Transcript Palliative Care - no pictures

Prescribing for Palliative Patients;
a primary care approach
Dr Laura Smith
GP ST1
Contents
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The role of the GP in palliative care
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Out of hours – out of ideas?
Pain
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Assessment
Analgesia
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Quiz
Which one?
When?
Which Route?
The role of the GP in palliative care
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Palliative care: 'the active, holistic care of patients with
advanced, progressive illness'
Why is the GP ideal to facilitate this?
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long-established relationships with their patients
used to dealing with co-morbidity and uncertainty
trained to treat patients holistically
Care needs to be PROACTIVE
When should we think about palliative care?
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If a patient is diagnosed with cancer?
If a patient needs a syringe driver?
If a patient has hours to live?
...When a patient is in the last year of their life (GSF)
Identify
GP
Assess
Plan
Imagine you are a GP...
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How many of your patients are in the last year of their life?
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10%
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1%
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0.1%
On average, each GP has 20 deaths per year:
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How many of these will be from cancer?
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How many will be from organ failure?
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How many from dementia/frailty or MOF?
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How many will be sudden/unexpected?
Out of hours – out of ideas?
Groups of 2-3
Imagine you are working as the OOH GP: you are called out to a
patient who is near the end of life suffering with cancer.
His wife is concerned because...
...he won't stop hiccuping doctor, it has been going on for hours!
What would you prescribe?
Pain in Palliative Care
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How many patients with cancer suffer pain?
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10%
30%
50%
70%
100%
How many patients dying with non malignant disease suffer
pain?
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25%
45%
65%
85%
Pain tolerance
Physio
Sleep
Social inclusion
Relief of symptoms
Relaxation
Boredom
Insomnia
Diversion
Mental isolation
Depression
Understanding
Explanation
Discomfort
Elevated mood
Finding meaning
Fatigue
Anger
Listening
Insomnia
Sadness
Anxiety
Fear
Pain is a complex subjective phenomenon and is affected by the
emotional context in which it is endured
History taking
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SOCRATES
Physical effects or manifestations
Functional impact of pain
Psychosocial factors
Spiritual aspects
Self assessment important as pain subjective
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Help patient to actively manage their pain
What is causing the pain?
The WHO pain ladder
Adjuvants
Drugs
Indications
NSAIDS
Bone pain
Hepatomegaly
Soft tissue infiltration
Corticosteroids
Raised ICP
Nerve compression
Hepatomegaly
Soft tissue infiltration
Antidepressants/Anticonvulsants
Nerve compression
Paraneoplastic neuropathies
Bisphosphonates
Bone pain
Ketamine
Neuropathic pain
Ischaemic limb pain
Non Opiates
Paracetamol
Weak
Few side effects
NSAIDS
Good for bone pain
SE: GI Bleed
Opiates
Weak opioids
Codiene
Tramadol
Use with non-opioids
Strong opioids
Morphine
“For patients with no renal or hepatic comorbidities, offer a
typical total daily starting dose schedule of 20-30 mg of
oral morphine plus 5 mg oral immediate-release morphine
for rescue doses during the titration phase” NICE
Converting between oral preparations
Converting from
Converting to
Codeine
Morphine
Divide by 10
Tramadol
Morphine
Divide by 5
Morphine
Oxycodone
Divide by 2
Example:
Mr Jones takes 60mg of codeine qds for his bony mets but is still
in agony – what dose of morphine would you start him on?
Answer: 60 x 4 = 240mg in 24 hours of codeine
240 / 10 = 24mg morphine needed in 24 hours
Therefore try 5mg every four hours = 30 mg in 24 hours
Breakthrough pain
1/6th of total 24 hour dose can be given as a “rescue
dose” for pain between doses of regular morphine
This can be repeated every 4 hours
AIM: Prevent pain, not relieve pain
Parental route of administration
When should this be used:
Patient unable to swallow, vomiting, weakness, dysphagia
IM/SC morphine = ½ oral morphine dose
IM/SC diamorphine = 1/3 oral morphine dose
Transdermal route of administration
NOT for acute pain, or for patients whose analgesic
requirements change rapidly
Use if: problems with oral route, constipation, subacute
obstruction or morphine intolerance
Oral Morphine Dose
Patch equivalent
45mg daily
Fentanyl “12” patch
90mg daily
Fentanyl “25” patch
180mg daily
Fentanyl “50” patch
270mg daily
Fentanyl “75” patch
360mg daily
Fentanyl “100” patch
Poor kidney function: preventing and managing opioid
toxicity
Consider dose reduction +/- increased dose interval
Use immediate-release oral formulation
Switch to alfentanil, buprenorphine or fentanyl, which are the
opioids of choice where eGFR <30ml/minute
Frequent monitoring and review
Seek specialist advice
Top Tips
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Continuous pain = regular analgesia NOT prn
Take breakthrough analgesia before undertaking a
potentially pain-provoking activity
KISS: Minimum number of drugs in the most acceptable
form and dose intervals possible
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Written guidance for patients and families
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Regular review of effectiveness and side effects
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Adequate prn medications
Quiz
Mr Smith comes to see you in your morning surgery.
18 months ago he was diagnosed with bowel cancer.
