Two Palliative Care Giants Dr Jennifer Vidrine ST4 Palliative Medicine.

Two Palliative Care Giants

Dr Jennifer VidrineST4 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• First modern hospice opened 1967• Based on concept of ‘Holistic’ care • Palliative care teams• Not just for patients with cancer

GPs and palliative care

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

• Found barriers on three levels:– Personal– Relational – Organisational

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

• Relational– Communication• Between pts, carers, other HCPs

– ‘Territory’ (GP? SPCT? Hospital team?)

• Organisational– Bureaucracy– Obtaining medications (Controlled drugs, CSCI etc)– Need to organise care/social work review etc

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

• Pain• Nausea and Vomiting• Shortness of Breath• Anxiety/Psychological Distress

Common Symptoms

• Pain• Nausea and Vomiting• Shortness of Breath• Anxiety/Psychological Distress

Pain

Nociceptive vs neuropathic pain

Nociceptive vs 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…

• History History History• Thinking abut possible/likely aetiologies• What has the pain responded to thus far?

• 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

WHO analgesic ladder

An approach…

• Patient specific• Tend to start with low dose strong opiate

(eg Oramorph 2.5-5mg PRN)• If possible also give regular paracetamol• Ask patient/relative to write down the

following:

Date Time Site Pain Pain score /10 before

What taken

Pain Score /10 after

Notes/Side effects

• 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?

• Would an adjunct help?Steroids (Dexamethasone)TCA (Amitriptyline)Anti-epileptics (Gabapentin/Pregabalin)

• Very often end up on combination

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

Anti-epileptic NNT

Carbmazepine 3.3

Gabapentin 3.5

Lamotrigine 4

Sodium valporate

2-2.5?

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

• Episodic Pain• High anxiety element (Total pain)• Non-concordance

Consider referral/involvement SPCT

What might be offered…

MethadoneKetamineSpinal Lines (epidural/intrathecal line)Nerve BlocksCordotomy (Division of lateral spinothalamic

tracts in the spine)Involvement of clinical psychology

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.

Comfort Break

Nausea &

Vomiting

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

• 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

• 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

• 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

• 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 (esp Metoclopramide)

Two ‘broad’ avenues..

1.Gastric-stasis2.Chemically mediated (central)

1. Gastric Stasis-presentation

• Early Satiety• Large volume vomits• Undigested food• Relief after vomiting• Hiccoughs/belching• Exacerbated by eating/medcations

1.Gastric stasis-causes

• Slowed gastric emptying• ‘Squashed stomach’ due to Hepatomegally• Ascites• Subacute obstruction (consider specialist

input)

1.Gastric Stasis-management

• Prokinetic eg Metoclopramide• 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

Vomiting

Centre

ChemicalMedicationBiochemical

Toxins

GI tractObstruction

Gastric stasisIrritation/hepatic

VestibularMotion sickness

Local tumourMedication

Central Anxiety

PainCerebral mets

Raised ICP

DopamineSeretonin 3

Dopamine Seretonin

4Acetylcholine

Histamine

HistamineCTZMetoclopramide

Two ‘broad’ avenues..

1.Gastric-stasis2.Chemically mediated (central)

2.Central Causes-presentation

• Constant nausea• No/little relief after vomiting• May be able to identify cause• Other signs drug toxicity

Central-Causes

Drugs:OpiatesAntidepressantsAEDs

Electrolyte ImbalanceRenal FailureHypercalcaemia

SepsisAnxietyPainRaised Intracranial

PressureIschemic Bowel

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

Vomiting

Centre

ChemicalMedicationBiochemical

Toxins

GI tractObstruction

Gastric stasisIrritation/hepatic

VestibularMotion sickness

Local tumourMedication

Central Anxiety

PainCerebral mets

Raised ICP

DopamineSeretonin 3

Dopamine Seretonin

4Acetylcholine

Histamine

HistamineCTZ

Cyclizine

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

Vomiting

Centre

ChemicalMedicationBiochemical

Toxins

GI tractObstruction

Gastric stasisIrritation/hepatic

VestibularMotion sickness

Local tumourMedication

Central Anxiety

PainCerebral mets

Raised ICP

DopamineSeretonin 3

Dopamine Seretonin

4Acetylcholine

Histamine

HistamineCTZ

Haloperidol

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

Vomiting

Centre

ChemicalMedicationBiochemical

Toxins

GI tractObstruction

Gastric stasisIrritation/hepatic

VestibularMotion sickness

Local tumourMedication

Central Anxiety

PainCerebral mets

Raised ICP

DopamineSeretonin 3

Dopamine Seretonin

4Acetylcholine

Histamine

HistamineCTZ

Levomepromazine

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

• 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

• 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.

Any questions?

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