Transcript Palliative management of Head

Palliative care
of Head and neck Oncology patients
Magdy Amin Riad
Professor of Otolaryngology . Ain Shams University
Senior Lecturer in Otolaryngology. University of Dundee
Symptom management
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Breaking difficult news.
Pain control.
Hydration and feeding.
Nausea and vomiting.
Confusion , withdrawal , anxiety or anger.
Unexpected deterioration.
Breaking difficult news
• Setting
Corridors are not appropriate
Time and place
privacy
• Understanding
Language
Hearing
Anxiety
Breaking difficult news
• What do they know
Most people have already guessed the seriousness
Denial
• Knowing more
Check before volunteering
Breaking difficult news
• Warn – pause – check
We found something abnormal
Pause to see response
Check if patient want to know more
Repeat with every statement
Breaking difficult news
• More help
Difficult questions have to be answered
immediately
Acknowledge the importance of the question
Check why the question is being asked
Being honest about uncertainty is acceptable
Diagnosing pain
• At rest.
• Related to movement.
• Persisting pain
Pain at rest
• On inspiration?
Exclude pleurisy
= NSAID
Intercostal block for pain localised to 1-3
dermatomes
Exclude rib metastases
=Consider radiotherapy
Nerve block , .
Pain at rest
• Periodic?
Exclude colic from bowel , bladder or ureter.
=Buscopan 10-20 mg SC
+/- NSAID (diclofenac ) 75 mg IM or
100 mg PR
Pain at rest
• Related to eating?
Exclude dental ,pharyngeal or peptic diseases.
Dental
= appropriate dental care.
Oropharyngeal ulcers
=Difflam or antiseptic mouthwash
Peptic
= ranitidine or omeprazole
Pain at rest
• Localised to dermatome ?
Exclude nerve compression .
= opioid
Exclude skeletal instability (e.g. vertebral collapse)
= immobilise
Exclude bone metastases
= dexamethasone 8 mg /day + opioid
Pain related to movement
• Active movement only?
Muscle strain or spasm
= inject trigger point with 3-5ml bupivacaine
Pain related to movement
• Slightest passive movement?
Exclude a fracture
=immobilise
Pain related to movement
• By bone strain or pressure?
Exclude bone metastases
= dexamethasone 8 mg/ daily or nerve block
Persisting pain
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Analgesic inappropriate.
Analgesic incorrectly administered.
Poor compliance.
Depression.
Unresolved fear or anger.
Pain Scales
• Number Scale
Describe your pain using a number from 0 to 10:
0= No Pain and 10= The worst pain you've ever
had.
• Word Scale
Describe the pain using the words that best tell
us how much you hurt:
No pain; Mild; Moderate; Severe; Very severe; or
Worst possible pain.
• Faces Scale
Place an X or point to the face that shows how
much you hurt
Some pain medications commonly
used include:
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Acetaminophen - Commonly known by its brand name, Tylenol. It takes
care of mild to moderate pain. It usually has very few side effects.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Aspirin and ibuprofen
(Motrin), are some NSAIDs you may know. They are commonly used to
reduce or prevent swelling. Some NSAIDs are available only by
prescription. Others can be purchased over the counter. NSAIDs may not
be the best choice for everyone because of some of their side effects.
Narcotic Analgesics - Also called opiates. These include morphine,
hydromorphone, meperidine, codeine, and oxycodone. Some narcotics are
commonly combined with acetaminophen. These include Tylenol #3,
Percocet, and Lortab. Narcotics are available only by prescription. Side
effects may include drowsiness, stomach upset, nausea, itching, and
constipation. Stool softeners or laxatives may be given if narcotics are used
for more than a few days. Don't drink alcoholic beverages while taking
narcotics.
How are pain medications given?
• Pain medications are given several ways. They may be
given by mouth, or through the nose or rectum. Some
may be given by injection or infusion. In some cases.,
Patient Controlled Analgesia (PCA) may be used. With
the use of PCA, you control a pump that gives you a
small dose of medication every 10-15 minutes. When
pain medications are given by epidural route, medication
is given through a very small tube into the spinal column.
