Palliative Care in Family Medicine

Palliative Care in Family Medicine

Phd, MD MIRA FLOREA UMF CLUJ-NAPOCA

Phd, MD MIRA FLOREA UMF CLUJ-NAPOCA

What Is Palliative Care?

"The art of doing everything when nothing more

is to be done“

Cicely Saunders, 1970

What Is Palliative Care?

• approach to care which focuses on comfort and quality of

life for those affected by life-limiting/life-threatening illness

• attention to pain control and other symptoms

• maximizing functional status

• supporting emotional, spiritual, and cultural needs

THE IMPORTANCE OF THE ISSUE

• 1. increasing patients with chronic life limiting illnesses (Alzheimer, vascular dementia, stroke, car accident, cerebral trauma, AIDS)

• 2. increasing life expectancy due to advances in medical technology

• 3. limitation of medical resources, limitation of long-term hospitalisation

• 4. insufficient development of Palliative care services and "hospices“

The concept of PALLIATIVE CARE

• Difficult to define versus: Cardiology,

Gastroentero-, Neurology,Pediatrics,

Geriatrics

• Palliative Medicine addresses:

-any group of age with oncological and

nononcological diseases

-in any location -hospital, hospice, at home

What is Palliative Medicine?

• Patient CENTERD CARE with the Goal of maximizing FUNCTIONAL STATUS of those affected by advanced progressive dideases

• It offers comfort and quality of life with a

• Special attention to the PAIN control and other symptoms control

• EMOTIONAL, SPIRITUAL CULTURAL NEEDS are also approached

How To “Raise The Bar” Of ExpectationsOn Such a Fundamentally Sad Issue?

Taking into account the principles of Palliative Care !

Palliative care PRINCIPLES

• Re-Assess and Informs the patient and his family about

-the disease evolution -reasonable possibilities for

influencing symptoms and side effects

chemotherapy/radiotherapy

Palliative care PRINCIPLES

• Supports family coping with the disease progression

• Offers Active and Pro-Active Interventions -anticipating new problems which may occur in evolution-ex. Prevention of scars- skin lesions for dependent patients in bed

• Encourages the patient to express their preferences in relation to the place where he wants to be cared

BENEFICIARIES of PALLIATIVE CARE

CHRONIC PROGRESSIVE life-limiting/life-threatening illness diseases -oncological and non-oncological:neurodegenerative Diseases (Alzheimer, Multiple Sclerosis, Parkinson )

MEDICAL CONDITIONS SUDDENLY FATAL

-Haemoragic Stroke-Acute Cranio-Cerebral Trauma -Post Resuscitation Encephalopathy

PALLIATIVE CARE SERVICE PROVIDERS

• Multiprofesional Team

• Core team: family doctors, neurologists, psychiatrists, nurses

• Contributors: based on interdisciplinary team:kinetotherapist, psychologists, social assistants, priest

• Family members and volunteers must be involved

THE ESSENTIAL COMPONENTS OF PALLIATIVE CARE

1. Pain and other symptoms Management

2. Effective communication with the patient, family and palliative care team

3. Continuity of care

4. Identification of new resources, collaborators, volunteers

5. Special Attention in end of life care

6. Support during the mourning

PAIN• Definition (IASP-International Association for The study

of Pain)-emotional and unpleasant sensory experience associated with tissue injuries

Influences of intensity and modes of perception of pain:• co-existence with other symptoms (dispnoea, coughing,

hiccups, vomiting, diarrhea, insomnia, asthenia) - ↑ perception of PAIN

• existence of psychological problems (anxiety, despair, sadness, apathy, denial, avoiding)- ↑ perception of PAIN

• specific cultural/spiritual needs (specific value system is shunned by his family for the patient, language barrier; questions about life, death, grief and remorse, guilt for past events, decrease of faith, loss of hope)

-↑ perception of PAIN Neglecting the approach of these factors make

difficult to treat pain!!!!!

Rules of Pain Assessment 1. acceptance of the patient’s description2. analysis of the pain’s characteristics

Assessmenta. verbal appreciation – weak/ absent, moderate, sever,

unbearable

b. numerical Rating Scale-the Visual Analog Scale -on a scale from 0 to 10, patient appreciates pain intensity

c. Assessment by FACES DRAWINGS for children or adults who cannot communicate verbally or in writing

Reassessment of pain and evolution of treatment efficiency is important

0-------1-------2-------3------4-------5--------6-----7--------8-------9-------10 I.Weak pain II. Moderate pain III. Severe pain

PAIN TREATMENT• Non-Opioids Analgesics:• Aspirin • Acetaminophen• Selective Non-Steroid Antiinflamatory• Steroids-Dexamethasone• ±Co-Analgesics

• Minor Opioids :• Codeine -30-60 mg• DHC-Dihidrocodeine60-120mg• Tramadol 100-400mg/24 hours

