things to consider
  • NSAIDs
    • If no contra-indications
    • Esp if inflamm element of pain
    • Useful in bone pain
    • Ibuprofen used most frequently
    • Ketorolac useful as can be used subcut (Generally only for short spells/at end of life)
  • Bisphosphonates
particular challenges
Particular Challenges
  • Episodic Pain
  • High anxiety element (Total pain)
  • Non-concordance

Consider referral/involvement SPCT

what might be offered
What might be offered…

Methadone

Ketamine

Spinal Lines (epidural/intrathecal line)

Nerve Blocks

Cordotomy (Division of lateral spinothalamic tracts in the spine)

Involvement of clinical psychology

case 1
Case 1
  • Break up into groups of 3-5
  • Look at the case and start to think about the issues involved for 20 mins
  • Try to approach as holistically as possible
  • Feed back to group.
slide30

Nausea

&

Vomiting

nausea vomiting background
Nausea & Vomiting-Background
  • Extremely common in cancer patients
  • Deeply distressing
  • Vomiting generally tolerated better than nausea

“Last night we went to a Chinese dinner at six and a French dinner at nine, and I can feel the shark’s fins navigating unhappily in the Burgundy”

Peter Flemming, Letter from Yunnanfu, March 1938

reality of the situation
Reality of the situation
  • Often as/more challenging to treat than pain
  • Many patients have multifactorial N&V
  • Absorption of the very stuff we are giving them to make them better
  • May well require more than one anti-emetic
  • Systematic/logical approach….
questions to ask
Questions to ask
  • Nausea/vomiting predominant?
  • Timing?
  • What is vomited? (Consistency, volume, colour)
  • Feel better after vomiting?
  • Associated features?
  • Exacerbating/relieving factors
  • Are there are any probable causes? (eg Constipation)
identify specifically treated causes
Identify specifically treated causes
  • Constipation-Laxatives/PR intervention (Prevention)
  • Gastritis-Would PPI help?
  • Oropharyngeal Candida-Often difficult to treat
  • Hypercalcaemia-IV hydration +/- Bisphosphonate
  • Pain-Optimise analgesia
  • If drug induced how essential is drug?
  • Treat infection
slide35

Think about non-drug measures

  • Select anti-emetic based on most likely cause
  • Basic principals:
    • Give regular antiemetics
    • Need to carefully assess risk of non-absorption and consider alt routes (CSCI) early
    • If you are relatively sure about cause consider maximising dose rather than switching (espMetoclopramide)
two broad avenues
Two ‘broad’ avenues..

1.Gastric-stasis

2.Chemically mediated (central)

1 gastric stasis presentation
1. Gastric Stasis-presentation
  • Early Satiety
  • Large volume vomits
  • Undigested food
  • Relief after vomiting
  • Hiccoughs/belching
  • Exacerbated by eating/medcations
1 gastric stasis causes
1.Gastric stasis-causes
  • Slowed gastric emptying
  • ‘Squashed stomach’ due to Hepatomegally
  • Ascites
  • Subacute obstruction (consider specialist input)
1 gastric stasis management
1.Gastric Stasis-management
  • ProkineticegMetoclopramide
  • Targets peripheral (and central) Dopamine (D2) receptors.
  • Caution in young females
  • CAUTION IN PARKINSON’S DISEASE/SYNDROMES
  • Dose: 10-20mg tds/qds
    • CSCI 30-120mg/24 hours
    • Domperidone (less side effects but limited routes)
  • OBSERVE FOR INTESTINAL COLIC
slide40

GI tract

Obstruction

Gastric stasis

Irritation/

hepatic

Vestibular

Motion sickness

Local tumour

Medication

Central

Anxiety

Pain

Cerebral mets

Raised ICP

Chemical

Medication

Biochemical

Toxins

Dopamine

Seretonin 4

Acetylcholine

Histamine

Metoclopramide

CTZ

Histamine

Dopamine

Seretonin 3

Vomiting Centre

two broad avenues1
Two ‘broad’ avenues..

