Palliative Care

Sylwia Dbska-Szmich, Sylwia Kamierczak- ukaszewicz Chemotherapy Department Medical University, Lodz

WHO Definition of Palliative Care

Palliative care - is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening 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.

Main problems

Pain management

Nausea and vomiting

Constipation Diarrhoea

Hiccup
Cachexia and anorexia Respiratory symptoms

Lymphoedema
Control of psychological distress

Main problems

Cancer

Toxicity of palliative treatment

Unrelated conditions

Symptoms
(physical, psychosocial, emotional or spiritual)

Pain
http://www.existentialpunk.com/.a/6a00d83452358069e20105369ff04a970c-800wi

It affects 51% of patients with cancer and 75% of patients terminally ill Pain is subjectively experienced and it dramtically makes worse quallity of patients life, it also influances patients family. This is important to describe pain, its duration, intensity, different types and localisation.

Pain Intensity Scale

0-10 Numeric Pain Intensity Scale

Simple Descriptive Pain Intensity Scale

Visual Analog Scale (VAS)

"Faces" Pain Scale

Categories of Pain by Duration

Acute Pain
Brief duration, goes away with healing usually 6 months or less. Not necessarily more severe than chronic May be sudden onset or slow in onset

Examples are broken bones and pain after surgery or injury

Chronic Cancer Pain Pain is expected to have an end, with cure or with death.
Aggressive treatment Addiction not a concern

Categories of Pain by Type

Type Somatic Source Skin, muscle, and connective tissue Description Localized, sharp/dull, worse with movement or touch Pain med: Most pain meds will help, if severe, need a stronger medication Activation of nerves ending with tissue damage

Visceral

Internal organs

Neuropathic Nerves

Not localized, Stronger pain refers constant and medications dull, less affected with movement Opioids + Burning, stabbin, adjuvant pins and needles, (anticonvulsant, shock-like, antidepressants shooting or other)

Consequences of Untreated Pain

Poor appetite and weight loss Disturbed sleep Withdrawal from talking or social activities Sadness, anxiety, fear or depression Physical and verbal aggression, wandering, acting-out behavior, resists care Difficulty walking or transferring; may become bed bound

Nonopioids
Nane
Paracetamol

Mechanism

Route

Adverse drug reactions

Hepatotoxic if >4g/d

inhibition of COX2 and p.o., COX3 in CNS. It is not p.r., helpful with inflammation. i.m., i.v.

Nonsteroidal antiinflammatory drugs (NSAIDs): classic: Aspirin, ibuprofen, ketoprofen, naproxen, diclofenac, piroxicam relatively COX-2 selective: nimesulid Selective COX-2 inhibitors (Coxibs): celecoxib, valdecoxib

Analgesic, antipyretic and, p.o., in higher doses, antip.r., inflammatory effects i.m., i.v. thanks to nonselective inhibition of the enzyme cyclooxygenase. Selective COX-2 inhibitors inhibit COX2 150x stronger then COX1.

Gastrointestinal: nausea/vomiting, dyspepsia, gastric ulceration/bleeding, diarrhea. Renal: salt and fluid retention, HA Antithrombotic Allergies Photosensitivity

Opioids
Opium (poppy tears, lachryma papaveris) is the dried latex obtained from the opium poppy (Papaver somniferum). Opium contains approximately 12% morphine, codeine and non-narcotic alkaloids such as papaverine, thebaine and noscapine. The traditional method of obtaining the latex is to scratch ("score") the immature seed pods (fruits) by hand; the latex leaks out and dries to a sticky yellowish residue that is later scraped off. Cultivation of opium poppies for food, anaesthesia, and ritual purposes dates back to at least the Neolithic Age (new stone age). The Sumerian, Assyrian, Egyptian, Indian, Minoan, Greek, Roman, Persian and Arab Empires all made widespread use of opium, which was the most potent form of pain relief then available, allowing ancient surgeons to perform prolonged surgical procedures.
http://pl.wikipedia.org/wiki/Opium

Opioids (2)
Opiates - natural alkaloids found in the resin of the opium poppy: morphine, codeine, thebaine and the semi-synthetic substances that are directly derived from the opium poppy . Opioid - a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract. The receptors in these organ systems mediate both the beneficial effects and the side effects of opioids. pure agonist: codeine, morphine, pethidine, fentanyl, methadone, oxycodone, partial agonist: buprenorphine agonist/antagonist: pentazocine antagonist: naloxone (antidotum)

Opioids benefits and side effects

Analgesia Inhibition of cough reflex Alleviation of diarrhoea

Respiratory depression Constipation Excessive contraction of sphincters Nausea, vomiting Pruritus Dysuria/ anuria Drowsiness Dry mouth Miosis

Common misconceptions about pain treatment with opioids

Opioids have potential for tolerance, but in many cases they are a successful long-term care strategy for patients in chronic cancer pain. Minimal effective dose does not produce euphoria and does not lead to psychological addiction. Physical addiction is a consequence of biological mechanism of drug action. The withdrawal symptoms appear after treatment suspension or antagonist administration. Physical withdrawal symptoms: tremor, cramps, muscle and bone pain, chills, perspiration , priapism, tachycardia, itch, restless legs syndrome, flu-like symptoms, rhinitis, yawning, sneezing, vomiting, diarrhea, weakness, akathisia. These symptoms appear during couple hours after withdrawal and last up to 72 h. Opioids withdrawal should be gradual.

