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Palliative Care
Part 1
Dr Christine Hirsch
School of Pharmacy, Aston University, Birmingham B4 7ET
What is Palliative Care?
“Palliative care is an approach that improves
quality of life of patients and their families
facing the problems associated with life
threatening illness, through prevention & relief
of suffering by means of early identification,
impeccable assessment and treatment of pain
and other problems physical, psychosocial and
spiritual.”
WHO 2004 www.who.int
Team Approach
Symptom prevalence patients with
advanced cancer
C. Faull and R. Woof .Palliative Care 2002 Oxford University Press
Symptom
% Cancer
Pain
60
Anorexia
60
Fatigue / weakness
50
Sleep disturbance
50
Constipation
50
Depression
45
Nausea or vomiting
40
Trouble breathing
40
Incontinence
40
Anxiety
40
Confusion
30
Objectives Part 1- Pain
Develop an individualised, safe, rational and
stepwise approach to pain management in
palliative care
Be able to advise on management of
breakthrough pain
Be able to ‘convert with confidence’
Understand the appropriate use of adjuvant
analgesics
Part 1 Patient 1
Mr S is a 78 year old man with advanced
prostate cancer and bone metastases.
He has been admitted via casualty
drowsy and confused.
He has a supply of paracetamol 1g qds
and tramadol 100mg qds which were his
own medications brought with him on
admission.
The label on the tramadol indicates that it
had been dispensed three days earlier.
Assessment of pain
An unpleasant sensory and emotional
experience
Is what the patient says it is
Location – underlying pathology (related to
cancer? Treatment?)
Duration and timing
Intensity and nature
What if anything eases it or makes it go away.
Pain management in cancer patients
Visceral pain - usually opioid sensitive
“deep ache”, “pressure”, “throbbing”
Bone pain – localised, “aching” variable
response to opioids, traditionally NSAID
sensitive, radiotherapy or bisphosphonates
may be appropriate
Neuropathic pain – difficult to describe,
dysaesthesia, may respond poorly to
opioids, adjuvant analgesics may be helpful
Incident pain - episodic
Pain due to cancer
30% do not develop pain
Pain may be:
cancer related
treatment related
related to consequent disability
due to concurrent disorder
may be controlled in 80% of patients
Tramadol
Opioid and non-opioid action
Metabolised to M1(O-desmethyltramadol) in liver,
2-4 x more potent than tramadol via CYP2D6
5-10% caucasians lack CYP2D6
Much lower affinity for opioid receptors than
morphine
Inhibits re-uptake of noradrenaline and serotonin
Drug interactions
Analgesic effect reduced by ondansetron
Warfarin - may prolong INR
WHO three-step analgesic ladder
Non-opioids +/adjuvant/s
Opioid for mild to
moderate pain +/non-opioid +/adjuvant
e.g
Paracetamol
NSAIDs
e.g.
Codeine
Dihydrocodeine
Tramadol
1
2
Opioid for
moderate to
severe pain +/non-opioid +/adjuvant
e.g.
Morphine
Diamorphine
Fentanyl
Oxycodone
Hydromorphone
Methadone
3
Analgesia in advanced cancer
Where possible give analgesia:
Regularly
By mouth
By the WHO analgesic ladder
Initiating morphine as a ‘strong opioid’
If previously on weak opioid give 10mg
morphine 4-hourly or mr 20-30mg bd
If frail or elderly 5mg morphine 4-hourly
In reduced renal function reduce dose or
lengthen dose interval or both.
If two or more prn doses taken in 24
hours increase by 30-50% every 2-3
days as long as pain is opioid
responsive.
If using mr morphine also provide
‘immediate release’ morphine liquid or
tablets
Goal: pain free, mentally alert
Anticipate – ‘Rescue’ doses
Choose opioid prescribed for regular
medication (exceptions may be fentanyl &
methadone)
Dose = up to 1/6 of 24 hour dose of baseline
analgesia
PHYSICAL
SPIRITUAL
TOTAL
PAIN
PSYCHOLOGICAL
SOCIAL
Alternative opioids
When would you use ?
Which would you use?
Patient 2 part 1
Mrs. B. A 65 year old lady with advanced
ovarian carcinoma has had her pain
controlled previously on Zomorph 60mg bd.
Very unwell
vomiting for 3 days
severe abdominal pain
Unable to take her usual modified release
morphine because of the vomiting
Alternative Step 3 opioid analgesics:
Fentanyl - (transdermal patch – reservoir & matrix,
transmucosal lozenge/ sl, buccal, alfentanil
injection-sc infusion)
Hydromorphone – (normal release capsules,
modified release capsules,‘Special’ – injectable)
Oxycodone – (normal release caps and liquid,
modified release tabs, injection)
Methadone - (liquid, caps/tabs, injection) specialist use only.
