Srivieng Pairojkul, MD.Karunruk Palliative Care Center

Srinagarind HospitalFaculty of Medicine, Khon Kaen University

• Is this an expected/unexpected manifestation of the disease?

• Is this an exacerbation of an intercurrent problem?

• Is this a new intercurrent problem?

• Can we do something about the problem?

• Whether the problem is likely to be reversible?

• What is the person’s wishes under these circumstance?

• Clinical benefit?

• Benefit VS. burden?

• Reversible condition?

• How to get the patients back to best condition as possible?

• Time frame of recover VS. survival

• “Whole person approach”

• Prevent and manage suffering symptoms

• Provides “specific disease modifying treatment”

• CMT, hormonal treatment, RT, restorative treatments

• PC medications different from standard setting

Antipsychotic drug – haloperidol ใช้ใน N/V

Antidepressants รักษา neuropathic pain

Opioids รักษา dyspnea

• “Off-license” prescribing

• Administration of medications at home

• When the patients could not swallow drugs

Subcutaneous route: MO, fentanyl, midazolam, hadol, metoclopramide,

buscopan, atropine

Sublingual route: lorazepam, fentanyl, ketamine, midazolam

Rectal suppository: MO, lorazepam, DZP

• Simple regimen

• Minimized number of medications

• Long-acting form to reduce numbers of tablet

• Use medication with multiple actions:

eg. Haloperidol - anti-emetic & mild sedative

• Review, review, and review

• Provide written instruction to the patient

• Metabolism: pharmacokinetics & dynamic of

drugs are unpredictable at EOL; polypharmacy

• Pathophysiology of death: systematic changes

rather than single organ failure.

• Prognostication.

• Measure of benefit NNTTertiary prevention of disease are likely to be

continued.

• Psychological concerns.

Stevenson J, et al. BMJ 2008;329:909-12.

Prevention Strategy

Tertiary

(Disease with

Symptoms)

Secondary

(Disease with

No symptoms)

Primary

(No disease)

Inflammatory

arthritis

DM Phenylketonuria

Pulmonary

Rehabilitation in

COPD

Hypertension Influenza

vaccination

Osteoporosis Hyperlipidemia Some aspirin use

To elderly people

Treatment likely to be changed later Treatment to be changed earlier

• Symptom never caused by physical or

psychological only

• Relationship between physical and

psychological is the principle of PC

• Goal of symptom management is the best

possible QoL

• Communication is the key

74%

70%

70%

67%

46%

47%

28%

25%

Pain

Dyspnea

Constipation

Oral symp.

Cough

Insomnia

Delirium

N/V

Pain Dyspnea Constipation Oral symp. Cough Insomnia Delirium N/V

Karunruk Palliative Care Center 2012

• Tissue inju ries• Easy to

localize•R esponse to opioids

•Difficult to localize• Liver capsule d istension

D

C

B

A

Fracture from bone metastasis

Pressure sore

Constipation colic

Inflammation from IV site

• By the clock

• By the mouth

• By the patient

• Background pain – continuous pain Use WHO 3-step ladder guideline Continue around the clock

• Episodic pain:

-E nd-of-dose failure – pain occurs before next scheduled dose Increase dosage

- Breakthrough pain – sudden, intense, spikes of pain immediate released opioid

- Incident pain – pain which is predictable, associated with activities eg. bone metastasis, wound dressing

prevent with rapid short acting analgesic.

Pain

Pain persists

or increases

Pain persists

or increases

Freedom from pain

Non-opioids for

mild - mod pain

± Adjuvant

Weak opioids for mild - mod pain± Non-opioid± Adjuvant

Strong opioids for mod–severe pain ± Non-opioid± Adjuvant

• Non-o pio ids: - Acetaminophen- NSAIDS

• Week opio ids: - Codeine- Tramadol

• Strong opio ids:- M orphine- Fentanyl- M ethadone

• Adjuvants: - An ticonvulsants- An tidepressants- Corticosteroids

Low doses o f s tep III opioid m ay be used instead o f codiene or tramadol.

