PALLIATIVE CARE: PALLIATIVE CARE: WHO Definition The active total care of patients whose disease is not responsive to curative treatment....
Mar 27, 2015
PALLIATIVE CARE:PALLIATIVE CARE:WHO Definition
The active total care of patients whose disease is not responsive to curative treatment....
SUFFERINGSUFFERINGEMOTIONALPSYCHOSOCIAL
PHYSICAL
SPIRITUAL
1.1. Adequate knowledge base Adequate knowledge base
2.2. Attitude / Behaviour / Philosophy Attitude / Behaviour / Philosophy
• Active, aggressive management of sufferingActive, aggressive management of suffering
• Team approachTeam approach
• Recognizing death as a natural closure of life Recognizing death as a natural closure of life
• Broadening your concept of “successful” care Broadening your concept of “successful” care
Effective nursing / medical care of the dying Effective nursing / medical care of the dying involves:involves:
Cure/Life-prolongingCure/Life-prolongingIntentIntent
Palliative/Palliative/Comfort IntentComfort Intent
Bereavement
Bereavement
DEATH
“Active Treatment”
PalliativePalliativeCareCare
DEATH
EVOLVING MODEL OF PALLIATIVE CAREEVOLVING MODEL OF PALLIATIVE CARE
SYMPTOMS IN ADVANCED CANCERSYMPTOMS IN ADVANCED CANCER
0 10 20 30 40 50 60 70 80 90
Asthenia
Anorexia
Pain
Nausea
Constipation
Sedation/Confusion
Dyspnea % Patients (n=275)
Ref: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-KetteringRef: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering
PREVALENCE OF CANCER PAINPREVALENCE OF CANCER PAIN
0 10 20 30 40 50 60 70 80 90
All
All: Advanced
Bone
Pancreas
Stomach
Uterus/Cervix
Lung
Breast
Prostate
Colon
Lymphoma
Leukemia% Patients
From Portenoy; From Portenoy; CancerCancer 63:2298, 1989 63:2298, 1989
TYPES OF PAINTYPES OF PAIN
NEUROPATHICNEUROPATHICNOCICEPTIVENOCICEPTIVE
SomaticSomatic VisceralVisceral
DeafferentationDeafferentation Sympathetic Sympathetic MaintainedMaintained
PeripheralPeripheral
Somatic Visceral
Features • Constant• Aching• Well localized
• Constant or crampy• Aching• Poorly localized• Referred
Examples • Bone metastases • Pancreatic CA• Liver tumor• Bowel obstruction
NOCICEPTIVE PAIN
COMPONENT DESCRIPTORS MEDICATIONS
Steady • Burning, Tingling• Constant, Aching• Squeezing, Itching• Allodynia• Hypersthesia
• Gabapentin• Tricyclic antidepressants• Corticosteroids• Mexilitene
Paroxysmal • Stabbing• Shocklike, electric• Shooting
• Gabapentin• Baclofen• Tegretol• Corticosteroids• Mexilitene
FEATURES OF NEUROPATHIC PAINFEATURES OF NEUROPATHIC PAIN
PAIN HISTORYPAIN HISTORY
• Temporal FeaturesTemporal Features
• Daily FrequencyDaily Frequency
• LocationLocation
• SeveritySeverity
• QualityQuality
• Aggravating & Alleviating FactorsAggravating & Alleviating Factors
• Previous HistoryPrevious History
• MeaningMeaning
+/- adjuvant+/- adjuvantNon-opioidNon-opioid
Weak opioidWeak opioid
Strong opioidStrong opioid
Pain persists or increases
Pain persists or increases
By the
Clock
W.H.OW.H.O. ANALGESIC LADDER. ANALGESIC LADDER
+/- adjuvant+/- adjuvant
+/- adjuvant+/- adjuvant
1
2
3
STRONG OPIOIDSSTRONG OPIOIDS
• most commonly use: most commonly use: – morphinemorphine– hydromorphonehydromorphone– transdermal fentanyl (Duragesic®)transdermal fentanyl (Duragesic®)– MethadoneMethadone
• DO NOT use meperidine (DemerolDO NOT use meperidine (Demerol) long-term) long-term– active metabolite active metabolite normeperidinenormeperidine seizuresseizures
OPIOIDS andOPIOIDS andINCOMPLETE CROSS-TOLERANCEINCOMPLETE CROSS-TOLERANCE