He underwent surgery and chemotherapy but 1 month ago was
diagnosed with recurrence with spread to the liver.
He comes to see you as he is getting worsening continuous
abdominal pain.
You take a careful history and you wish to change his pain
relief.
Question 1
Mr Smith currently takes:
Paracetamol 1g po qds
Ibuprofen 400mg po tds
Codeine 60mg qds
Oral morphine 20mg immediate release tablets twice daily
You wish to convert him to a higher dose of morphine and stop
the codeine – what dose of immediate release morphine
tablets will you prescribe?
A) 10mg prn
B) 10mg 4 hourly
C) 5mg 4 hourly
D) 20mg 4 hourly
Question 2
What breakthrough dose of oromorph does he need?
A)10mg
B) 5mg
C) 6mg
D) 10ml
Question 3
Mr Smith returns to the surgery later that week. You review his
analgesia use:
He has taken 10mg four hourly regularly but most days has
needed a breakthrough dose before bed and when taking his
dog for a walk (twice a day).
How would you alter his morphine dose?
A) 45mg four hourly with 10mg breakthrough
B) 15mg four hourly with 10mg breakthrough
C) 15mg four hourly with 15mg breakthrough
D) 20mg four hourly with 20mg breakthrough
Question 4
As a good GP what else might you prescribe Mr Smith when
you prescribe his morphine?
A)Naloxone
B)Phosphate enema
C)Lactulose and senna
D)Ondansetron
Question 5
Mr Smith comes the following week – his pain much better
controlled and he is not needing any breakthrough treatment,
but is concerned that he feels he is taking medication all the
time.
What could you do?
A)Tell him to skip some doses and see how he feels
B)Convert him to a twice daily morphine slow release dose of
45mg bd
C)Convert him to a twice daily morphine slow release dose of
90mg bd
D)Prescribe a fentanyl “25” patch
Question 6
2 months later you are asked to see Mr Smith on a home visit.
He has been reviewed by your colleagues and is now taking
75mg bd or MR morphine sulphate tablets.
He now describes a burning and tingling type pain in his feet
which is making it difficult to walk. It started 14 months ago
after the chemotherapy but is now worsening.
What would you prescribe?
A) MR MST 90mg bd
B) Amitriptiline 10mg po nocte
C) Gabapentin 600mg tds
D) Crutches
Question 7
Unfortunately several weeks later Mr Smith is admitted to
hospital overnight unwell with confusion. When discharged
home the EDS notes for GP state: “Please alter medication
as found to have renal impairment.”
On his last repeat prescription he was on 90mg bd MR MST,
ibuprofen 400mg tds, amitriptiline 10mg nocte with 30mg
oromorph as breakthrough prn, lactulose 10ml bd, senna TT
po nocte.
Which of his medicines needs to be altered?
A)Reduce ibuprofen only
B)Stop MST only
C)Stop ibuprofen, change MST to fentanyl patch
D)Reduce ibupofen, change MST to fentanyl patch
Question 8
What dose of fentanyl patch will you prescribe and when should
it be started?
A) Fentanyl “50” apply at same time as last dose of MR MST
given
B) Fentanyl “25” apply 12 hours after last dose MR MST given
C) Fentanyl “75” apply at same time as last dose of MR MST
given
D) Fentanyl “12” apply 12 hours after last dose MR MST given
Question 8
Luckily whilst you are working this out the receptionist receives
a phone call from the oncall FY1 – who sent the EDS in
error: the patient does not have renal failure – but has
deteriorated so could you do a home visit to check on him?
On visiting the patient you confirm that he has quickly
deteriorated, but he wishes to die at home, with his family
supporting him. He is too weak to swallow tablets, and
seems in pain.
You wish to convert his 90mg bd MR MST to subcut
diamorphine - what is the daily dose?
A) 45mg
B) 30mg
C) 90mg
D) 60mg
Question 9
The Macmillan nurse telephones you to let you know that no
diamorphine is in stock – they only have sub cut morphine
can you re-prescribe it?
What daily dose do you use now?
A) 45mg
B) 30mg
C) 90mg
D) 60mg
Question 10
You visit Mr Smith on a home visit 3 days later. He is in bed,
and is asleep. His breathing has slowed but is very noisy due
to secretions. His wife is upset thinking that he is in distress.
You think he may be entering the last few hours of life.
What might you prescribe?
A) Increase his morphine to speed up his death and lessen the
agony for his wife.
B) Hyoscine hydrobromide 400 microgram subcut
C) Midazolam 2.5-5mg subcut
D) Cyclizine 50mg subcut
Summary
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The role of the GP in palliative care
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Pain
–
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Assessment
Analgesia
•
•
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Which one?
When?
Which Route?
References
Pain Control in Palliative Care: Patient.co.uk
Liverpool Care Pathway for the Dying Patient (LCP)
Palliative Care Guidelines: NHS Scotland
Opioids in palliative care: safe and effective prescribing of
strong opioids for pain in palliative care of adults: NICE
guidelines
Final thoughts
Mr Smith passes away peacefully that night. His family are
happy with the care he has received and thank you for not
putting him on that awful death pathway like they do in
Liverpool!
How do you respond?