Transcript Palliative Care 4.3.10

The Mary Stevens Hospice
Stourbridge
Lucy Martin - Medical Director
(BCVTS 1997 – 2000!)
VTS March 4th 2010
1.30
2.45
3.00
3.45
4.30
Session on Palliative Care and
Basics of Pain Control, plus
discussion and questions
Coffee / Tea
Case discussion 1 & feedback
Case discussion 2 & feedback
Plenary and close
What is Palliative Care?
WHO Definition
Palliative care is an approach that
improves the quality of life of patients and
their families facing the problem
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.
provides relief from pain and other distressing
symptoms
affirms life and regards dying as a normal
process
intends neither to hasten or postpone death
integrates the psychological and spiritual
aspects of patient care
offers a support system to help patients live as
actively as possible until death
offers a support system to help the family cope
during the patient's illness and in their own
bereavement
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 an illness
is applicable early in the course of illness, in
conjunction with other therapies that are
intended to prolong life, such as chemotherapy
or radiation therapy, and includes those
investigations needed to better understand and
manage distressing clinical complications.
Who provides Palliative Care?
Generalist
GPs, District Nurses, Hospitals
Providing day-to-day care in hospital or patients home
Specialist
Palliative Care Teams based in hospices, hospitals,
community
Multidisciplinary – Core members are doctors &
nurses, AHPs
In-patient and Day care facilities, hospice at home
Ongoing advice and support in any setting
Bereavement support
Education and training for specialists and generalists
Day care since 1993, and residential since 1999
Referral form @ www.marystevenshospice.co.uk
Specialist Palliative Care in
Dudley
Hospice in-patient care / day care
Mary Stevens covers the whole Dudley borough
Hospital in-patient care
no dedicated hospital beds
0.4 WTE consultant – out pt and consultation
hospital palliative care team & MDT meeting
Community Service
Macmillan CNS and OT / Physio team
Palliative Care end of life team
What you know about pain management?
What do you feel confident about?
What makes you nervous?
WHO ladder / lift
Cancer and non-cancer chronic pain
Dudley Pain Management Guidelines
Principles of analgesic use
By the mouth
By the clock
By the ladder
– Refers to WHO analgesic ladder
Treatment should be individualised
Use adjuvants
– Drugs for specific situations e.g. Neuropathy
– Drugs to control side effects
– Psychotropics
Twycross, R ‘Introducing Palliative Care’, ‘Symptom management of advanced cancer’
Strong opioids
Should be given according to need and
response
Should not be given according to
prognosis
Administration still surrounded by concern
Little clinically significant respiratory
depression, tolerance not a problem,
dependence does not occur
Naloxone – very rare
Patients generally have been receiving
weak opiates first
Dose gets titrated – ‘start low, go slow’
Pain is an antagonist to central depressant
effects of strong opiates
Therapeutic dose vs. toxic / lethal dose
Opioids in the well person
(or How I did it by H. Shipman)
Opioids in Cancer Pain
(and probably non-cancer pain too)
Morphine
Pros
200+ years of experience
Cheap
4 formulations – IR elixir
and tablet, SR liquid and
tablet / capsule
Flexibility in dosing,
multiple strengths
available, flexible routes
Predictable titration
schedule
Cons
Metabolites accumulate
in brain and CSF if renal
dysfunction
20 – 30 % population do
not tolerate
Equivalent Doses
Comfortable Dose for Rx
Codeine 60mg qds p.o.
Dihydrocodeine 60mg
qds p.o.
Pethidine 50mg qds p.o.
Tramadol 100mg qds p.o.
Fentanyl 25mcg t.d.
Diamorphine 2.5mg s.c.
every 30 mins
Equivalent 24hr Morphine
Dose
Morphine 25mg
Morphine 25mg
Morphine 25mg
Morphine 40 - 80mg
Morphine 60mg
Morphine 7.5mg p.o.
every 30 mins
Titrating in the community
Easiest method is the 4-hourly plus rescue
1.
2.
3.
4.
5.
6.
Calculate current morphine equivalent / 24hr
+/- make allowance for uncontrolled pain
Divide by 6
4 hourly dose / rescue dose
2 – 3 days record
Review, then divide and convert to sustained
release prep, plus rescue (1/6th of total daily
dose)
Increasing doses of opioid
Gradual escalation of doses if pain control
inadequate
Dose escalations of less than 30 – 50%
are unlikely to have much effect
Experience shows 30 – 50% dose
increases are safe
Absolute dose is immaterial as long as
balance between analgesia / side effects
Less is known about titration for dyspnea
Why / when to switch opioid
Intolerable side effects
Itching, neurotoxicity, that persist despite
appropriate intervention
Lack of desired analgesic effect
Even with rapidly escalating doses
Moderate or severe renal disease
Egfr <60 ??
Alternative route is required
Unstable pain on a patch
Patient’s personal choice / opiophobia
Diamorphine
Pros
Cheap
May work via receptors
other than µ - explaining
the apparent differences
with morphine
More soluble / lipophilic
than morphine –
parenteral use /small
volumes
Quicker action, less
vomiting
Cons
Not useful orally
More sedating than
morphine
Fear / preconceptions of
patients and HCPs
Oxycodone
Pros
Potent drug orally
Flexibility in SR dose
formulations
Effective levels within 1
hour – good for titration
Rectal formulation
Metabolites not part of
the analgesic picture
Possibility of neuropathic
effect
Cons
Differing views in different
countries – USA see it as
a step 2 drug
Common drug of abuse in
USA
Hydromorphone (palladone)
Pros
Multiple routes of admin –
oral, parenteral, rectal
and intraspinal
Very soluble – good for
subcut use
Cons
Oral dosing complicated
and oral breakthrough
dose multiple capsules
Difficulty predicting dose
equivalency with
morphine
Fentanyl & alfentanil
Pros
Transdermal delivery due
to lipophilic nature
Intravenous – rapid onset
of action
Buccal / sublingual /
intranasal immediate
release formulation
Convenience /
compliance
Possibly less constipation
Cons
Delay of effective
analgesia 8 -12 hrs
initially
Poor dosing flexibility
Uncertainty with BMI
Cost
Contraindication in
uncontrolled pain due to
titration period
Patch adhesion problems
Methadone
Pros
Potent orally
Useful in pain with
neurological components
Cons
Unpredictable
accumulation / plasma
concentration rises over
long periods –
unpredictable side effects
Steady state ~ 1 week
Not really practical in
community setting
Please don’t forget
Constipation
– senna/ lactulose
– movicol
– co-danthrusate / co-danthramer
Nausea
– metoclopramide / domperidone
– haloperidol
Where to look for information?
Twycross books are the ‘bibles’
Palliative Care Formulary – 3rd Edition
Symptom management of advanced cancer - 4th
Edition
Introducing Palliative Care
Palliativedrugs.com – online version of PCF
More detail
Oxford Textbook of Palliative Medicine
West Midlands pain handbook