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Palliative Medicine: the basics Tara Tucker MD FRCPC Lisa Aldridge MD CCFP Objectives 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 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!” We will all face death in our lives and in our work. 10% of us will die suddenly…. but what about the rest? Sudden death, unexpected cause < 10%, MI, accident, etc Health Status Death Time Steady decline, short terminal phase Slow decline, periodic crises, sudden death End of Life Care 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 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 Relieve suffering Provide Comfort and compassion to both the patient and the family Formulate a Plan for the Dying Patient 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 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 People need time to reflect on goals, values, beliefs EOL decision making is a process, not a one time event 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 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 “It doesn’t look good” “Do you want us to do everything?” “We will not do anything extraordinary, heroic, or aggressive.” Too vague, be more specific Implies substandard care There’s nothing more that we can do. Implies abandonment Language to describe the goals of care… 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 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 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? 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 … 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 Chronic pain serves no physiologic purpose 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 Direct effects of the disease Related to disease ie: constipation Secondary to treatment – 20% Surgery Chemotherapy Radiation Physiological Pain Categories Nociceptive –localised Somatic: superficial, deep Visceral Bone mets, cellulitis Infiltration, compression, distension of viscera Neuropathic – may radiate along dermatome, nerve distribution TGN, herpes zoster Neuropathic Pain Sympathetic Central Peripheral (non-sympathetic) Neuropathic Pain Spontaneous pain Dysesthesia Neuralgia e.g. burning e.g. lancinating, “electric shocks” Evoked pain Allodynia Hyperalgesia Pain from a non-painful stimulus Pain more than expected from a mildly painful stimulus Hyperpathia Explosive build-up of pain with repetitive stimuli Evaluating Pain Believe the patient Initiate discussions Detailed pain history Careful physical exam Investigations Monitor results of treatment Pain History – the key! P = provokes and palliates Q = quality R = Radiates - location S = severity T = time – duration, time of day O = other ie: red flags Headache + vomiting Principles of Analgesic Therapy 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 Antiinflammatory Adverse effects Gastropathy, renal failure, platelet inhibition, cardiac Risk factors Age, PUD, cachexia, dehydration, steroids, comorbid conditions Combination medications Percocet (oxycodone and tylenol) Tylenol #3 (Codeine and tylenol) Limited by dose of acetaminophen Opioids:choosing the right drug Morphine is first line Morphine metabolites will accumulate in renal failure patients; suggest fentanyl or hydromorphone Do NOT use meperidine (Demerol) due to metabolites causing adverse effects Opioids – choosing the right drug Pt’s previous experience with opioids Compliance Fears and myths – pt + MD! Physician comfort + experience Opioids – choosing the right dose 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 Percocet Some references give higher starting doses – CAUTION! Opioids – choosing the right schedule Immediate Release (IR) Q4h dosing – straight Prn q1-2h at 10% of daily dose Sustained release (the Contins) Q12h, prn IR 10% daily dose Opioids – adverse events Common Constipation is easier to prevent than treat Softener + laxative Nausea (tolerance develops) Maxeran, Haldol Sedation (tolerance develops) Dry mouth Opioids - Adverse events Less common Urinary retention Pruritis Delirium Myoclonus Psychotomimetic effects Postural hypotension Vertigo Opioids – adverse events Rare Allergy Codeine allergy most common, unlikely cross-reactivity with other opioids Respiratory depression Fentanyl Patch See table for equianalgesic doses For stable pain Dosage increases in 2-3 day intervals Careful in opioid naïve patients! 25 mcg/hr= 90 mg/d morphine = 18 mg/d hydromorphone Withdrawal… Tachycardia, hypertension, diaphoresis, pilo-erection, N, V, diarrhea, body aches, abdo pain, psychosis, hallucinations Opioids and Tolerance 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 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 Carbamazepine Block Sodium channels Reduce hyperexcitability Gabapentin Action unclear, ? Ca channels SE: dizziness, sedation Tri-cyclic antidepressants Nortriptylline 10 mg po qHS Inhibit serotonin and NE reuptake Block Sodium channels SE: dry mouth, sedation, hypotension Constipation Debility Decreased fluids and food Metabolic: hypothyroid, hypokalemia, hypercalcemia DRUGS Autonomic dysfunction: DM, CA, SCC Obstruction DRUGS Anticholinergics: ex TCAs Antacids Iron Zofran Diuretics Anticonvulsants NSAIDS Chemotherapy OPIOIDS Increase Bowel tone Decrease pancreatic and biliary secretions Delay Gastric emptying Decrease peristalsis Increase transit time Decrease the urge to defecate Managing Constipation 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 Metabolic: Hypoxemia, Hypoglycemia, Hypothyroid, Thiamine def ’n 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 Determine WHO is at risk Screen with MMSE Find underlying cause Obtain collateral history Consent when delirious 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 Haldol or atypical antipsychotic (olanzapine, risperidone) NO Ativan Causes of Nausea 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 Drugs, toxins, metabolic (CRTZ) Vestibular Anti-dopaminergic: maxeran, haldol anticholinergic, antihistamines Chemo/radiation - ondansetron Dyspnea 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 The physician supplies the patient with the means, usually medication, to end their life. Not legal in Canada. Euthanasia 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!!”