• conversion tables assume full cross-toleranceconversion tables assume full cross-tolerance
• cross-tolerance unpredictable, especially in:cross-tolerance unpredictable, especially in:– high doseshigh doses– long-term uselong-term use
• divide calculated dose in ½ and titratedivide calculated dose in ½ and titrate
CONVERTING OPIOIDSCONVERTING OPIOIDS
Medication Approx. Equiv. Oral Dose (mg)
Morphine 10
Hydromorphone 2
Methadone 1
Codeine 60
NB: Does not consider incomplete cross-tolerance
TITRATING OPIOIDSTITRATING OPIOIDS
• dose increase depends on the situationdose increase depends on the situation• dose dose by by 25 - 100%25 - 100%
EXAMPLE: (doses in mg q4h)EXAMPLE: (doses in mg q4h)
Morphine 5 10 15 20 25 30 40 50 60
Hydromorphone 1 2 3 4 5 6 8 10 12
Using Opioids for Breakthrough PainUsing Opioids for Breakthrough Pain
• Patient must feel in control, empowered• Use aggressive dose and interval
Patient Taking Short-Acting Opioids:• 50 - 100% of the q4h dose given q1h prn
Patient Taking Long-Acting Opioids:• 10 - 20% of total daily dose given q1h prn with short-acting opioid preparation
TOLERANCETOLERANCE
PHYSICAL PHYSICAL DEPENDENCEDEPENDENCE
PSYCHOLOGICALPSYCHOLOGICALDEPENDENCE /DEPENDENCE /
ADDICTIONADDICTION
TOLERANCE
A normal physiological phenomenon in which
increasing doses are required to produce the same effect
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
PHYSICAL DEPENDENCE
A normal physiological phenomenon
in which a withdrawal syndrome occurs
when an opioid is abruptly discontinued
or an opioid antagonist is administered
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
PSYCHOLOGICAL DEPENDENCEand ADDICTION
A pattern of drug use characterized by a continued craving for an opioid
which is manifest as compulsive drug-seeking behaviour leading to an
overwhelming involvement in the use and procurement of the drug
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
In In chronicchronic opioid dosing: opioid dosing:
po / sublingual / rectal routespo / sublingual / rectal routes
sq / iv / IM routessq / iv / IM routes
reduce by ½
ADJUVANT DRUGSADJUVANT DRUGS
• primary indication usually other than painprimary indication usually other than pain• analgesic in some painful conditionsanalgesic in some painful conditions• enhance analgesia of opioidsenhance analgesia of opioids• other roles:other roles:
– treat opioid side effectstreat opioid side effects– treat symptoms associated with paintreat symptoms associated with pain
ANTI-ANTI-CHOLINERGICCHOLINERGIC
EFFECTSEFFECTS
AmitriptylineAmitriptyline
NortriptylineNortriptyline
DesipramineDesipramine
inflammationinflammationedemaedema
spontaneous nerve depolarization spontaneous nerve depolarization
tumor tumor mass effectsmass effects
CORTICOSTEROIDS AS ADJUVANTSCORTICOSTEROIDS AS ADJUVANTS
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IMMEDIATE LONG-TERM
• Psychiatric• Hyperglycemia risk of GI bleed
gastritis aggravation of existing lesion (ulcer, tumor)
• Immunosuppression
• Proximal myopathy
** often < 15 days **• Cushing’s syndrome• Osteoporosis• Aseptic / avascular necrosis of bone
CORTICOSTEROIDS: ADVERSE EFFECTS CORTICOSTEROIDS: ADVERSE EFFECTS
DEXAMETHASONE: DOSING DEXAMETHASONE: DOSING
• minimal mineralcorticoid effects– po/iv/sq/?sublingual routes
• can be given once/day; often given bid – qid to facilitate titration
• typically administer as follows:» 4 mg qid x 7 days then» 4 mg tid x 1 day then» 4 mg bid x 1 day then» 4 mg once/day x 1 day then D/C