Transcript Palliative Medicine: the basics

Palliative Medicine:
the basics
Tara Tucker MD FRCPC
Lisa Aldridge MD CCFP
Objectives
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Definition of Palliative Care
The Role of Palliative Medicine
Pain
Constipation
Nausea
Dyspnea
ETHICS
Palliative Care
"an approach that improves the quality of life of
patients and their families facing the problems
associated with life-threatening illness." WHO
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palliative treatments may be used to alleviate the side effects of curative
treatments, such as relieving nausea
1967: Dame Cicely Saunders opens St.
Christopher’s Hospice
1995, first stand alone paediatric hospice
in N.A., Canuck Place, Vancouver
“Dr. Bohen will be out here to talk to you in just a minute – All I can tell
you is that your husband’s condition has stabilized!”
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We will all face death in our lives and in our
work.
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10% of us will die suddenly…. but what about
the rest?
Sudden death,
unexpected cause
< 10%, MI, accident, etc
Health Status
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Death
Time
Steady decline, short
terminal phase
Slow decline, periodic
crises, sudden death
End of Life Care
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Most of us in this room will DO and NEED palliative care…
220 000 Canadians die each year
Process and outcome has tremendous effect on others…
“collateral suffering”
Only 5% people receive integrated, multidisciplinary palliative
care
Cancer patients (25% deaths) receive 90% palliative care
Pain and symptoms are poorly controlled
Medicine’s Shift in Focus
Many health care providers feel they have failed
if the patient dies… our own fear of death may
influence how we approach others
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To cure sometimes
To relieve often
To comfort always
Socrates
Where does Palliative Care fit in?
Disease-focused care
Comfort-focused care
Death
F/up
The Dying Patient:
Your Role
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Relieve suffering
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Provide Comfort and compassion to both
the patient and the family
Formulate a Plan for the
Dying Patient
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Pain Control
Maintain human dignity
Avoid isolation of patient
Discuss with patients their wishes or refer to
advance directive
Provide emotional and spiritual support
Advance Care Planning
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Process of making decisions about future medical care
with the help of health care providers, family and loved
ones
Discuss diagnosis, prognosis, expected course of illness,
treatment alternatives, risks, benefits
In context of patients goals, expectations, values,
beliefs and fears
EOL Decision Making
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People need time to reflect on goals, values, beliefs
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EOL decision making is a process, not a one time event
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Multidisciplinary team to convey info, discuss alternatives,
provide emotional and psychological support – avoid mixed
messages
“What you need, Mr. Terwilliger, is a bit of human
caring; a gentle, reassuring touch; a warm smile that
shows concern--all of which, I’m afraid, were not a part
of my medical training.”
Communication
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Talk about death – find the words
“Hope for the best, plan for the worst”
Lose the medical jargon
Being, not doing
Compassion/presence and balance
Cultural sensitivity
Collaboration with team members
Phrases to Avoid
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“It doesn’t look good”
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“Do you want us to do everything?”
“We will not do anything extraordinary, heroic, or
aggressive.”
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Too vague, be more specific
Implies substandard care
There’s nothing more that we can do.
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Implies abandonment
Language to describe the goals of care…
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We want to give the best care possible until the day you
die.
We will concentrate on improving the quality of your
child’s life.
We want to help you live meaningfully in the time that
you have.
…language to describe the goals of care
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I will focus my efforts on treating your symptoms.
Let’s discuss what we can do to fulfill your wish to stay
at home.
Withholding or Withdrawing
Treatment
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What does the pt/family know and understand about life
sustaining Rx – ie: risks and benefits
What are the goals of care/ pt’s wishes
Explain how it will be done and what to expect
How will pain/distress be managed
Pertinent religious/cultural issues
Time limited trials for some interventions ie: dialysis
“I wish you’d called me sooner, Mrs. Moodie.”
When to call on Palliative Medicine
Specialist?