Acetaminophen500-1000 mg. q4-6H. (not more than 6-8 gm/D)Acute over dose (150 mg/kg) hepatic necrosis

NSAIDs – anti-inflammatory action Effective in bone pain, liver pain, inflammatory pain SE : G I irritation, Plt dysfunction, avoid in RF, CHF

Drug Do sage Duration of Action (H)

Ibuprofen 400 m g bid, qid 4-6

Diclofenac 50 m g bid, tid 8

Celecoxib 100-200 m g od, bid 12

Acetaminophen + NSAID additive effect

• Codeine: Derivative of morphinePotency 1/10 of MO, dosage: 30–60 mg q4h.

• Tramadol: weak μ agonistSerotonin & NE reuptake inhibitorSome anti-neuropathic effect

Potency 1/20 – 1/5 of MO

Adverse effect: N/V, constipationLess respiratory depression

Minimal use in cancer pain management

Dosage: 50-100 mg q 6-8H, max 400 mg/D

• Morphine: Full μ agonistStandard opioid which others are compared

Metabolized by hepatic conjugation

– MO-3-glucuronide neurotoxic symptoms

– MO-6-glucuronide analgesic activity• Methadone

• Pethidine X

• Fentanyl: μ agonistPotency 100 X of morphine Injection - rapid onset, short duration of action

Approxim ate dose conversion ratio; PO to POConversion Ratio Calculation Example

Codeine to MO 10:1 Divide 24h codeine dose by 10 Codeine 240mg/24h PO

morphine 24mg/24h PO

Tramadol to MO 5:1 Divide 24h tramadol dose by 5 Tramadol 400mg/24h PO

Morphine 80 mg/24h PO

MO to methadone Discuss with palliative medicine consultant

Approximate dose conversion ratio; PO to SC/IV

MO to MO 3:1 Divide 24h morphine dose by 3 Morphine 30mg/24h PO

morphine 10 mg/24h SC/IV

morphine 0.4mg/h SC/IV

Methadone to

methadone

2:1 Divide 24h methadone dose by 2 Methadone 30mg/24h PO

methadone 15 mg/24h SC/IV

MO to fentanyl Use same calculation as for transdermal patch

Approximate dose conversion ratio; PO to TD

MO to fentanyl 100:1 Multiply 24h morphine PO dose in

mg by 10 to obtain 24h fentanyl

dose; divide answer by 24 to

obtain mcg/hr patch strength

Morphine 120 mg/24h PO

Fentanyl 1,200 mcg/24h;

1,200/24= 50 mcg patch q

72h.

oral morphine iv/sc hourly infusions td patchmorphine normal morphine tab morphine fentanyl fentanyl

release minture sustained release infusion infusion patch

(MST)

mg mg mg/hr mcg/hr mcg/hr

4hrly 12 hrly continuous continuous every 72 hrs

2.5 10 0.2 4 - 6

5 10 or 20 0.4 8 - 12 12

10 30 0.8 17 - 25 25

15 40 or 50 1.2 25 - 37 37

20 60 1.6 33 - 50 50

25 70 or 80 2.1 42 - 62 62

30 90 2.5 50 - 75 75

35 100 2.9 58 - 87 87

40 120 3.3 67 - 100 100

50 150 4.1 83 - 125 125

60 180 5 100 - 150 150

80 240 6.7 133 - 200 200

90 270 7.5 150 - 225 225

100 300 8.3 167 - 250 250

120 360 10 200 - 300 300

140 420 11.7 233 - 350 350

• No ceiling effect, no max dose, titrate until effect• Conversion PO:IV = 3:1• Severe hepatic impairment – reduce freq (q6-8H.)• Renal impairment- ovoid if possible

Preparations & administration:

• Immediate-released – duration 4H.- MO syrup (2mg/ml) - Immediate released tablet 10 mg (MO-IR)

• Slow-released: MST (10, 30, 60, 100 mg/tab) q8-12H. Kapanol (20, 50, 100 mg/cap) q12-24H.

