Palliative Care for HIV/AIDS and Cancer Patients in … · Review of Key Concepts in Pain Assessment and Treatment ... • F. Amos Bailey, MD, University of Alabama at Birmingham

Palliative Care for HIV/AIDSand Cancer Patients in Vietnam

Advanced Training Curriculum

Krakauer

•Palliative

Care

forH

IV/A

IDS

andC

ancerPatients

inV

ietnam:A

dvancedC

urriculum

Harvard Medical SchoolCenter for Palliative Care

Eric L. KrakauerEditor-in -Chief

MASSACHUSETTSGENERAL HOSPITAL

Cover File:Layout 1 6/16/09 4:22 PM Page 1

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam

Advanced Training Curriculum

Copyright © 2008 Massachusetts General Hospital. Compilation by Eric L. Krakauer. All rights reserved. iii

Note Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors and editors are not responsible for errors or omissions or for any consequences from application of the information in this curriculum and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of this curriculum. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors and editors have exerted every effort to ensure that drug selection and dosage set forth in this curriculum are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. The drugs and dosages set forth do not necessarily have specific approval by the US Food and Drug Administration (FDA) for use as described in this curriculum. This curriculum is copyrighted by Massachusetts General Hospital and was developed by Eric L. Krakauer. The copyright holder provides permission for free reproduction, translation, and printing of the curriculum, or of any part of the curriculum, with appropriate citation and reference, solely for educational, non-commercial purposes.

Table of Contents

Acknowledgements............................................................................................................................vii

List of Contributors............................................................................................................................ix

Sample Palliative Care Advanced (Module 2) Training Schedule.....................................................xi

Day 1

1.1 Sample Orientation to the Palliative Care (Module 2) Training Course...........................3

1.2 Achievements of Palliative Care in Vietnam, Period 2005-2008Slide Presentation.............................................................................................................4

1.3 Opioid Policy in VietnamSlide Presentation.............................................................................................................7

1.4 The History of the Palliative Care Movement / the AsiaPacific Hospice Palliative Care NetworkSyllabus.............................................................................................................................16Slide Presentation..............................................................................................................23

1.5 Palliative Care for Patients with Heart / Lung DiseasePart A: Congestive Heart FailureSyllabus.............................................................................................................................29

Palliative Care for Patients with Heart / Lung DiseasePart B: Chronic Lung DiseaseSyllabus.............................................................................................................................35

Palliative Care for Patients with Congestive Heart Failureor Chronic Lung DiseaseSlide Presentation..............................................................................................................44

Day 2

2.1 Neurobiology of PainSyllabus.............................................................................................................................51Slide Presentation..............................................................................................................67

Review of Key Concepts in Pain Assessment and TreatmentSlide Presentation..............................................................................................................72

v

Table of Contents

vi

2.2 Death and Dying in Vietnamese Culture and BuddhismSyllabus.............................................................................................................................75

Death and Dying in Vietnamese CultureSlide Presentation..............................................................................................................80

2.3 Palliative Care for Patients with End-stage Kidney Disease,End-stage Liver Disease, and Massive HemorrhageSyllabus..............................................................................................................................85Slide Presentation..............................................................................................................96

2.4 Participant’s Projects: Development of Palliative CareServices or Research in Home InstitutionsSlide Presentation..............................................................................................................101

Group Pictures...................................................................................................................102

vii

Acknowledgements

I would like to express profound thanks to my gracious hosts and collaborators who invited me to help imple-ment palliative care training in Vietnam and who made it possible for me to develop and compile these train-ing materials. I thank especially Dr. Luong Ngoc Khue, Mme. Nguyen Thi Phuong Cham, and the MedicalServices Administration of the Vietnam Ministry of Health; Prof. Nguyen Ba Duc and the National CancerHospital of Vietnam; Prof. Nguyen Duc Hien and the National Institute of Infectious and Tropical Diseaseof Vietnam; Dr. Le Truong Giang and the People’s AIDS Committee of Ho Chi Minh City; Dr. HowardLibman and the Harvard Medical School AIDS Initiative in Vietnam. I am very grateful to all those whocontributed their expertise and experience to this curriculum. Finally, I thank the United States Centers forDisease Control, the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the OpenSociety Institute’s International Palliative Care Initiative, and the United States Cancer Pain ReliefCommittee for their generous financial support.

E.L.K.

This curriculum has been endorsed by the Lien Centre for Palliative Care, Duke – National University ofSingapore Graduate Medical School, Singapore, for palliative care training in Vietnam.

This project was supported in part by Cooperative Agreement Number U62/CCU122408 from the United States Centers forDisease Control and Prevention (CDC). The contents are the sole responsibility of the authors and do not necessarily representthe official views of the CDC or the US Government.