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Early in the trajectory of life limiting illness –
again, find the words to use
When major decisions have to made re:
treatment
When symptom management is problematic
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Pain
“an unpleasant sensory or emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage”
World Health Organization
Pain
“a state of distress associated with events that
threaten the intactness of a person”
Eric J Cassell. The Nature of Suffering and the
Goals of Medicine. NEJM 1982; 306: 639-645
Pain
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Chronic pain serves no physiologic purpose
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Under-treated pain may lead to depression
and suicide
Total Pain Pie
physical
e.g. arthritis,
bowel spasms,
headache
caused by CVA
social
Loss of role, loss
of social
contacts
emotional
e.g. depression,
anxiety, loss of
control
spiritual
- search for meaning
Lili/presentations/1999/pie.ppt
Causes of Cancer Pain
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Direct effects of the disease
Related to disease ie: constipation
Secondary to treatment – 20%
Surgery
 Chemotherapy
 Radiation
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Physiological Pain Categories
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Nociceptive –localised
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Somatic: superficial, deep
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Visceral
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Bone mets, cellulitis
Infiltration, compression, distension of viscera
Neuropathic – may radiate along dermatome, nerve
distribution
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TGN, herpes zoster
Neuropathic Pain
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Sympathetic
Central
Peripheral (non-sympathetic)
Neuropathic Pain
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Spontaneous pain
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Dysesthesia
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Neuralgia
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e.g. burning
e.g. lancinating, “electric shocks”
Evoked pain
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Allodynia
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Hyperalgesia
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Pain from a non-painful stimulus
Pain more than expected from a mildly painful stimulus
Hyperpathia
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Explosive build-up of pain with repetitive stimuli
Evaluating Pain
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Believe the patient
Initiate discussions
Detailed pain history
Careful physical exam
Investigations
Monitor results of treatment
Pain History – the key!
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P = provokes and palliates
Q = quality
R = Radiates - location
S = severity
T = time – duration, time of day
O = other ie: red flags
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Headache + vomiting
Principles of Analgesic Therapy
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By the mouth
By the clock
By the ladder
For the individual
Attention to detail
The ideal treatment for any pain is to remove the
cause.
Treating Pain
Use a Multidisciplinary approach
 Medications
 Counselling
 Physical
Therapy
 Nerve block
 Surgery
WHO Pain Ladder
WHO Pain Ladder
3
Severe
Morphine
2 Moderate
Hydromorphone
Methadone
1
Acetaminophen +
Codeine
Mild
Acetaminophen +
Oxycodone
Acetaminophen
± NSAIDs
NSAIDs
± Adjuvants
± Adjuvants
Fentanyl
Oxycodone
± Acetaminophen
± NSAIDs
± Adjuvants
NSAIDS
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Antiinflammatory
Adverse effects
Gastropathy, renal failure, platelet inhibition, cardiac
 Risk factors
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Age, PUD, cachexia, dehydration, steroids, comorbid
conditions
Combination medications
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Percocet (oxycodone and tylenol)
Tylenol #3 (Codeine and tylenol)
Limited by dose of acetaminophen
Opioids:choosing the right
drug
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Morphine is first line
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Morphine metabolites will accumulate in renal
failure patients; suggest fentanyl or hydromorphone
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Do NOT use meperidine (Demerol) due to
metabolites causing adverse effects
Opioids – choosing the right drug
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Pt’s previous experience with opioids
Compliance
Fears and myths – pt + MD!
Physician comfort + experience
Opioids – choosing the right dose
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Opioid naïve patient
Morphine 2.5 - 5 – 10 mg po q4h
 Hydomorphone 0.5 – 1 mg po q4h
 Oxycodone 2.5 - 5 mg po q4h
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Percocet
Some references give higher starting doses –
CAUTION!
Opioids – choosing the right
schedule
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Immediate Release (IR)
Q4h dosing – straight
 Prn q1-2h at 10% of daily dose
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Sustained release (the Contins)
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Q12h, prn IR 10% daily dose
Opioids – adverse events
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Common
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Constipation is easier to prevent than treat
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Softener + laxative
Nausea (tolerance develops)
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Maxeran, Haldol
 Sedation
(tolerance develops)
 Dry mouth
Opioids - Adverse events
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Less common
Urinary retention
 Pruritis
 Delirium
 Myoclonus
 Psychotomimetic effects
 Postural hypotension
 Vertigo
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Opioids – adverse events
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Rare
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Allergy
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Codeine allergy most common, unlikely cross-reactivity
with other opioids
Respiratory depression
Fentanyl Patch
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See table for equianalgesic doses
For stable pain
Dosage increases in 2-3 day intervals
Careful in opioid naïve patients!