1.Gastric-stasis

2.Chemically mediated (central)

2 central causes presentation
2.Central Causes-presentation
  • Constant nausea
  • No/little relief after vomiting
  • May be able to identify cause
  • Other signs drug toxicity
central causes
Central-Causes

Drugs:

Opiates

Antidepressants

AEDs

Electrolyte Imbalance

Renal Failure

Hypercalcaemia

Sepsis

Anxiety

Pain

Raised Intracranial Pressure

Ischemic Bowel

2 central causes management
2. Central Causes-Management

Cyclizine

  • Antihistaminic/Anticholinergic antiemetic acting at AChM and H1 receptors
  • Acts centrally to help with vagally mediated nausea.
  • Can give anticholinergic side effects
  • Dose: 25-50mg tds
    • CSCI: 150mg/24 hour
  • Particularly useful if raised intracerebral pressure
slide45

GI tract

Obstruction

Gastric stasis

Irritation/

hepatic

Vestibular

Motion sickness

Local tumour

Medication

Central

Anxiety

Pain

Cerebral mets

Raised ICP

Chemical

Medication

Biochemical

Toxins

Dopamine

Seretonin 4

Acetylcholine

Histamine

CTZ

Histamine

Dopamine

Seretonin 3

Vomiting Centre

Cyclizine

2 central causes management1
2. Central Causes-Management

Haloperidol

  • Useful for chemical induced nausea (inc Drug induced)
  • Centrally acting anti-emetic acting at D2 receptor at the CTZ
  • Contraindications
  • Dose: 1.5mg Nocte (0.5-1.5mg bd)
    • CSCI: 2.5-5mg/24 hours
slide47

Haloperidol

GI tract

Obstruction

Gastric stasis

Irritation/

hepatic

Vestibular

Motion sickness

Local tumour

Medication

Central

Anxiety

Pain

Cerebral mets

Raised ICP

Chemical

Medication

Biochemical

Toxins

Dopamine

Seretonin 4

Acetylcholine

Histamine

CTZ

Histamine

Dopamine

Seretonin 3

Vomiting Centre

if at first you don t succeed
If at first you don’t succeed
  • Remember often multifactorial
  • Consider increasing dose
  • Consider combinations (that target diff receptors)
  • Dex 4mg will often enhance affect anti-emetic (unknown mech)
  • Levomepromazine
slide49

GI tract

Obstruction

Gastric stasis

Irritation/

hepatic

Vestibular

Motion sickness

Local tumour

Medication

Central

Anxiety

Pain

Cerebral mets

Raised ICP

Chemical

Medication

Biochemical

Toxins

Dopamine

Seretonin 4

Acetylcholine

Histamine

CTZ

Histamine

Dopamine

Seretonin 3

Vomiting Centre

Levomepromazine

chemotherapy induced n v
Chemotherapy Induced N&V
  • Ondansetron often used
  • Best to time limit it’s use
  • Headaches
  • Constipation
  • Has a very specific role
  • Consider anticipatory n&v
    • Levomepromazine
    • Lorazapam
case 2
Case 2
  • Break up into groups of 3-5
  • Look at the case and start to think about the issues involved for 20 mins
  • Try to approach as holistically as possible
  • Feed back to group.
in summary
In summary
  • A whistle stop tour of two pretty meaty subjects
  • The importance of a thorough assessment in managing symptoms
  • The importance of a systematic approach in managing them
  • Make use of community SPCT/hospice advice lines if in doubt.
slide54

Watson, M. Lucas, C. Hoy, A. Wells, J (2010) The Oxford Handbook of palliative care. Oxford university press.

Twycross, R. Wilcock, A. Palliative care formulary 4th Edition (2012) Palliativedrugs.com

Groot, M. Vernooij-Dassen, M. Crul, B. Grol, R. (2005) General practitioners (GPs) and palliative care: percieved tasks and barriers in daily practice. J Pall Med. (19)111-118