• IV injection (10mg/ml)

• MO naive - start with low dose and titrate to effect

• Needs 2-3 days for titration

• Use immediate released for titrationGive background dose q4H + PRN q2H

• If pain not controlled - Increase dose 30-100% according to pain severity Severe 100%

Moderate 50% Mild 30%

- Readjust dose Total MO required in 24H Regular + PRN in 24H

MO naïve - start with

• Oral 0.15-0.3 mg/kg PO 5 mg (max 10-15 mg) q4H

• Injection 0.05-0.1 mg/kg IV/SC 3 mg (max 5-10 mg) q4H

Example

• 5 mg immediate released MO MO-IR (10 mg) ½ tab or MO syr (2mg/cc) 2.5 cc PO q4H.

or 10 mg controlled release tab (MST) q8H.

• Break through dose = dose q4H (or 24H MO ÷ 6) MO-IR ½ tab or MO syr 2.5 cc PRN for BTP q2H

MO-IR (10 mg) ½ tab at 6, 10, 14, 18, 1 tab at 22.and ½ tab MOIR PRN for BTP q2H (MO syr. 2.5 cc.)

Patient required 4 PRN doses in past 24HAdjusted dose = regular 30 + BTP 20 50 mg/d 50/6 ~7.5 mg/dose ¾ tab of MO-IR q4h + ¾ tab of MO-IR PRN for BTP q2H (MO syr 3.5 cc)

• Dose adjustment on the next day (regular + PRN)

• Adjust dose by increasing dose 30-100%

24h MO = 5 mg x 6 doses = 30 mg (PS - moderate) Increase 50% =15 mg 30+15 = 45 mg/d 45/6 7.5 mg/dose ¾ tab of MO-IR q4h.

• Mr.A received MO 3 mg IV q4H, required 1 BTP 3mg Pain well controlled, plan for discharge MO 3 mg x 6 + BTP 3 mg =21 mg MO inj 21 mg = MO oral 21 x 3 = 63 mg MST (30mg) 1 tab q12H + BTP (60÷6) = 10 mg PRN q2H (MO-IR 1 tab orMO syr 5 ml BTP q2H)

• Follow up 2 months later, required 3 BT doses/D. MO adjustment? MO (background) 60 + PRN (10x3) 30mg = 90 mg MST(30 mg)1 tab q8H +MOIR (10mg)1.5 tab PRN

or MO syr 7.5 ml PRN q2H

• Constipation (90%) will not tolerance to this SE needs to prescribe laxative continuously

• Nausea/vomiting (30%)

• Sedation on the first few dayssedation score recorded

0 = alert 2 = very sleepy, easily awakened1 = sligh t drowsy 3 = deep sleep, unable to wake up

If sedation score >2 decrease dose 30-50%Score >3 skip next dose and decrease 30-50%

• Itchy (7%) Rx antihistamine

• Dry mouth, urinary retention, delirium- rare

• Potent synthetic opioid agonist

• Less SE profile (constipation, CNS)

• Transdermal route, slow onset (12-24H)

• Difficult titration/conversion factor

• Peak onset 24H, cont controlled release for 72H

• Breakthrough analgesia is difficult

• Transdermal patch 25 ug/H= ~60mg oral/24H = ~20-30mg SC/24H

• When take off, effect still last for 24H

Common in:

• Bone metastases

• Neuropathic pain

• Wound dressing, debridement

• Urinary catheterization

• Evacuation feces Use quick onset and short duration analgesic

• Fentanyl inj 12.5 mcg (0.25 cc) SL 5-10 min

onset of action ~ 5-15 min, max ~ 20 min,

duration ~ 45 min.

• If not controlled repeat same dose 1-2 times in

5-10 min.