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25 mcg/hr= 90 mg/d morphine = 18 mg/d
hydromorphone
Withdrawal…
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Tachycardia, hypertension, diaphoresis, pilo-erection,
N, V, diarrhea, body aches, abdo pain, psychosis,
hallucinations
Opioids and Tolerance
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Characterized by decreased efficacy and duration
of action with prolonged repeated use of the
drug
Need for higher doses to maintain same level of
analgesia
Normal pharmacological response
Opioids and Psychological
Dependence
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Addiction
Characterized by craving for the drug and a
preoccupation for it
Rarely occurs in cancer patients
Beware of labeling a patient who actually has
uncontrolled pain
Screening for addiction potential (CAGE)
“I hate to tell you this, but I’ve still got the headache.”
Anti-convulsants
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Carbamazepine
Block Sodium channels
 Reduce hyperexcitability
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Gabapentin
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Action unclear, ? Ca channels
SE: dizziness, sedation
Tri-cyclic antidepressants
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Nortriptylline 10 mg po qHS
Inhibit serotonin and NE reuptake
 Block Sodium channels
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SE: dry mouth, sedation, hypotension
Constipation
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Debility
Decreased fluids and food
Metabolic: hypothyroid, hypokalemia,
hypercalcemia
DRUGS
Autonomic dysfunction: DM, CA, SCC
Obstruction
DRUGS
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Anticholinergics: ex TCAs
Antacids
Iron
Zofran
Diuretics
Anticonvulsants
NSAIDS
Chemotherapy
OPIOIDS
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Increase Bowel tone
Decrease pancreatic and biliary secretions
Delay Gastric emptying
Decrease peristalsis
Increase transit time
Decrease the urge to defecate
Managing Constipation
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PRIVACY
Increase fluids and activity
R/O obstruction, with an Xray if necessary
All patients starting on Opioids need laxatives
Suggested Laxative Regime
Start:
Stimulant: Senokot 2-4 tabs po qhs and
Softener: Colace 200mg po daily
If needed add:
Osmotic agent: Lactulose 30 cc po BID prn or M of M 60 mls/ day
If needed:
Rectal agents: Bisocodyl supp and/ or Fleet enema
Warning…
Fiber + no water = cement
DELIRIUM: Common and under-recognized
A Disturbance in consciousness
Characterized by:
decreased attention, acute onset & fluctuation
Causes of Delirium
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Metabolic: Hypoxemia, Hypoglycemia, Hypothyroid,
Thiamine def ’n
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Electrolyte AbN: High Na++, Ca++, or Mg++
Drugs and toxins: opioids, anticholinergics, withdrawal
Organ failure: RF, Liver, CHF, CO2, sepsis
Brain: tumor, infection, vascular events, seizures
Management
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Determine WHO is at risk
Screen with MMSE
Find underlying cause
Obtain collateral history
Consent when delirious
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You may use : ”substituted judgment” – if you
know the patient well
Use a substitute-decision maker otherwise
Treat without consent if in an emergency
Treatment for Delirium
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Haldol or atypical antipsychotic (olanzapine,
risperidone)
NO Ativan
Causes of Nausea
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GI: gerd, motility, tumor, gastritis, obstruction
BRAIN: High ICP, tumor, anxiety
EAR: Vestibular disturbances
DRUGS
SYSTEMIC: infection, toxins, uremia
CANCER: paraneoplastic syndromes, ov ca
Treatment – mechanistic approach
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Drugs, toxins, metabolic (CRTZ)
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Vestibular
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Anti-dopaminergic: maxeran, haldol
anticholinergic, antihistamines
Chemo/radiation - ondansetron
Dyspnea
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Treat the cause
O2 if helpful or hypoxic
Opioids
Double Effect
Appropriate treatment of pain is morally
acceptable even if it hastens death as long as
there was no intention to do so.
Physician Assisted Suicide
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The physician supplies the patient with the
means, usually medication, to end their life. Not
legal in Canada.
Euthanasia
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The physician administers a medication with the
intent of causing death. Also not legal in
Canada.
Speak gently, treat aggressively
“SAVE the patient you idiot!! I said we’ve got
to do whatever we can to SAVE the patient!!”