Palliative Medicine: the basics
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Transcript of Palliative Medicine: the basics
Palliative Palliative Medicine: Medicine:
the basicsthe basics
Tara Tucker MD FRCPCTara Tucker MD FRCPC
Lisa Aldridge MD CCFPLisa Aldridge MD CCFP
ObjectivesObjectives
Definition of Palliative CareDefinition of Palliative Care The Role of Palliative MedicineThe Role of Palliative Medicine PainPain ConstipationConstipation NauseaNausea DyspneaDyspnea ETHICSETHICS
Palliative CarePalliative Care
"an approach that improves the "an approach that improves the quality of life of patients and their quality of life of patients and their families facing the problems families facing the problems associated with life-threatening associated with life-threatening illness." WHOillness." WHO
palliative treatments may be used to alleviate the side palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving effects of curative treatments, such as relieving nauseanausea
1967: Dame Cicely Saunders opens 1967: Dame Cicely Saunders opens St. Christopher’s HospiceSt. Christopher’s Hospice
1995, first stand alone 1995, first stand alone paediatric paediatric hospice in N.A., hospice in N.A.,
Canuck Place, VancouverCanuck 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!”
We will all face death in our lives We will all face death in our lives and in our work.and in our work.
10% of us will die suddenly…. but 10% of us will die suddenly…. but what about the rest?what about the rest?
Sudden death, unexpected causeSudden death, unexpected cause < 10%, MI, accident, etc < 10%, MI, accident, etc< 10%, MI, accident, etc
Death
Time
He
alth
Sta
tus
Steady decline, short terminal phaseSteady decline, short terminal phase
Slow decline, periodic crises, sudden deathSlow decline, periodic crises, sudden death
End of Life CareEnd of Life Care
Most of us in this room will DO and NEED Most of us in this room will DO and NEED palliative care…palliative care…
220 000 Canadians die each year220 000 Canadians die each year Process and outcome has tremendous effect on Process and outcome has tremendous effect on
others… “collateral suffering”others… “collateral suffering” Only 5% people receive integrated, Only 5% people receive integrated,
multidisciplinary palliative caremultidisciplinary palliative care Cancer patients (25% deaths) receive 90% Cancer patients (25% deaths) receive 90%
palliative carepalliative care Pain and symptoms are poorly controlledPain and symptoms are poorly controlled
Medicine’s Shift in FocusMedicine’s Shift in Focus
Many health care providers feel they Many health care providers feel they have failed if the patient dies… our have failed if the patient dies… our own fear of death may influence how own fear of death may influence how we approach otherswe approach others
To cure sometimesTo cure sometimes To relieve oftenTo relieve often To comfort alwaysTo comfort always
SocratesSocrates
Where does Palliative Care fit Where does Palliative Care fit in?in?
Disease-focused care
Death Comfort-focused care F/up
The Dying Patient:The Dying Patient:Your RoleYour Role
Relieve sufferingRelieve suffering
Provide Comfort and compassion Provide Comfort and compassion to both the patient and the familyto both the patient and the family
Formulate a Plan for Formulate a Plan for the Dying Patientthe Dying Patient
Pain ControlPain Control Maintain human dignityMaintain human dignity Avoid isolation of patientAvoid isolation of patient Discuss with patients their wishes Discuss with patients their wishes
or refer to advance directiveor refer to advance directive Provide emotional and spiritual Provide emotional and spiritual
supportsupport
Advance Care PlanningAdvance Care Planning Process of making decisions about future Process of making decisions about future
medical care with the help of health care medical care with the help of health care providers, family and loved onesproviders, family and loved ones
Discuss diagnosis, prognosis, expected Discuss diagnosis, prognosis, expected course of illness, treatment alternatives, course of illness, treatment alternatives, risks, benefitsrisks, benefits
In context of patients goals, expectations, In context of patients goals, expectations, values, beliefs and fearsvalues, beliefs and fears
EOL Decision MakingEOL Decision Making People need time to reflect on goals, values, People need time to reflect on goals, values,
beliefsbeliefs
EOL decision making is a process, not a one EOL decision making is a process, not a one time eventtime event
Multidisciplinary team to convey info, discuss Multidisciplinary team to convey info, discuss alternatives, provide emotional and psychological alternatives, provide emotional and psychological support – avoid mixed messagessupport – 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.”