• Increase dosage to 25 50 100 mcg if pain

not well controlled

http://onco -prn .blogspo t.com/2010/02/fentanyl-citra te-sublingua l-dosing-and.html

• NeuropathicCommon in advanced cancerInvasion, compression of neural structuresIatrogenic: from CMT, surgery

• Bone painCommon in advance cancer Reponses to opioidsDifficult to management bone pain: weight bearing bone, impending fracture, nerve compression

• Visceral painPancreatic painPelvic pain: Bladder spasms, rectal pain

Cherny NI, Ann Onco 2005;16(Supp 2):ii79

• Opioids are used more frequently in cancer-related NP- NP may not exist in isolation but with another

pain which can be highly opioid responsive

- NP may linked with a painful mass which requires opioid treatment

- Some patients may achieve a better analgesia/side-effect profile with an opioid rather than an adjuvant for NP

• Opioid NNT in NP 2.6 to 5.1, TCAs NNT 2.1 to 2.8, G abapentin NNT 4.2 to 6.4

Brit J Anaesthesia 2013;111:105-11

Management• Responsive to opioids• Radiotherapy - overall response 58-59% • NSAIDS opioids• Bisphosphonate less effective than opioids/RT

second line therapy

Characteristics:• Moderate/severe background pain• Breakthrough pain - common• Incident pain - common

Cognitive and behavioral methods:

• Distraction

• Imagery

• Hypnosis

• Relaxation Techniques

– Deep breathing

– Progressive relaxation

– Meditation

Physiological methods

– Warm baths

– Massage

– Acupuncture

1. Consider primary therapies of underlying causes: RT in bone pain

CMT - reduce tumor size

Surgery - relieve obstruction

AB – Occult infection of fungating tumor in head

neck CA

2. Titrate opioids until controlled with tolerable SE

3. Medical treatment of SE , if not tolerate opioid switching

Cherny NI, Ann Onco 2005;16(Supp 2):ii79

4. Use adjuvant analgesics- Non-opioid co-analgesic: Paracetamol, NSAID

- Dexamethasone in: ICP, spinal cord compression, SVC obstruction, bone pain, neuropathic pain

- Non-pharmacological interventions

- Tropical local anesthetics

5. Regional anesthesia

6. Invasive neuroablative interventions

7. Last resource - Palliative sedation

Cherny NI, Ann Onco 2005;16(Supp 2):ii79

• Severe pain associated with movement fracture of a long bone vertebral collapse

• Severe pain that disturb sleep

Parenteral Medication

• Intravenous morphine

• Sublingual ketamine

• Sublingual fentanyl

Morphine is the first-line d rug used

1. Starting dose Opioid Naïve MO 2-5 mg IVOpioid Tolerant 10-20% of the total opioid requirement in the previous

24 hours (around the clock/scheduled doses plus as-needed doses)

2. Re-assess in 15 minutes (60 minutes if oral)- PS unchanged/higher increase 50-100% - PS decreased to 4-6 repeat same dose- PS 0-3 continue at current dose q4h

From: Shoenbe rge r J. Malignant pa in . In : Pa llia tive aspects of eme rgency ca re . Oxfo rd 2013

• COPD 90-95%

• Heart disease 60-90%

• AIDS and renal disease 10-60%

• Last few weeks of life 70%

**Breathlessness at rest is an independent predictor o f surviva l second only to performance s tatus**

• n = 80, Last week of life

• 50% had severe/very severe dyspnea

less than ½ of these were offered effective treatment

Dying from cancer: the views of bereaved family and friends

about the experience of terminally ill patients. Addington -Ha ll JM, et al. Palliat Med, 1991 5:207-214.

• Direct tumor effects

• Indirect tumor effects

• Treatment-related

• Unrelated to cancer

• Only on exertion? At rest?

• Comfortable position?

• Interference with daily activities or sleep? How?

• Relieved/improved with oxygen?

• Onset and progression?Rapid changes often provide an opportunity for corrective treatment,

eg. effusion, pneumonia• Meaning , patient’s knowledge, beliefs

Meaning : terminal, choking to death• Oxygen saturation has poor correlation with the sensation of

breathlessness!

