Palliative care

Published on 09/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2326 times

7 Palliative care

TV. Ajithkumar

Introduction

Palliative care is the active holistic care of patients with advanced progressive illness and includes areas other than oncology. Apart from, managing pain and other symptoms, palliative care is aimed at delivering psychological, social and spiritual support to patients and their family to achieve the best quality of life. Development of cancer palliative care and hospices has gained momentum in the UK since the opening of the World’s first hospice in London in 1967 by Cicely Saunders and colleagues. Today, palliative care and end-of-life care are growing areas of research worldwide. This chapter deals mainly with symptom management in cancer patients and a detailed discussion of the principles of multidisciplinary palliative care is beyond the scope of this chapter.

Pain management

Pain control is an important component of cancer management and uncontrollable pain is the major fear for many cancer patients. More than 80% of patients with advanced cancer suffer pain and around 20% of pain in cancer patients may be attributed to surgery, radiotherapy and chemotherapy. Pain control involves two important steps: assessment of pain and management of pain.

Assessment of pain

It is important to assess the multidimensional nature of pain. Intensity of pain, location, duration and factors that modify pain should be assessed. There are various tools to assess the pain and the commonly used ones are shown in Box 7.1.

Box 7.1
Numerical rating score (NRS) – Wong-Baker FACES Pain Rating Scale.*

image

* From Hockenberry MJ, Wilson D: Wong’s essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.

Management of pain

The management of pain includes analgesics as well as non-pharmacological measures. The World Health Organization (WHO) analgesic ladder (Figure 7.1) has been the gold standard in the management of pain and has been shown to eliminate pain in 80% of patients. The remaining 20% have complex pain which may require specialist interventions. Measures used in complex pain include neuro-anaesthetic interventions, palliative surgery, radiotherapy, chemotherapy, physiotherapy, occupational therapy, and psychosocial care.

image

Figure 7.1 The WHO analgesic ladder. *NRS – numberical rating score using 10 point coding.

Analgesics

Commonly used analgesics are given in Table 7.1. Strong opioids are started at a low dose and titrated according to the clinical need (Box 7.2). Morphine is the strong agent of choice and oral administration is preferred. Transdermal preparations are useful only in stable pain. Some agents may only be prescribed by specialists in palliative care medicine or anaesthetia.

Table 7.1 Analgesics in pain management

image

Box 7.2
Titration of opioid dose

Step 1

• Start with immediate release opioid (e.g. oral morphine 2.5–10 mg depending on age and intensity of pain) 4 hourly.
• Break through analgesia (immediate release) is given at the same dose as regular dose.

Step 2

• Calculate total analgesic requirement (after 48–72 hours).

Step 3

• Start controlled release preparation at the equivalent daily dose of immediate release (e.g. if oral morphine requirement is 120 mg/day, MST started as 60 mg 12-hourly).
• Breakthrough analgesia is the same analgesia at one-sixth of the regular total daily dose (e.g. oral morphine 20 mg from the previous example).

Step 4

• If patient needs >4 breakthrough doses per day, the baseline controlled release dose needs to be increased by following steps 2 and 3.

Opioid side effects, toxicity and management

All patients feel some degree of drowsiness when starting or increasing their dosage. This usually wears off 3–5 days after being on a stable dose. Constipation is inevitable and 30–50% patients develop nausea and vomiting; these symptoms should be managed prophylactically. Intolerable side effects necessitate switching to an alternative opioid (Figure 7.2).

image

Figure 7.2 Conversion of opioids.

Opioid toxicity usually manifests pseudo-hallucinations (shadows at the peripheries of the field of vision), myoclonic jerks, cognitive impairment, and visual and auditory hallucinations. Initial management includes adequate hydration (dehydration is often a precipitant of toxicity), reduction of opioid and haloperidol (1.5–3 mg oral) for cognitive impairment. If the patient has persistent toxicity without adequate analgesia, opioid switching is needed (Figure 7.2). Though there is no best choice, oxycodone and hydromorphone are the usual alternatives. Naloxone is a short acting opioid antagonist used intravenously for reversing accidental severe opioid overdose.