CommunicationCommunication
Talk about death – find the wordsTalk about death – find the words ““Hope for the best, plan for the worst”Hope for the best, plan for the worst” Lose the medical jargonLose the medical jargon Being, not doingBeing, not doing Compassion/presence and balanceCompassion/presence and balance Cultural sensitivityCultural sensitivity Collaboration with team membersCollaboration with team members
Phrases to AvoidPhrases to Avoid
““It doesn’t look good”It doesn’t look good” Too vague, be more specificToo vague, be more specific
““Do you want us to do everything?”Do you want us to do everything?” ““We will not do anything extraordinary, We will not do anything extraordinary,
heroic, or aggressive.”heroic, or aggressive.” Implies substandard careImplies substandard care
There’s nothing more that we can do.There’s nothing more that we can do. Implies abandonmentImplies abandonment
Language to describe the goals Language to describe the goals of care…of care…
We want to give the best care possible We want to give the best care possible until the day you die.until the day you die.
We will concentrate on improving the We will concentrate on improving the quality of your child’s life.quality of your child’s life.
We want to help you live meaningfully in We want to help you live meaningfully in the time that you have.the time that you have.
……language to describe the language to describe the goals of caregoals of care
I will focus my efforts on treating your I will focus my efforts on treating your symptoms.symptoms.
Let’s discuss what we can do to fulfill your Let’s discuss what we can do to fulfill your wish to stay at home.wish to stay at home.
Withholding or Withholding or Withdrawing Withdrawing TreatmentTreatment
What does the pt/family know and understand What does the pt/family know and understand about life sustaining Rx – ie: risks and benefitsabout life sustaining Rx – ie: risks and benefits
What are the goals of care/ pt’s wishesWhat are the goals of care/ pt’s wishes Explain how it will be done and what to expectExplain how it will be done and what to expect How will pain/distress be managedHow will pain/distress be managed Pertinent religious/cultural issuesPertinent religious/cultural issues Time limited trials for some interventions ie: Time limited trials for some interventions ie:
dialysisdialysis
“I wish you’d called me sooner, Mrs. Moodie.”
When to call on Palliative When to call on Palliative Medicine Specialist?Medicine Specialist?
Early in the trajectory of life limiting Early in the trajectory of life limiting illness – again, find the words to useillness – again, find the words to use
When major decisions have to made When major decisions have to made re: treatmentre: treatment
When symptom management is When symptom management is problematicproblematic
……
PainPain
““an unpleasant sensory or emotional an unpleasant sensory or emotional experience associated with actual or experience associated with actual or potential tissue damage, or potential tissue damage, or described in terms of such damage”described in terms of such damage”
World Health World Health OrganizationOrganization
PainPain
““a state of distress associated with a state of distress associated with events that threaten the intactness events that threaten the intactness of a person”of a person”
Eric J Cassell. The Nature of Suffering and the Eric J Cassell. The Nature of Suffering and the
Goals of Medicine. NEJM 1982; 306: 639-645Goals of Medicine. NEJM 1982; 306: 639-645
PainPain
Chronic pain serves no Chronic pain serves no physiologic purposephysiologic purpose
Under-treated pain may lead to Under-treated pain may lead to depression and suicidedepression and suicide
physical emotional
social spiritual
e.g. arthritis, bowel spasms, headache caused by CVA
e.g. depression, anxiety, loss of control
Loss of role, loss of social contacts
- search for meaning
Total Pain Pie
Lili/presentations/1999/pie.ppt
Causes of Cancer PainCauses of Cancer Pain
Direct effects of the diseaseDirect effects of the disease Related to disease ie: constipationRelated to disease ie: constipation Secondary to treatment – 20%Secondary to treatment – 20%
SurgerySurgery ChemotherapyChemotherapy RadiationRadiation
Physiological Pain Physiological Pain CategoriesCategories
Nociceptive –localisedNociceptive –localised Somatic: superficial, deepSomatic: superficial, deep
Bone mets, cellulitisBone mets, cellulitis VisceralVisceral
Infiltration, compression, distension of visceraInfiltration, compression, distension of viscera
Neuropathic – may radiate along Neuropathic – may radiate along dermatome, nerve distributiondermatome, nerve distribution
TGN, herpes zosterTGN, herpes zoster
Neuropathic PainNeuropathic Pain
Sympathetic Sympathetic CentralCentral Peripheral (non-sympathetic)Peripheral (non-sympathetic)
Neuropathic PainNeuropathic Pain Spontaneous painSpontaneous pain
DysesthesiaDysesthesia e.g. burninge.g. burning
NeuralgiaNeuralgia e.g. lancinating, “electric shocks”e.g. lancinating, “electric shocks”
Evoked painEvoked pain AllodyniaAllodynia
Pain from a non-painful stimulusPain from a non-painful stimulus HyperalgesiaHyperalgesia
Pain more than expected from a mildly painful Pain more than expected from a mildly painful stimulusstimulus
HyperpathiaHyperpathia Explosive build-up of pain with repetitive stimuliExplosive build-up of pain with repetitive stimuli
Evaluating PainEvaluating Pain
Believe the patientBelieve the patient Initiate discussionsInitiate discussions Detailed pain historyDetailed pain history Careful physical examCareful physical exam InvestigationsInvestigations Monitor results of treatmentMonitor results of treatment
Pain History – the key!Pain History – the key!