Correct the correctable

Symptomatic drug treatmentNon-drug treatment

In fe ction An tibiotics , PT

COP D/asthma Bronchodilators, s teroids, PT

Obstruction o f trachea/bronchus/S VC Steroids, radiotherapy, laser therapy, s tenting, chemotherapy

Ly mphangitis carcinomatosis Steroids, d iuretics , bronchodilators

Pleural e ffusion Drainage +/-P leurodesis

Pericardial e ffusion Paracentesis, s teroids

Ascites Diuretics , paracentesis

Anemia Blood transfusion

Pulmonary embo lism An ticoagu lation

Heart fa ilure Diuretics , AC E inhibitors, opioids

• Positioning - leaning forward, arms resting on table- Sleep with the normal lung up

• Use electric fan or stay near open window

• Gentle physiotherapy (rebreathing techniques, aid expectoration)

• Relaxation techniques, breathing exercise

• Discussion and reassurance

• Information & support for patient and family

• Bronchodilators for bronchospasm (COPD, asthma)

• Mucolytics or NSS nebulizer if tenacious sputum is contributing to breathlessness

• Opioids for symptom management

• Benzodiazepines

• Corticosteroids for lymphangitis carcinomatosis or lung mets

MildSco re 1-3

Mo derateSco re 4-7

SevereSco re 8-10

Re fracto ry

Fan

Position

Breathing exercise

Relaxation

Education

Short-acting MO prn. for dyspnea attack

Long-acting schedule MO

Sedation

• Breathing training, walking aids, neuro-electrical muscle stimulation and

chest wall vibration appear to be effective non-pharmacological interventions

for relieving breathlessness in advanced stages of disease

(C ochrane Da tabase of Systema tic Reviews 2008, Issue 2)

• Opioids reduce ventilatory response to hypercapnia, hypoxia, and exercise decrease respiratory effort and breathlessness

• Opioids are more beneficial in patients who are breathlessness at rest than on exertion

• Non-drug measures are of primary importance in breathlessness on exertion

• Improvement is seen at doses that do not cause respiratory depression

• Reduced bronchoconstriction

• Improved gas exchange due to higher CO2 and lower O2 concentrations- Reduction in responses to hypoxia and hypercapnia- Reduction in the drive to breath- Reduction in total ventilation

• Less oxygen required at rest or to exercise

• Vasodilatation of pulmonary vasculature

• Attenuate limbic responses to dyspnea.

• Several RCTs supported use of opioids in cancer patients (Ann In tern Med 1993, J Pain Sympt Manag 1990 ,

Sou th Med J 1991 , Ann Oncol 1999)

• Systematic reviews (18 RCTs) showed opioids reduced dyspnea symptom in cancer patients

(C ochrane Da tabase of Systema tic Reviews 2001, Issue 3)

• Current evidence does not support nebulized opioids for dyspnea management

(Annals of P harmacotherapy 2005)

• Positive e ffect o f opioids on breathlessness (p=0.0008)• Greater e ffect for o ral/parenteral than nebulized opioids• Subgroup o f COPD showed same results.

Breathlessness Exercisetolerance

• Endogenous opioids in COPD

• Meta-analysis - oral & parenteral opioids relief dyspnea.(Bruera E. J Pain Symptom Manage 2005)

• NNT 1.5 (Currow DC . J Pain Symptom Manage 2011;42 :388)

• Recommended dose in clinical trials low dose sustained-released 10-20 mg/d in opioid –naïve or 30% increment if receiving opioids

(Abernethy AP . BMJ 2003;327:523)

• In opioid-naïve patient:

- Start with 2.5-5 mg PO PRN.

- If > 2 doses/24 h are needed give regularly and titrate according to response

• In patients already taking opioids:

- 30% increase of current MO- As with pain, individual titration is required

• Slow titration in type 2 respiratory failure

Actions: perception of dyspnea, anxiety & pain

Actions: Decrease anxiety, act as muscle relaxants, reduce anxiety and panic attacks

Drug Dose Comments

Diazepam 2 -5mg PO up to TDS

Long acting (T2 = 20-100h)

Lorazepam 0.5 - 1mg SL/PO q 8h PRN

Shorter acting (T2= 12–15h) Fast onset of action

Midazolam 2.5 - 5 mg SC q 4h Short acting (T2= 2-5h) For intractable breathlessness

MO = morphine 3 mg Mi = midazolam 2 mg MM = MO + midazolam

Navigante et al, J Pain Symptom Manage 2010;39:820

• Review treatment after 5 days.