If pain is relieved rapidly, for example after a nerve block, opioids can be stopped abruptly in many patients without any side effects. However, up to 10% may experience a withdrawal syndrome due to physiological dependence which is managed by reducing doses of opioids over a few days.

Adjuvant analgesics

Adjuvant analgesics (Table 7.2) are a useful complement to regular analgesics in complex pain. These include anticonvulsants, antidepressants, antispasmodics, bisphosphonates, steroids, muscle relaxants and N-methyl-D-aspartate antagonist (ketamine).

Table 7.2 Adjuvant analgesics

Indication Drug Dosage
Neuropathic pain Dexamethasone 8–16 mg daily
Gabapentin 100–300 mg (nocte) Titrate to 600 mg TDS
Amitriptyline
Starting dose 25 mg (nocte)
In elderly start at 10 mg

Pregabalin 150–600 mg Carbamazepine 100 mg BD up to 1200 in divided doses daily Sodium valproate 200–500 mg nocte Muscle spasm Diazepam 2–10 mg daily Baclofen 5 mg TDS increased up to max 100 mg daily Smooth muscle spasm Hyoscine butylbromide SC 20 mg stat or SC infusion 60 mg up to 120 mg in 24 hours Tenesmus Nifedipine 5/20 mg BD oral

Complex pain

Neuropathic pain is often difficult to control. Agents useful to control neuropathic pain are shown in Table 7.2. Amitryptyline along with regular analgesics is the first line management. If pain is not adequately controlled, gabapentin can be either added to amitryptyline or used as substitute. In nerve compression pain steroids or TENS (transcutaneous electrical nerve stimulation) can be considered. Ketamine is useful if these measures fail to control pain. If pain continues to be a problem neuro-anaesthetic interventions such as neural blockade (nerve block, epidural opioids) or neurodestruction (as a last resort) are considered.

Radiotherapy is useful in controlling bone pain. 41% of patients achieve a 50% pain relief within 4 weeks of treatment. Bone pain associated with mechanical instability is difficult to control and often precipitated by movement. In patients with extensive bone metastases, bisphosphonates are shown to reduce skeletal events whereas its analgesic benefit is less clear.

Non-pharmacological interventions

Non-pharmacological interventions such as TENS, acupuncture, relaxation techniques and massage may all be useful.

Nausea and vomiting

Nausea and vomiting are the most common symptoms in cancer management. A thorough clinical assessment including detailed history and examination to establish the cause and severity is important. Possible causes include treatment related (chemotherapy, radiotherapy or other drugs), gastrointestinal pathology (e.g. obstruction), electrolyte abnormalities (e.g. hypercalcaemia), and brain metastases. Investigations are governed by findings from history, clinical examination, and a review of the drug chart and chemotherapy prescription. First-line treatment depends on the possible cause and examples are given in Table 7.3. Levomepromazine (6.25–25 mg subcutaneous per day) and dexamethasone are used as second line treatment.

Table 7.3 Agent of choice in nausea and vomiting based on cause

Cause Treatment – first line anti-emetic
Chemotherapy
Granisetron 1 mg BD PO
Ondansetron 8 mg PO BD
Dexamethasone 4–8 mg OD PO
Metoclopramide 20 mg QDS PO

Radiotherapy
Granisetron 1 mg BD PO
Ondansetron 8 mg OD
Haloperidol 1.5 mg OD or BD PO
Raised intra-cranial pressure Cyclizine 50 mg tds PO Delayed gastric emptying
Metoclopramide 10–20 mg QDS PO
Domperidone 10–20 mg QDS PO
Drug induced Haloperidol 1.5 mg OD or BD PO. Metabolic e.g. uraemia or hypercalcaemia Haloperidol 1.5 mg OD or BD PO.

Constipation

Around 50% of cancer patients will develop constipation, which is due to a number of disease and treatment related causes. Assessment is to evaluate the possible cause(s). Prevention is important, particularly those starting on opioids. Adequate fluid intake should be encouraged except when associated with vomiting related to small bowel obstruction. A combined stimulant/softener is preferred e.g. co-danthramer (2 caps once or twice daily) or movicol is the choice in advanced cancer. Osmotic laxatives are useful in patients who have sufficient oral intake. Rectal preparations are indicated when oral laxatives fail. Glycerol suppositories soften stools while bisacodyl suppositories stimulate the rectum. Resistant cases require an enema.