Transdermal buprenorphine- (place in palliative
pain control still not determined)
‘Converting’
doses of opioid
Refer to tables- as guidance only
NB : Opioid metabolism varies between
individuals
Titrate to individual requirements
NB: Compromised renal or hepatic
function and concomitant drugs.
Episodic pain
Breakthrough pain – (exacerbations against a
background on controlled pain or occurring
before next opioid dose is due).
Spontaneous pain - ‘idiopathic pain’
unpredictable
Incident pain – (predictable) related to specific
actions e.g. movement, dressing change,
coughing
End-of-dose failure
‘Any acute transient pain that is severe and has
an intensity that flares over the baseline’ EAPC
working group 2002
Patient 3 – Part 1
A 72 year-old man
Prostate cancer, diagnosed 2002
Bone secondaries, March 2007
Spinal cord compression recently
His assessment – ’20 year-old, locked
in an old body’
Problems: mobility, pain, constipation
Drug history on admission
Co-codamol 8/500 2 qds (not taken)
Diethylstilbestrol 1mg od
Lansoprazole 30mg od
Dexamethasone 8mg bd
Cyclizine 50mg tds
Aspirin 150mg od
Lactulose 10ml bd
Adjuvant analgesics
Corticosteroids
Antidepressants
Antiepileptics
Bisphosphonates
MNDA receptor blockade
Antispasmodics
Muscle relaxants
TENS / Acupuncture
Radiotherapy
Patient 4 Part 1 - BS 49 year old female
Bilateral carcinoma of breast
Long standing back pain
Severe pain
Straining to pass urine
Pain lower abdomen
Numbness in hands
NIDDM
Prescribed drugs
Zomorph 60mg bd
Paracetamol 1g qds
Lansoprazole 30mg od
Co-danthramer 2 nocte
Diclofenac 75mg MR bd
Sodium clodronate
1600mg od
Gabapentin 300mg tds
Dexamethasone 2mg od
Gliclazide 40mg od plus
BM measurement.
Temazepam 10mg prn
Hyoscine Hydrobromide
400mcg prn
Midazolam 2.5mg prn
Levomepromazine 6mg
po prn/ 5mg sc
Oromorph 20mg prn
Diamorphine 5mg sc prn
Gold Standards Framework
Communication
Co-ordination
Control of symptoms
Continuity out of
hours
Continued learning
Carer support
Care in the dying
phase
Availability of drugs in the community
Anticipation
In-hours availability
Out of hours availability
Gold Standards Framework
Liverpool Care Pathway
Communication
References:
West Midlands Palliative Care Physicians Guidelines for the use of drugs in symptom
control 4th Ed 2007.
Faull C, Carter Y,Daniels, 2005 Handbook of
Palliative Care Blackwells Oxford.
Twycross R, Wilcock A. Palliative Care
Formulary 3rd Ed. 2007.
Dickman A,Schneider J, Varga J. The
syringe driver in palliative care.2nd Ed, 2005
Oxford University Press. Oxford.
Dickman A. Basics of managing breakthrough
cancer pain. The Pharmaceutical Journal
2009;283,21
References cntd:
Fallon M, Hanks G. ABC of Palliative Care.
2nd Ed 2006. Blackwell Publishing.
Dickman A. Chronic pain management:
advances. Pharm J. 2007;279:354-356.
Palliative drugs website:
www.palliativedrugs.com
Scottish intercollegiate guidelines network
website www.sign.ac.uk
Palliative Care
Part 2
Dr Christine Hirsch
School of Pharmacy, Aston University, Birmingham B4 7ET
Objectives Part 2
To advise on aspects of symptom control
other than pain
To understand the place of the syringe driver
in symptom control in palliative care
Pain
Nausea
Agitation
Secretions
Pathway for care of the dying
Integrated care pathway e.g. Liverpool Care
Pathway
Initial assessment
Ongoing care
Care after death
When should a syringe driver be
started?
Persistent nausea & vomiting
Difficulty swallowing
Poor alimentary absorption
Intestinal obstruction
Unconscious or profoundly weak
Opioids via syringe driver will
NOT
give better analgesia
unless there is a problem with
absorption or administration
Patient 1 Part 2 Mrs BS 49 year old female
Bilateral carcinoma of breast
Long standing back pain
Severe pain
Straining to pass urine
Pain lower abdomen
Numbness in hands
NIDDM
Prescribed drugs
Zomorph 60mg bd
Paracetamol 1g qds
Lansoprazole 30mg od
Co-danthramer 2 nocte
Diclofenac 75mg MR bd
Sodium clodronate
1600mg od
Gabapentin 300mg tds
Dexamethasone 2mg od
Gliclazide 40mg od plus
BM measurement.
Temazepam 10mg prn
Hyoscine Hydrobromide
400mcg prn
Midazolam 2.5mg prn
Levomepromazine 6mg
po prn/ 5mg sc
Oromorph 20mg prn
Diamorphine 5mg sc prn
Data on drug compatibility and stability is
limited:
Generally dilute with water - unless 0.9%
saline is specified – debate!