Pain Management - principles

Pain Management - principles

Use the lowest effective dose by the simplest route

Use scheduled, long-acting pain medications for constant or frequent pain.

Use short-acting medication available for breakthrough pain Treat breakthrough pain with 10 15% of the 24 hours scheduled dose

Pain Management - principles

Common rules
Treat or prevent side effects, such as constipation and nausea Change medication as necessary
Do not stop pain medication in terminal patients !!!!! Chang the route if needed

Constipation
It is a decrease in the number of bowel movements and/or the difficult passage of hard stool.
This often causes pain, discomfort and sometimes bleeding from the rectum.

In patients being treated for cancer, constipation can be caused by:

poor food and fluid intake decreased activity and weakness

certain medications, especially pain medications and chemotherapy drugs

cancer itself in certain location

Constipation - management
Diet modification: Fresh raw vegetables Fresh raw fruits, especially those with skins (pears and plums) and seeds Bran, whole grains and cereals Dried fruits, especially dates, prunes and apricots Prune juice Avoid or decrease: chocolate, cheese, eggs, bananas, rice, apples Increase your fluid intake. Increase your physical activity as much as possible.

Constipation - treatment
Emollient or lubricant cathartics (docusate sodium, glycerin suppositories ) to soften stools.

Bulk cathartics to increase mass and soften stools (psyllium, osmotic laxatives disaccharides and saline cathartics)
Stimulant carthatics to promote spontaneous movement of the intestines, which is the action that opiates suppress Combination agents Enemas (should be considered as a last resort rather than part of routine treatment)

Nausea and vomiting

They occur in up to 70% of patients with advanced cancer
thorough assessment identification of mechanism a logical choice of anti-emetic

Hiccup - mechanisms

90% caused by gastric distension

gastroparesis connected with opioid therapy

pathology involving diaphragm: disease around the lower oesophageal sphincter, the crura of the diaphragm, phrenic nerves subphrenic abscess

lower lobe consolidation or empyema

brain tumors uraemia

Hiccup - treatment
Correct the correctable
tricks

breath holding, rebreathing from a paper bag A couple of heaped teaspoonsfuls of granulated sugar or dry bread or biscuit Rubbing the roof of the mouth at the junction of the soft and hard palate quickly and repetitively to and fro

Hiccup - treatment
Medicaments

Saline nebulizer Enhance GI motility and encourage stomach emptying with metoclopramide or domperidone 30 min before meal times Finish each meal with an anti-foaming and anti-flatulant antacid containing dimeticone Relaxation of diaphragmic spasm with baclofen or nifedipine For phrenic nerves involvement treat similarly to neuropathic pain with steroids and with antineuropatic pain adjuvant such gabapentin or sodium valproate Central depression of the hiccup reflex in the brainstem with midazolam or levomepromazine

Diarrhoea
The passage of abnormally loose stool; usually combined with increased frequency of bowel movement. Causes:
Pathogens (bacterial, viral, fungal) Overflow diarrhoea caused by opioid therapy without a laxative Too much laxative Bowel resection Post-radiotherapy diarrhoea Malabsorbtion of pancreatic insufficiency Carcinoid syndrome Cholegenic diarrhoea Autonomic neuropathy or post-lumbar sympathectomy Drug induced- chemotherapy, misoprostol, NSAID, antibiotics, laxatives

Diarrhoea - treatment
Loperamide - peripheral opioid receptors agonist with no central action Loperamide 2mg= codeine 30 mg = morphine 15-30mg Loperamide alone initially codeine alone combination loperamide+morphine If transit time is very short (severe diarrhoea) and drug is lost prematurely, opioid via continuous subcutaneous unfusion maybe necessary to guarantee absorption and efficacy. Post-radiotherapy diarrhoea - loperamide, codeine, morphine, local steroid foam enemata, ondansetron, octreotide Malabsorbtion of pancreatic insufficiency Creon Bacterial overgrowth probiotics, metronidazole Carcinoid syndrome- ondansetron, octreotide Candida overgrowth - fluconazole Autonomic neuropathy - clonidine

Cachexia and anorexia

Cachexia involuntary increase in basal energy expenditure culminating in loss of both lean muscle and adipose tissue
Affects>85% of patients with advanced cancer Often associated with anorexia, Cachexiastarvation It cannot be reversed by simply increasing calorific intake

Mechanism-unknown, circulating cytokines (TNF) play role causing metabolic abnormalities such as protein breakdown, lipolysis, increased gluconeogenesis, chronic inflamatory state

Anorexia reduced/absent appetite for food

May be associated with the fatigue and cachexia

Consider potentially reversible causes:

Inadequate pain control Nausea Constipation Depression Metabolic abnormalities (hypercalcaemia, uraemia) Infection Obstruction/ascites

Cachexia and anorexia - management

Correct reversible causes Non-pharmacological Dietary advice: small, frequent meals, eat when hungry, highcalorie, low-volume foods, small amounts of alcohol as an appetite stimulant Education: try to minimize any stress related to food, promote enjoyment of food Activity: maximize any potential for exercise

Cachexia and anorexia - managemant

Pharmacological
Supplements: high-protein, high-calorie

Enteral/parenteral feeding is occasionally appropriate during active anti-cancer therapy. It is rarely appropriate
in the latter stages of progressive disease.