P = provokes and palliatesP = provokes and palliates Q = qualityQ = quality R = Radiates - locationR = Radiates - location S = severityS = severity T = time – duration, time of dayT = time – duration, time of day O = other ie: red flagsO = other ie: red flags
Headache + vomitingHeadache + vomiting
Principles of Analgesic Principles of Analgesic TherapyTherapy
By the mouthBy the mouth By the clockBy the clock By the ladderBy the ladder For the individualFor the individual Attention to detailAttention to detail
The ideal treatment for any pain is to The ideal treatment for any pain is to remove the cause.remove the cause.
Treating PainTreating PainUse a Multidisciplinary approachUse a Multidisciplinary approach
MedicationsMedications CounsellingCounselling Physical TherapyPhysical Therapy Nerve blockNerve block SurgerySurgery
WHO Pain LadderWHO Pain Ladder
WHO Pain LadderWHO Pain Ladder
1 Mild
2 Moderate
3 Severe
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
± Acetaminophen
± NSAIDs
± Adjuvants
Acetaminophen + Codeine
Acetaminophen + Oxycodone
± NSAIDs
± Adjuvants
Acetaminophen
NSAIDs
± Adjuvants
NSAIDSNSAIDS
AntiinflammatoryAntiinflammatory Adverse effectsAdverse effects
Gastropathy, renal failure, platelet Gastropathy, renal failure, platelet inhibition, cardiacinhibition, cardiac
Risk factorsRisk factors Age, PUD, cachexia, dehydration, steroids, Age, PUD, cachexia, dehydration, steroids,
comorbid conditionscomorbid conditions
Combination Combination medicationsmedications
Percocet (oxycodone and tylenol)Percocet (oxycodone and tylenol) Tylenol #3 (Codeine and tylenol)Tylenol #3 (Codeine and tylenol) Limited by dose of acetaminophenLimited by dose of acetaminophen
Opioids:choosing the Opioids:choosing the right drugright drug
Morphine is first lineMorphine is first line
Morphine metabolites will accumulate Morphine metabolites will accumulate in renal failure patients; suggest in renal failure patients; suggest fentanyl or hydromorphonefentanyl or hydromorphone
Do NOT use meperidine (Demerol) due Do NOT use meperidine (Demerol) due to metabolites causing adverse effectsto metabolites causing adverse effects
Opioids – choosing the right Opioids – choosing the right drugdrug
Pt’s previous experience with Pt’s previous experience with opioidsopioids
ComplianceCompliance Fears and myths – pt + MD!Fears and myths – pt + MD! Physician comfort + experiencePhysician comfort + experience
Opioids – choosing the right Opioids – choosing the right dosedose
Opioid naïve patientOpioid naïve patient Morphine 2.5 - 5 – 10 mg po q4hMorphine 2.5 - 5 – 10 mg po q4h Hydomorphone 0.5 – 1 mg po q4hHydomorphone 0.5 – 1 mg po q4h Oxycodone 2.5 - 5 mg po q4hOxycodone 2.5 - 5 mg po q4h
PercocetPercocet Some references give higher starting Some references give higher starting
doses – CAUTION! doses – CAUTION!
