Palliative care

Published on 09/04/2015 by admin

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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.*

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* 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.

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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

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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).

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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)
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