Diarrhoea

Diarrhoea in cancer patients can be due to chemotherapy (e.g. 5-fluorouracil, docetaxel), pelvic radiotherapy, infection or other medical conditions. Clinical evaluation should be aimed at establishing the cause and severity. Treatment is essentially supportive aimed at improving hydration and correct electrolyte imbalance if any. Infections are treated with appropriate antibiotics. Diarrhoea due to chemotherapy and radiotherapy is treated with dietetic management and loperamide. Octreotide is useful in severe diarrhoea (200–1200 micrograms per day subcutaneously).

Intestinal obstruction

Intestinal obstruction is common with colorectal and ovarian cancers. Treatment depends on a number of factors. Surgery is the treatment of choice if feasible; however, many patients are only suitable for conservative management. Depending on the level of obstruction, surgical intervention includes bypass surgery, stent or surgical excision. In general surgery is only recommended if there is a single focus of tumour or adhesion causing compression. Multiple areas of involvement or extensive peritoneal involvement is best managed by conservative measures. Conservative management is by bowel rest, nasogastric tube (in case of persistent vomiting), parenteral steroids (to control nausea, bowel oedema and extrinsic compression, control of nausea and vomiting (cyclizine when there is complete obstruction) and metoclopromide (in partial obstruction) and somatostatin analogues to reduce gastrointestinal secretions, promote absorption of fluid and reduce intestinal motility and colic (octreotide 600–800 mcg/day subcutaneously).

Oral infections

Mouth care is important in cancer patients. Immunosuppression and steroids predispose to oral candidiasis, which manifest as white-yellow plaques or as a painful bleeding red area. Treatment is with anti-fungals, e.g. oral fluconazole and may be given prophylactically with high risk treatments. Herpes simplex virus presents as painful, yellow lesions on the oral mucosa. Systemic anti-viral agents and strong opioid analgesics are usually needed. Bacterial infections are treated according to culture results.

Hiccups

Hiccups are a reflex spasm of the diaphragm causing sudden movement of the glottis. Common causes include gastric distension, raised intra-abdominal pressure, high dose steroids and electrolyte imbalance (e.g. hyponatraemia, uraemia). Metoclopramide (10 mg qds PO) is useful in gastric distension. Dimethicone which is an antifoaming agent which eases flatulence and distension (Asilone 5 ml qds) can be effective. Baclofen (5 mg tds PO) or nifedipine (5 mg tds) can act as smooth muscle relaxants. When these measures fail, chlorpromazine can be used as a central hiccup reflex suppressant (12.5–25 mg daily).

Breathlessness

Breathlessness is the subjective experience of discomfort in breathing. Common causes include disease affecting the lungs, increased intracranial pressure, anaemia and pulmonary embolism. Supportive measures include breathing exercises, a stream of air, either from a fan or through an open window, and treatment of infections, cardiac failure, effusion, COPD and anaemia. Radiotherapy is useful for large tumours and bronchial obstruction. Lymphangitis carcinomatosis is treated with dexamethasone 16 mg daily. Oxygen therapy is useful in patients with SaO2 <90%. Morphine 5 mg 6-hourly is also useful in breathlessness.

Cough

Cough in cancer patients can be either due to underlying malignancy or due to co-existing non-malignant conditions. Treatment depends on the type of cough and underlying cause. Treatable causes should be appropriately treated. Physiotherapy aids expectoration and repositioning may alleviate the cough (e.g. lying on same side as pleural effusion). Codeine linctus and strong opioids (e.g. oral morphine sulphate) are also beneficial in symptomatic relief.

Haemoptysis

Haemoptysis is managed with oral haemostatic agents (e.g. tranexamic acid), local radiotherapy or bronchoscopic intervention. Massive terminal exanguination requires appropriate sedation.