Opioids – choosing the right Opioids – choosing the right schedule schedule
Immediate Release (IR)Immediate Release (IR) Q4h dosing – straightQ4h dosing – straight Prn q1-2h at 10% of daily dosePrn q1-2h at 10% of daily dose
Sustained release (the Contins)Sustained release (the Contins) Q12h, prn IR 10% daily doseQ12h, prn IR 10% daily dose
Opioids – adverse eventsOpioids – adverse events
CommonCommon Constipation is easier to prevent than Constipation is easier to prevent than
treattreat Softener + laxativeSoftener + laxative
Nausea (tolerance develops)Nausea (tolerance develops) Maxeran, HaldolMaxeran, Haldol
Sedation (tolerance develops)Sedation (tolerance develops) Dry mouthDry mouth
Opioids - Adverse eventsOpioids - Adverse events
Less commonLess common Urinary retentionUrinary retention PruritisPruritis DeliriumDelirium MyoclonusMyoclonus Psychotomimetic effectsPsychotomimetic effects Postural hypotensionPostural hypotension VertigoVertigo
Opioids – adverse eventsOpioids – adverse events
RareRare AllergyAllergy
Codeine allergy most common, unlikely Codeine allergy most common, unlikely cross-reactivity with other opioidscross-reactivity with other opioids
Respiratory depressionRespiratory depression
Fentanyl PatchFentanyl Patch
See table for equianalgesic dosesSee table for equianalgesic doses For stable painFor stable pain Dosage increases in 2-3 day Dosage increases in 2-3 day
intervalsintervals Careful in opioid naïve patients!Careful in opioid naïve patients!
25 mcg/hr= 90 mg/d morphine = 18 25 mcg/hr= 90 mg/d morphine = 18 mg/d hydromorphonemg/d hydromorphone
Withdrawal…Withdrawal…
Tachycardia, hypertension, diaphoresis, Tachycardia, hypertension, diaphoresis, pilo-erection, N, V, diarrhea, body pilo-erection, N, V, diarrhea, body aches, abdo pain, psychosis, aches, abdo pain, psychosis, hallucinationshallucinations
Opioids and ToleranceOpioids and Tolerance
Characterized by decreased efficacy Characterized by decreased efficacy and duration of action with and duration of action with prolonged repeated use of the drugprolonged repeated use of the drug
Need for higher doses to maintain Need for higher doses to maintain same level of analgesiasame level of analgesia
Normal pharmacological responseNormal pharmacological response
Opioids and Psychological Opioids and Psychological DependenceDependence
AddictionAddiction Characterized by craving for the drug Characterized by craving for the drug
and a preoccupation for itand a preoccupation for it Rarely occurs in cancer patientsRarely occurs in cancer patients Beware of labeling a patient who Beware of labeling a patient who
actually has uncontrolled painactually has uncontrolled pain Screening for addiction potential Screening for addiction potential
(CAGE)(CAGE)
“I hate to tell you this, but I’ve still got the headache.”
Anti-convulsantsAnti-convulsants
Carbamazepine Carbamazepine Block Sodium channelsBlock Sodium channels Reduce hyperexcitabilityReduce hyperexcitability
GabapentinGabapentin Action unclear, ? Ca channels Action unclear, ? Ca channels
SE: dizziness, sedationSE: dizziness, sedation
Tri-cyclic Tri-cyclic antidepressantsantidepressants
Nortriptylline 10 mg po qHS Nortriptylline 10 mg po qHS Inhibit serotonin and NE reuptakeInhibit serotonin and NE reuptake Block Sodium channelsBlock Sodium channels
SE: dry mouth, sedation, SE: dry mouth, sedation, hypotensionhypotension
ConstipationConstipation
DebilityDebility Decreased fluids and foodDecreased fluids and food Metabolic: hypothyroid, Metabolic: hypothyroid,
hypokalemia, hypercalcemiahypokalemia, hypercalcemia DRUGSDRUGS Autonomic dysfunction: DM, CA, Autonomic dysfunction: DM, CA,
SCCSCC ObstructionObstruction
DRUGSDRUGS
Anticholinergics: ex TCAsAnticholinergics: ex TCAs AntacidsAntacids IronIron ZofranZofran DiureticsDiuretics AnticonvulsantsAnticonvulsants NSAIDSNSAIDS ChemotherapyChemotherapy
OPIOIDSOPIOIDS
Increase Bowel toneIncrease Bowel tone Decrease pancreatic and biliary Decrease pancreatic and biliary
secretionssecretions Delay Gastric emptyingDelay Gastric emptying Decrease peristalsisDecrease peristalsis Increase transit timeIncrease transit time Decrease the urge to defecateDecrease the urge to defecate