• If improved, reduce dose to the lowest effective dose

• If not improved, stopped or reduced to previous maintenance dose.

• If taken steroids for < 14 days stop abruptly.

Indication Dexamethasone dose SVC obstruction 16 mg Stridor 8-16 mg Lymphangitis carcinomatosisPost - Radiotherapy Bronchospasm

8mg

Action: Reduce inflammatory edema

• Calm down

• Rest on a chair, elbows on thighs

• “Purse lip breathing”

• If not improved take morphine syrup 2 cc. Takes 20-30 min before action.

• Lorazepam tab 0.5 mg SL rapid onset.

• Breathlessness is a complicated sensation

great variation in oxygen response

• In patient with SaO2 <90% oxygen may be benefit

• Advance cancer patients who were hypoxemic on room air benefited from oxygen therapy

(Lance t 1993, J Pain Symptom Manage 1992 , Palliat Med 2003)

• Sudden onset / rapid worsening of dyspnea

• Often imminently terminal situation

Pulmonary embolism

Fulminant pneumonia

Upper airway obstruction

Hemoptysis

• Aggressively pursue comfort• Ideally use intravenous route

• G enerally employ non-specific measures:

» Calm reassurance

» Oxygen

» Opioids

» Possibly sedatives: benzodiazepines (lorazepam, midazolam)

IV push with escalating doses q 10 min

MO 3-5 mg IV

MO 5-10 mg IV

MO 10-15 mg IV

No t im prove in 10 m in

No t im prove in 10 m in

Ellershaw, Care of the dying: A pathway to excellence

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ยาที่ผสมรวมกนัได้ Compatibility ตัวท ำละลำย

Morphine, Haloperidol / NSS SWI

Morphine, Metocloplamide / NSS SWI

Morphine, Midazolam / NSS SWI

Morphine, Metoclopramide, Midazolam

/ NSS

• Positioning

• Antisecretory agents

-H yoscine H Br (Buscopan) 20 m g Q6h .

- Atropine 0.4 - 0.8 mg SC q1h prn- Atropine eye drop 1% 4 drops SL q 4h prn

• Consider suctioning if secretions are:

- Distressing, proximal, accessible- Not responding to antisecretory agents

Etiology of Nausea & Vomiting

• Chemical causes

• Gastrointestinal causes

• Cranial causes

• Other causes

Neuro transmitters:S erotonin, dopaminehistamine

Serotonin receptor antagonistsOn dansetronProkinetic/dopamine antagonistsMetoclo promide , ha lo perido l

Benzodiazepines Lo razepamDexam ethasone

Prokinetic drug for s tasis/partial obstruction: Metoclo pramideSurge ry/co rticosteroids for in testinal obstructionOctreotide , Busco pan to decrease secretions

Drugs : opioids, chemoTxBiochem: hyperCa, renal/liver fa ilure

• Oral hygiene care - essential

• Small, frequent meals

• Avoid strong smells

• Acupuncture/acupressure

• Relaxation and imagery

MedicationCla ss

Drug s

Dopamine An tagonists

Metoclopramide 10-20m g po/iv/sc/pr q4-8h

Haloperidol 0.5-1 m g po/sc/iv q6-12h

Domperidone 10 m g po q4-8h

Prokinetic Metoclopramide 10-20 m g po/sc/pr q4-8h

Domperidone 10 m g po q4-8h

Serotonin An tagonists

Ondansetron 4-8 m g b id-tid po/sc/iv

Granisetron 0.5–1 m g po/sc/iv OD - b id

H1 An tagonists Dim enhydrinate 25-100 m g po/iv/pr q4-8h

Promethazine 25 m g po/iv q4-6h

Misce llaneous Dexam ethasone 2-4 m g po/sc/iv OD-qid

Lorazepam 0.5 - 1 m g po/s l/iv q4-12h

• Drugs (70-100%): opioid, anticholinergic drugs, TCA, diuretics, iron, 5HT3 antagonists

• Advance cancer:

Bowel obstruction

Spinal cord compression

Hyper Ca• Comorbids: hypothyroidism

• Debility:

- Fatigue, decreased mobility, bed bound - Dehydration

History: bowel pattern (frequency, consistency , difficulty) pain, N/V,

neurological symptoms

Frequent soiling following severe constipation

overflow diarrhea

Beware

PR:

• PR rectal tone? impact stool?

