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Principles of Palliative Care
Dr. Tony O’Brien
Marymount Hospice &
Cork University Hospital
Wednesday March 9th, 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.
No two people ever share the same illness.
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
PASTPAST FUTURFUTUREE
BirthBirth DeatDeathh
PASTPAST
BirthBirth DeatDeathh
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 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 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
Living
Dying
My world
Hospice
DyingDying
LivingLiving
Dame Cicely Saunders
1918 - 2005
Disease ModifyingDisease Modifying TreatmentsTreatments
EndEndOf Of
Life Life CareCare
‘‘There is nothing There is nothing more to be done’more to be done’
TimeTime
Disease modifying
Symptomatic
Palliative Care / Bereavement
TimeTime
Pain
Pain is an unpleasant sensory and Pain is an unpleasant sensory and EMOTIONAL experience……EMOTIONAL experience……
Pain is always subjectivePain is always subjective Pain is what the patient says hurtsPain is what the patient says hurts Pain is what the patient says it isPain is what the patient says it is
Pain Types
Nociceptive Neuropathic
Peripheral CentralSomatic Visceral
Mixed
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
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
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
No PainNo Pain Worst PainWorst Pain
Visual Analogue ScaleVisual Analogue Scale
0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10
Numerical Rating ScoreNumerical Rating Score
None Mild Moderate Severe ExcruciatingNone Mild Moderate Severe Excruciating
Verbal Descriptor ScaleVerbal Descriptor Scale
Assessment Site Radiation Duration Progression Severity Frequency Significance Effect on mood
Quality Precipitating Factors Aggravating Factors Relieving Factors Effect on activity Effect on sleep
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
Palliative Interventions
SurgerySurgery Radiology Chemotherapy / Systemic therapy Radiotherapy Anaesthesia Psychiatric / psychological
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
Gastrointestinal stents Biliary stents Renal stents Paracentesis Pleural drain Gastrostomy tube Vascular stents / Filters
Systemic therapy
Pain & symptom relief Functional Improvement ? Life Prolonging ? Life enhancing - Balance
Radiation Therapy
Metastatic bone disease SVC obstruction Spinal Cord compression Brain metastases Bleeding Ulcerating / fungating tumours Tumour shrinkage
Anaesthesia
Nerve blocks Plexus blocks Epidural medication Intrathecal medication
Pain Distress
Severity (Visual Analogue Scale / Verbal rating score)
Previous pain experience Mood (Pain tolerance threshold) SIGNIFICANCE
Pain Control - Essentials
Believe, do not doubt! Detailed assessment of EACH pain Understand common pain types Understand treatment modalities Total pain concept
Total Pain
PainPain
PhysicalPhysical
EmotionalEmotional
SocialSocial
SpiritualSpiritual
W.H.O. Analgesic Ladder
Non-OpioidsNon-Opioids
Weak Weak OpioidsOpioids
Strong Strong OpioidsOpioids
+/- +/- AdjuvantsAdjuvants
+/-+/-AdjuvantsAdjuvants
Adjuvant Drugs
Non-steroidal anti-inflammatory drugs Corticosteroids Anti-convulsants Anti-depressants Anti-spasmodics Anxiolytics Local anaesthetic agents NMDA receptor antagonists
Strong Opioids
MORPHINEMORPHINE
OxycodoneOxycodone
BuprenorphineBuprenorphine
FentanylFentanyl
DiamorphineDiamorphine MethadoneMethadone
HydromorphoneHydromorphone
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
Central nervous system* Gastrointestinal system* Endocrine system Immune system Others
* hypercalcaemia
Opioid induced CNS toxicity
Sleepiness, drowsiness Confusion Visual hallucinations Myoclonus Pruritus Distorted sound of voice
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
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 mediated by action of opioid on GUT mu receptors
Selective blockade of peripheral receptors Maintain centrally mediated analgesia Avoid risk of opioid withdrawal
Total Pain
PainPain
PhysicalPhysical
EmotionalEmotional
SocialSocial
SpiritualSpiritual
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
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
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
7
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
PASTPAST
BirthBirth DeatDeathh
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
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!!!
SUFFERINGSUFFERING
PainPain