TreatmentMajor Opioids :

• Morphine: Oral -Rapid Action -SEVREDOL 10mg -Slow releasing -MST CONTINUS, -VENDAL 30mg, 60mg, 100-200mg,

300mg/24hours -OXYCODON 20,40,80mg;OXYCONTIN 2 X 40mg

• Fentanyl- Long Acting Patch -72 hours -2,5mg, 5mg, 7,5 mg, 10mg • Hidromorphon• Heroine

Analgesic Treatment

It is led by WHO’scale of analgesia in 3 steps:

Step I – Non-Opioids analgesics +/- Co-Analgesics

Step II- Minor opioids +/-Co-Analgesics if pain is not controlled by Step I Drugs

Step I and Step II Drugs may be combined if the pain is difficult to controle

Step III-Major Opioids with Optimal Dose, achieved by titration (depending on response and occurrence of side effects)

DO NOT combine stage II Drugs with stage III Drugs !!!

Rules for prescribing and administration of opioids

1. Regular administration, after a certain time, depending on the duration of opioid’s action, before the appearance of pain, for the prevention of maximum intensity

2. Opioid's dosage will be the minimum necessary, which relieves the pain (maximum effect with low dosage)

3. The preferably route of administration, is oral and intra-rectal in order not to cause additional pain

4. Progressive increase of the dose, with evening dose increased

5. Never associates two opioids, but one opioids you can assign with non-opioids painkillers, depending on the type of pain

Errors in opioids therapy approach

• Professional Opiofobia

• “morphine-"should be managed only in the Terminal phase“

• "morphine - hurry death “

• "morphine -cause unacceptable side-effects: constipation, respiratory depression, nausea, confusion“

• "fear of tolerance, physical dependence, psychological dependence"

Patient and family Opiofobia

“If morphine is recommended, it means I will die soon”

• “No longer remains anything for pain when will be worsen "

• "I will become addicted"• "I am allergic to morphine” • “Morphine was of no help for

me"

Misconceptions concerning the opioid therapy

1. “ORAL morphine is an ineffective analgetic” American Medical Association have proved that ORAL proper Opioid dosage is effective in 95% of those treated and well tolerated in 85-90% cases

2. Tolerance to morphine ("habit") is installed to the ORAL administration.

• Progressive growth of morphine doses to obtain the same effect (tolerance) do not install quick with Oral administration

Most cases do not require increasing doses of importance in time and this is due to the progression of the disease and no installation of tolerance

Misconceptions concerning the opioid therapy

3. ORAL Administration of Morphine produce respiratory depression

If doses are adjusted to the chronic pulmonary pathology and age, clinical depression is rare

4. Addiction mental illness produced by Morphine is a major problem in the treatment of pain.

There are exaggerated fear towards this topic. In medical practice appears in patients with drug and

alcohol users and rare in cancer patients (4 cases to 11,000 patients treated).

Misconceptions concerning the opioid therapy

5. Strong pain cannot be improved unless with PARENTERAL morphine.

Through regular ORAL administration of morphine, even severe pain can be controlled. Oral administration is convenient and economical.

6. Morphine does not associate with other analgesics• Most patients have comorbidities, so many types of

pain. • Morphine joins• - with NSAIDS in the sufferings of the musculo-skeletal

system • -with GCS and antidepressants in neuropathic pain.

Co-Analgesics• Drugs that do not belong to the analgesics class, but

contributing to the analgesia Triciclic antidepresive• Amitriptilin 25-75 mg• Doxepin 25-300mg• Mianserin- It is less sedative and has few cardiac side effects• Fluoxetin- It is less sedative

Anxiolitics: • Diazepam 20mg, Oxazepam 20mg, Hidroxizin 25-100mg

Anticonvulsant : Lyrica(Pregabalin)2x150mgAnti-Hypertensions Drugs: Clonidina 0,9mg Bis-Phosphonates- osteoclasts’ inhibitors - Pamidronat disodic-IV

Pepper Extract - Capsaicine Patch in neuropathic pain

The new law of opioids Legislation on the use of opioids and

psychotropic substances changed in 2005 after 30 years !!!!!

Thanks to this law, Romania is presented as a positive example of the INCB (International Narcotics Central Board, the body that regulates international narcotics) requesting participation in the ATOME Project (Access to Opioid and veterinary medicines in Europe).

The differences between new and old legislation

• Any physician with authorization for medical practice may prescribe opioids and may modify doses(not only the oncologist)

• Indications for opiates were: cancer and acute peripheral ischemia with gangrene

• Now, any pain unrelieved by non-opiods in appropriate doses is eligible for opioid therapy

• You can specify 3 drugs on 1 recipe; it can be written also drugs for opioids side effects: Metoclopramid and Lactulosis

"Doctors cure sometimes, often relieves and always bring relief“

(anonymous 16th)