Finally, pain relief may be provided by administering
local anesthetics through a very small tube next to a
nerve bundle, into a joint or directly into the surgical
incision
Pain killers in advanced disease
WHO analgesic staircase
• Paracitamol
• Codeine or dihydrocodiene
• Oral morphine
Start by 10mg/day up to 600 mg /day ,median 120mg
• Titrate opioids.
50% increase every third day.
Hydration and feeding
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Anxiety and depression.
Swallowing problems.
Orientation , confusion.
Constipation.
Nausea and vomiting
Drugs causing nausea , gastric stasis
Hydration and feeding
• IV Infusions
1-3 litres day , for few days
• Nasogastric tubes.
1-3 weeks
• PEG tubes.
Long term feeding
Nausea and vomiting
• Regurgitation.
Inappropriate tube feeding
Pharyng-oesphageal obstruction
• Delayed gastric emptying.
Metoclopramide10-20 mg /8 hours
• Raised intracranial pressure.
Cyclizine 50 mg/8hours
Nausea and vomiting
• Chemical causes.
Hypercalcaemia
Morphine
• Bowel obstruction.
Treat obstruction if possible
If inoperable start cyclizine 150 mg/day SC infusion
Agitation
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Do not leave patient unattended.
Ensure environment is safe.
Do not use opioids to treat agitation.
Hypoxia should be excluded .100%
Oxygen via facemask
• Midazolam 2-10 mg IV or 5mg IM until
settled
Confusion
• Memory failure
Dementia
Cerebral tumour
• Change in alertness.
Drugs
Hypercalcaemia
Cardiac
Pulmonary
Subdural
Confusion
Hallucinations.
Altered behaviour
The withdrawn patient
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Usual behaviour
Refusing help
Confusion
Fears ,guilt or shame.
Clinical depression.
Organic cause
The withdrawn patient
• Usual behaviour
Offer tome to establish trust
• Refusing help
Their right
Acknowledge refusal and offer help in future
• Confusion
The withdrawn patient
• Fears ,guilt or shame.
• Clinical depression.
Persistent low mood for>4weeks , for>50%
of time
4 other depressive symptoms (early morning
rise, diurnal variation, hopelessness..)
Lofepramine 70 mg at night up to 140 mg
The withdrawn patient
• Organic cause
Parkinson’s
Severe fatigue
Drugs causing Parkinson’s like symptoms
The angry patient
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Appropriateness of anger.
Escalating anger.
Depression
Persisting anger.
The angry patient
• Appropriateness of anger.
Explore cause
Show understanding without being defensive
Apologise if it is your fault
Do not apologise for others
The angry patient
• Escalating anger
If anger is not defusing or worsening :
Position yourself near exit door
Set limits
If patient cannot accept limits =pathological anger
Stop interview and leave immediately
The angry patient
• Depression
Anger can be a feature
• Persisting anger.
Consider specialist help
Unexpected deterioration
• Drugs are the cause.
• Uncertainty about treatment.
• Comfort only.
Unexpected deterioration
• Drugs are the cause.
Check medications
Check any recent additions
Reduce dose
Unexpected deterioration
• Uncertainty about treatment.
Review plans
Hour by hour deterioration review every 3 hours
Day by day deterioration review every 3 days
Further deterioration consider treatment for comfort only
Unexpected deterioration
Comfort only
Rapid deterioration
Irreversible cause
Very short prognosis
Patient refusing treatment
Sedation if agitated
Analgesia if in pain
Support patient and family +/-staff
End-of-life Care Just as Important
as Cures
• Being able to have a peaceful death with
dignity can be among the positive
milestones in the cycle of life
• Studies show that up to 88 percent of
people in our country want to die at home
surrounded by their loved ones. Yet the
reality is that only about one in four people
have a peaceful death at home or in a
hospice setting