• Hard loading stool softeners

• Soft loading senna, bisacodyl

• Empty with ballooning rectum

high fecal impaction vs. gut obst. plain film

abdomen and treat accordingly.

** Abdominal exam & PR**

Abd. exam: distension, sausage-like mass LLQ,

visible peristalsis, bowel sounds

Score >7 aggressive treatment

Dalal s. J Pall Med, 2006

Rectal treatment for

• Impact feces evacuate

Metoclopramide & abdominal massage

SSE, Unison enema, laxative + stool softener• Paraplegic/bedbound patient patients.

0 = No feces

1 = Stool occupy <50% of lumen

2 = Stool occupy >50% of lumen

3 = Stool completely occupy

the lumen

• Stimulants

Senna (Senokot)

Bisacodyl (Dulcolax)

• Softeners

Lactulose

Magnesium salts

• Fibre*psyllium (Metamucil)

* Avoid fibre laxatives in

palliative care

• Suppositories & enemasGlycerin / bisacodyl

Bisphosphanate (Unison enema)

Class Medication Dose Route SE

Stimulants Senna 2-4 tab HS PO Nausea,

cramping

Bisacodyl

5mg/tab

5-15 mg OD PO

PR

Nausea,

clamping

Stool Lactulose

15g/10 ml

15-30 ml PO Diarrhea,

nausea

Docusate

100mg/tab

50-200 mg/d

divide 1-4

PO Diarrhea,

nausea

• Address any reversible causes.

• Good oral fluid intake (2 L/d).

• Review diet.

• Increase mobility

• Toilet training.

• Explain importance of preventing constipation.

• Ensure privacy and access to toilet facilities.

• Avoid bulk forming laxatives fecal impact

• Lactulose needs a high fluid intake; can causes

flatulence and clamps.

• Almost all PC patients on opioid need a regular

laxative.

• Review laxative regimen when opioid medication

or dose is changed.

• If maximal laxative therapy fails, consider

changing opioid to fentanyl

• Common finding in palliative patient

– Not improve with rest

– Not related to activities

• Become more severe at last few months of life

• Effected quality of life

Ph ys ical

• CA, HF, COPD, E SRD

• Poor symptom control

• Side effect of medications: CMT, RT, diuretics

• Cachexia

• Anemia

• Fluid-electrolyte imbalance

• Insomnia

Ps ychosocial

• Anxiety

• Depression

• Family issues

• Psychosocial & spiritual

problems

• Information giving• Rehabilitation program• Effectively treat symptoms• Review mediations• Assess fluid-electrolytes, intake• Blood transfusion for anemia• Treated anxiety and depression• Psychosocial & spiritual support

• Dexamethasone (in patients with <4 w survival)

Feeling of well-being

Effects wean after 4-6 weeks.

• CNS stimulants: methylphenidate

• Unavoidable in PC patients especially CA, HF

• Caused by hormonal dysregulation, inflammatory mediators

• Other causes: - Drugs and treatment eg. Diuretics - Poor control of symptoms: Pain, constipation, dyspepsia, gastric stasis

dry/sore-mouth, mucositis, candidiasis- Psychosocial & E motional distress

• Severity associated with survival

Non-pharm R x

• Finding cause and treatment

• Provided information

• Small frequent meals

• Eating with family

Pharm R X

• Nutritional support in G I obst

patients.

• Appetite stimulants

- Progestogens

(Megestrol acetate)

- Dexamethasone in patients with

< 4wks survival

• Reduce suffering

• Maximize comfort

• Preserve function

• Prevent complications

• Prolong survival