Depression

Depression is common in cancer patients. In a physically well patient, depression usually manifests as poor appetite, weight loss, and even fatigue. The Hospital Anxiety and Depression Scale (HADS) is useful in diagnosing anxiety and depression. Management is with counselling, psychological interventions and antidepressants. Some cancer centres have a designated psycho-oncology service to assist in the management of these patients. The commonly used antidepressants are:

• Citalopram, an SSRI used as first line treatment of depression at a dose of 20 mg which can be increased to 40 mg.
• Mirtazapine, a noradrenaline and specific serotonin antagonist (NaSSA) given at a dose of 15–45 mg daily.
• Venlafaxine, a serotonin-noradrenergic reuptake inhibitor (SNRI), the starting dose is 75 mg daily.

Treatment is usually started with one class of agent and if a patient does not respond in 4 weeks, it is changed to another class of antidepressant.

Delirium

Delirium (acute confusional state) is a common psychiatric disorder in cancer patients. Common causes include metabolic abnormalities (hyponatraemia, hypercalcaemia), drug toxicity (opioids, steroids), infection and metastatic brain disease or its treatment. Antipsychotic medications are often needed and the commonly used agent is haloperidol 5–30 mg daily.

Cancer-related fatigue

Cancer-related fatigue has been defined as ‘a persistent subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning’. The aetiology is multifactorial. Treatment includes relaxation, stress management, regular exercise and psychological interventions.

Cancer cachexia

Cachexia has been defined by a triad of weight loss >10%, reduced food intake (<1500 kcal/day) and systemic inflammation (CRP >10 mg/l). All reversible causes of anorexia should be identified and treated. Nutritional support may be helpful. Progestogens are commonly used to improve appetite and weight. The commonly used agents are megestrol acetate (160–320 mg/day) and medroxyprogesterone acetate (200 mg tds). Steroids may help to improve appetite and give a sense of wellbeing but caution should be used if given for prolonged periods as they can exacerbate proximal weakness.

Symptom cluster

A symptom cluster is defined as three or more concurrent symptoms that are related to each other. Commonly occurring symptom clusters are:

• fatigue, pain and drowsiness
• poor appetite and nausea and anxiety and low mood
• pain, fatigue, low mood and function.

These symptom clusters highlight the importance of treating several symptoms in unison, rather than individually.

End-of-life care

End-of-life care of the cancer patient is most challenging. Management of the primary illness is no longer the priority and the focus of care shifts to optimize symptom control. An important aspect of this is recognition of end-of-life and it is often difficult to make a decision to stop anticancer treatment. This needs a very sensitive approach involving patients, their families and all concerned parties in the care of patients.

In patients with advanced cancer the following signs and symptom suggest that the patient is dying:

• bedbound or immobile
• difficulty managing medication
• confusion
• marked generalized weakness
• drowsy or comatose
• poor appetite and decreased fluid intake.

The Liverpool Care Pathway for the Dying Patient (LCP) is a framework for the care of the dying patient. This framework emphasizes the need to discontinue all inappropriate interventions including monitoring of vital signs, use of IV fluids and antibiotics. All the clinical measures are to improve comfort for the patient. The minimum medications are used to ease distress and pain and medications are given by a syringe driver.

Principles of management of specific symptoms are as discussed previously. Terminal agitation is treated initially with haloperidol and midazolam. Severe uncontrolled agitation may need titrating doses of methotrimeprazine. Respiratory secretions, which produce ‘death rattle’, should be treated with anti-muscarinic agents such as hyoscine hydrobromide, hyoscine butylbromide and glycopyrronium.

An important psychological aspect of end-of-life care is patient dignity. Place of death should be discussed with the patient and their carers whilst they are still able to make the decision. Although the majority of patients die in hospital many would prefer to die in a hospice or home environment. This may take time to organize so should be considered early in the outcome is poor so that there is sufficient time to make the necessary arrangements.

After death, the death certificate should be issued with appropriate advice on the necessary legal requirements and process of arranging a funeral. Bereavement care is often offered either actively or passively to family members. The family should be offered an opportunity to discuss any unanswered questions which may ease the process of bereavement.

Further reading

Fallon M, Hanks G. ABC of Palliative care, 2nd Edition. Oxford: Wiley Blackwell. 2006.

Related posts:

Cancer in pregnancy Cancers of unknown primary Head and neck cancer Cancers of the genitourinary system Cancers of the musculoskeletal system Cancers of the haematopoietic system