Avoid mixing more than two drugs in a syringe,
unless stability data is available
Analgesia - usually diamorphine
Alternatives: Morphine, Oxycodone,
Hydromorphone, Alfentanil
Dose conversions – consult local palliative
care guidelines
Consider, renal failure, liver failure, stable
pain
Timing
Antiemetics
First line agent - based on underlying cause:
haloperidol, metoclopramide, cyclizine
Second line, add another first line or change to
‘broad spectrum e.g. Levomepromazine
Third line, if other agents not controlling try 3
days 5HT3 receptor antagonist
Antiemetics - in syringe drivers
Cyclizine & levomepromazine (Nozinan) irritation at infusion site.
Try saline as diluent for levomepromazine
Do not use saline to dilute cyclizine
Cyclizine / diamorphine mixture may
precipitate if cyclizine conc >10mg/ml or
either drug > 25mg/ml. Use larger volume
Do not mix cyclizine and oxycodone
Agitation and delirium
Consider causes; e.g. drugs (opioids),
biochemistry (e.g. calcium) infection,
constipation
Delirium/psychosis:
Haloperidol
Levomepromazine
Restlessness & agitation
Where agitation & anxiety are predominant
features:
Midazolam
Levomepromazine
Myoclonic jerking
May be exacerbated by drugs, rapid
escalation of opioid dose and
anticholinergics
Midazolam
Clonazepam (specialist use only)
Terminal respiratory secretions
Positioning
Reassurance
Hyoscine hydrobromide -crosses blood brain
barrier, absorbed transdermally, paradoxical agitation,
sedation.
Hyoscine butylbromide - for colic with intestinal
obstruction, may be used to control secretions. Does
not cross blood brain barrier.
Glycopyrronium - for excessive respiratory
secretions and bowel colic. Does not cross blood brain
barrier. Unstable above pH6, avoid mixing with
dexamethasone.
Prescribed drugs
Zomorph 60mg bd
Paracetamol 1g qds
Lansoprazole 30mg od
Co-danthramer 2 nocte
Diclofenac 75mg MR bd
Sodium clodronate
1600mg od
Gabapentin 300mg tds
Dexamethasone 2mg od
Gliclazide 40mg od plus
BM measurement.
Temazepam 10mg prn
Hyoscine Hydrobromide
400mcg prn
Midazolam 2.5mg prn
Levomepromazine 6mg
po prn/ 5mg sc
Oromorph 20mg prn
Diamorphine 5mg sc prn
BS syringe driver
Diamorphine 40mg over 24 hours
Cyclizine 150mg over 24 hours
Increased by 10mg diamorphine after 3 days
and to 60mg diamorphine after further 3
days.
High gastric output, obstruction,
fistulae:
•Opioids, regular or continuous
•Octreotide 0.1-0.6mg per day (may be
given as continuous infusion.)
Dyspnoea
Diazepam 2.5-10mg
Lorazepam 0.5mg sublingually
Midazolam 2.5-5mg 4 hourly subcutaneously
Opioids, 2.5-5mg diamorphine 4 hourly s.c. for
opioid naïve patients
Levomepromazine 25-50mg 6-8 hourly if extreme
agitation
Other symptoms: Mouth Care
•Water sips, ice chips, mouth swabs
•Emollients, paraffin jelly
•Artificial saliva - not glycerin
•Candidiasis
•Benzydamine
Use of drugs beyond licence‘a legitimate aspect of clinical practice’
‘currently both necessary and common’
‘..professionals should inform, change &
monitor……… in light of evidence from audit
and published research.’
Association for Palliative Medicine and the Pain
Society – position statement 2001.
Gold Standards Framework
Communication
Co-ordination
Control of symptoms
Continuity out of
hours
Continued learning
Carer support
Care in the dying
phase
Availability of drugs in the community
Anticipation
In-hours availability
Out of hours availability
Gold Standards Framework
Liverpool Care Pathway
Communication
References:
West Midlands Palliative Care Physicians Guidelines for the use of drugs in symptom
control 4th Ed 2007.
Faull C, Carter Y,Daniels, 2005 Handbook of
Palliative Care Blackwells Oxford.
Twycross R, Wilcock A. Palliative Care
Formulary 3rd Ed. 2007.
Dickman A,Schneider J, Varga J. The
syringe driver in palliative care.2nd Ed, 2005
Oxford University Press. Oxford.
Dickman A. Basics of managing breakthrough
cancer pain. The Pharmaceutical Journal
2009;283,21
References cntd:
Fallon M, Hanks G. ABC of Palliative Care.
2nd Ed 2006. Blackwell Publishing.
Dickman A. Chronic pain management:
advances. Pharm J. 2007;279:354-356.
Palliative drugs website:
www.palliativedrugs.com
Scottish intercollegiate guidelines network
website www.sign.ac.uk