Corticosteroids may stimulate appetite, reduce nausea. Fluorinated corticosteroids should be used only for

short time (side effects). In the longer term it is better to change to progestogen. Progestogens: aid appetite, limited evidence for weight gain (better effect when combined with ibuprofen or celecoxib), but it does not increase lean body mass, it increases both fat and total body water and increases risk of thromboembolism (Megestrol acetate) EPA (eicosapentanoic acid) is one of the -3 essential fatty acids, hepls dampen down the acute inflammatory
response and protects muscles against proteolysis-inducing factors.

Respiratory symptoms
Dyspoea (SOB - shortness of breath) necessity to increase the rate and/or depth of respiration
Multifactorial in origin Pulmonary: lung tumour, pneumonia, pleural effusion, lymphangitis carcinomatosa, obstruction of large airways, distal collapse, concomitant chronic obstructive pulmonary disease Cardiovascular: pericardial effusion, congestive cardiac failure, pulmonary emboli, superior vena cava obstruction, anaemia, arrhythmias Chest wall and diaphragm: muscle weakness/fatigue, restrictive malignant infiltration of the chest wall, lytic bone metastases/pathological fracture(s) affecting the ribs, pleurisy, infiltration of phrenic nerve at any point along its course Ventilation-perfusion mismatch: pleural effusion, empyema, basal consolidation, multiple metastases, lung tumour or basal collapse, poor basal expansion due to paralysis of the diaphragm, splinting of the diaphragm due to abdominal cause of distension

Decreased compliance/ increased airway resistance: Pulmonary fibrosis, consolidation, tumour, pulmonary oedema, lymphangitis carcinomatosa, exophytic endobronchial tumour, reversible airway obstruction Psychological: anxiety, fear

Respiratory symptoms - management

Correct the correctable

Multidisciplinary approach is helpful

Nonpharmacological strategies: breathing exercises, physiotherapy, relaxation therapy, massage, companionship, reassurance, distraction therapies Treat pain

Respiratory symptoms - management

Drug palliation to relieve dyspnoea Opioids decrease respiratory panic , reduce anxiety, decrease the sesivity of the respiratory centre to a raised pCO2, reducing excessive respiratory drive (morphine 2,5 mg/4h/po)
Benzodiazepines are anxiolytic, sedative, muscle relaxants (lorazepam 0,5-2 mg po prn)

O2 can be beneficial for correcting hypoxia, can also relieve SOB through a cooling affect on the face or as a placego

Respiratory symptoms 2
Cough, protective reflex for clearing the airways
Management Treat the cause (infection-> antibiotics) Aid expectoration with saline nebulizers, bronchodilators Soothing cough syrup , can be combined with low-dose morphine Radiotherapy/ laser ablation if endobronchial tumour is cause of continued large-airway irritation/obstruction

Lymphoedema
A chronic incurable condition characterized by swelling and associated with chronic skin changes. It can lead to significant impairment of function. Damage to the lymphatics due to malignant disease or as a consequence of treatment is called secondary lymphoedema
Tumour infiltration of lymphatics Surgery damaging lymphatics or excision of lymph nodes during block dissection Radiotherapy
Affects most commonly the limbs but can affect any part, Often non-pitting

Lymphoedema - pathogenesis
Stasis of protein-rich tissue fluid impaired immune function impaired macrophage fuction protein, debris and inflammatory factors accumulate excellent culture medium for bacteria and/or fungi reccurent infection eventually leads to fibrosis, irreversible swelling and thickening of the tissues and skin fibrin deposition within tissues and blood vessels leads to poor perfusion and oxygenation accumulating protein increases osmotic pressure tending to draw in even more fluid uninterrupted cycles of recurrent infection can lead to end-stage of lymphoedema - elephantiasis Exclude other causes of swollen limb (extrinsic venous compression or deep vein thrombosis)

Lymphoedema - management
Minimizing risk of infection/trauma/insect bites Avoid venepuncture or blood pressure measurement on the affected limb Prevent progression by preventing acute inflammatory episodes, treat infections Limphorrhoea should be managed promptly with skin care and padded bandaging

Daily skin care Self-massage and exercise

Specialist fitted gradient compression garnments

No drug therapy available

Psychological distress
Presentation denial/confusion, anger, anxiety, sadness/depression, sense of loss, alienation, seemingly poor control of physical symptoms, attention seeking manipulative behaviour Management Self-help Informal and formal support Psychological therapies Psychiatric intervensions

Bibliography:
Oxford Handbook of Oncology. Jim Cassidy, Donald Bissett, Roy Spence, Miranda Payn