Managing ConstipationManaging Constipation
PRIVACYPRIVACY Increase fluids and activityIncrease fluids and activity R/O obstruction, with an Xray if R/O obstruction, with an Xray if
necessarynecessary All patients starting on Opioids need All patients starting on Opioids need
laxativeslaxatives
Suggested Laxative Suggested Laxative RegimeRegime
Start:Start:Stimulant: Senokot 2-4 tabs po qhs andStimulant: Senokot 2-4 tabs po qhs andSoftener: Colace 200mg po dailySoftener: Colace 200mg po daily
If needed add:If needed add:Osmotic agent: Lactulose 30 cc po BID prn or M of Osmotic agent: Lactulose 30 cc po BID prn or M of
M 60 mls/ dayM 60 mls/ day
If needed:If needed:Rectal agents: Bisocodyl supp and/ or Fleet enemaRectal agents: Bisocodyl supp and/ or Fleet enema
Warning… Warning…
Fiber + no water = cementFiber + no water = cement
DELIRIUM: DELIRIUM: Common and under-Common and under-recognizedrecognized
A Disturbance in consciousnessA Disturbance in consciousness
Characterized by:Characterized by:
decreased attention, acute onset & decreased attention, acute onset & fluctuationfluctuation
Causes of Delirium Causes of Delirium
Metabolic: Metabolic: Hypoxemia, Hypoglycemia, Hypoxemia, Hypoglycemia, Hypothyroid, Thiamine def’nHypothyroid, Thiamine def’n
Electrolyte AbN: Electrolyte AbN: High Na++, Ca++, or Mg+High Na++, Ca++, or Mg+++
Drugs and toxins: Drugs and toxins: opioids, anticholinergics, opioids, anticholinergics, withdrawalwithdrawal
Organ failure: Organ failure: RF, Liver, CHF, CO2, sepsisRF, Liver, CHF, CO2, sepsis
Brain: Brain: tumor, infection, vascular events, tumor, infection, vascular events, seizuresseizures
ManagementManagement
Determine WHO is at riskDetermine WHO is at risk Screen with MMSEScreen with MMSE Find underlying causeFind underlying cause Obtain collateral historyObtain collateral history
Consent when deliriousConsent when delirious
You may use : ”substituted You may use : ”substituted judgment” – if you know the patient judgment” – if you know the patient wellwell
Use a substitute-decision maker Use a substitute-decision maker otherwiseotherwise
Treat without consent if in an Treat without consent if in an emergencyemergency
Treatment for DeliriumTreatment for Delirium
Haldol or atypical antipsychotic Haldol or atypical antipsychotic (olanzapine, risperidone)(olanzapine, risperidone)
NO AtivanNO Ativan
Causes of NauseaCauses of Nausea GI: gerd, motility, tumor, gastritis, GI: gerd, motility, tumor, gastritis,
obstructionobstruction BRAIN: High ICP, tumor, anxiety BRAIN: High ICP, tumor, anxiety EAR: Vestibular disturbancesEAR: Vestibular disturbances DRUGSDRUGS SYSTEMIC: infection, toxins, uremiaSYSTEMIC: infection, toxins, uremia CANCER: paraneoplastic syndromes, ov CANCER: paraneoplastic syndromes, ov
caca
Treatment – mechanistic Treatment – mechanistic approachapproach
Drugs, toxins, metabolic (CRTZ)Drugs, toxins, metabolic (CRTZ) Anti-dopaminergic: maxeran, haldolAnti-dopaminergic: maxeran, haldol
Vestibular Vestibular anticholinergic, antihistamines anticholinergic, antihistamines
Chemo/radiation - ondansetronChemo/radiation - ondansetron
DyspneaDyspnea
Treat the causeTreat the cause O2 if helpful or hypoxicO2 if helpful or hypoxic OpioidsOpioids
Double EffectDouble Effect
Appropriate treatment of pain is Appropriate treatment of pain is morally acceptable even if it hastens morally acceptable even if it hastens death as long as there was no death as long as there was no intention to do so.intention to do so.
Physician Assisted Physician Assisted SuicideSuicide
The physician supplies the patient The physician supplies the patient with the means, usually medication, with the means, usually medication, to end their life. Not legal in Canada.to end their life. Not legal in Canada.
EuthanasiaEuthanasia
The physician administers a The physician administers a medication with the intent of medication with the intent of causing death. Also not legal in causing death. Also not legal in Canada.Canada.
Speak gently, treat Speak gently, treat aggressivelyaggressively
“SAVE the patient you idiot!! I said we’ve got to do whatever we can to SAVE the patient!!”