Acknowledgements

viii

List of Contributors

Editor-in-Chief

• Eric L. Krakauer, MD, PhD, Director of International Programs, Harvard Medical School Center for Palliative Care; Attending Physician, Massachusetts General Hospital, Boston, USA

Co-Editors

• Luong Ngoc Khue, MD, MPH, PhD, Vice Director, Medical Services Administration, Ministry of

Health of Vietnam, Hanoi, Vietnam • Nguyen Ba Duc, MD, PhD, Director (ret.), National Cancer Institute of Vietnam; Professor Emeritus,

Hanoi Medical University, Hanoi, Vietnam • Nguyen Duc Hien, MD, PhD, Director (ret.), National Institute of Infectious and Tropical Diseases of

Vietnam; Professor Emeritus, Hanoi Medical University, Hanoi, Vietnam

Contributing Editors • Bui Bich Thuy, MD, Chief, Department of Infectious Disease, Haiphong Medical University,

Haiphong, Vietnam • Nguyen Thi Phi Yen, MD, National Cancer Hospital of Vietnam, Hanoi, Vietnam • Nguyen Thi Phuong Cham, RP, Senior Pharmacy Expert, Medical Services Administration, Ministry

of Health of Vietnam, Hanoi, Vietnam

Managing Editors • Chu Phuc Thi, MD, MS, Former Project Officer, Vietnam-CDC-Harvard Medical School AIDS

Partnership (VCHAP), Hanoi, Vietnam • Oscar Salas, Harvard Medical School Center for Palliative Care, Boston, USA

Contributors • F. Amos Bailey, MD, University of Alabama at Birmingham School of Medicine, Birmingham, USA • Gary J. Brenner, MD, PhD, Harvard Medical School & Massachusetts General Hospital, Boston, USA • Nguyen Thi Phuong Cham, RP, Ministry of Health of Vietnam, Hanoi, Vietnam • Do Duy Cuong, MD, Bach Mai National Hospital, Hanoi, Vietnam • Cynthia Goh, MBBS, PhD, Singapore National Cancer Centre, Singapore • Luong Ngoc Khue, MD, MPH, PhD, Ministry of Health of Vietnam, Hanoi, Vietnam • Eric L. Krakauer, MD, PhD, Harvard Medical School & Massachusetts General Hospital, Boston, USA • Shaun K. Malarney, PhD, International Christian University, Tokyo, Japan • Tran Quynh Thai, MD, Hanoi Center for HIV/AIDS Treatment, Hanoi, Vietnam • Bui Bich Thuy, MD, Haiphong Medical University, Haiphong, Vietnam • Nguyen Thi Phi Yen, MD, National Cancer Hospital of Vietnam, Hanoi, Vietnam

Translators • Pham Thi Van Anh, MD, MPH, Haiphong Medical University, Haiphong, Vietnam • Do Duy Cuong, MD, Bach Mai National Hospital, Hanoi, Vietnam • Le Thuy Lan Thao, MD, MPH, Consultant, Harvard Medical School Center for Palliative Care,

Boston, USA

ix

10

xi

Sample Palliative Care Module 2 Advanced Training Schedule

Day 1

8am – 8:30am Welcome

8:30am – 9:30am One-Year Follow-Up Survey

9:30am – 10:15am Lecture: Update on Viet Nam Pallia tive Care Ini tia tive: Accomplishments and Plans

10:15am – 10:30am Break

10:30am – 11:30am Lecture: Update on Opioid Availabi lity

11:30am – 1:30pm Lunch

1:30pm – 2:00pm Lecture: The Internat ional Palliative Care Movement & Asia Pacific Hospice Pal lia tive Care Network

2:00pm – 3:00pm Lecture: Palliative Care for Patients with Congestive Heart Fai lure and Chronic Lung Disease

3:00pm – 3:15pm Break

3:15pm – 4:30pm HIV/AIDS Case Presentat ion & Discussion

6:30pm – 8:30pm Reunion Dinner

Day 2

8:00am – 9:15am Lecture: Neurobiology of Pain / Review of Key Concepts in Pain Relief Brief pain case

9:15am – 10:00am Cancer Case Presentation & Discussion

10:00am – 10:20am Break

10:20am – 12:00pm Lecture: Death and Dying in Vietnamese Culture

12:00pm – 1:30pm Lunch

CONTINUED

Sample Palliative Care Module 2 Advanced Training Schedule

12

1:30pm – 2:30pm Lecture: Pal lia tive Care for Pat ients with End-stage Liver Disease, Massive Hemorrhage, and End-stage Renal Disease

2:30pm – 2:50pm Break

2:50pm – 4:00pm Large Group Discussion: Palliative Care in Participants Home Institutions:• Existing programs• Needs• Barriers

4:00pm – 4:30pm Concluding Ceremony

xii

xiii

Day 1

3

Sample Orientation to the VCHAP Palliative CareModule 2 Training Course

Eric L. Krakauer, MD, PhDHarvard Medical School & Massachusetts General Hospital

Welcome• Delighted to welcome back our course participants and colleagues from last year.

Goals• To provide advanced and refresher training for our previous palliative care

Module 1 trainees, and thereby:- To help make palliative care available for HIV/AIDS and cancer patients throughout Vietnam;- With time, to help make palliative care in Vietnam sustainable without foreign funding or

technical assistance.• Sustainability will require well-trained and motivated palliative care clinicians to:

- Train other physicians as well as nurses and community health workers in palliative care.- Implement and lead palliative care services for HIV/AIDS and cancer patients.- Do research to assess:

• Unmet needs of patients with HIV/AIDS, cancer, and other life-threatening illnesses in Vietnam.• Treatment outcomes of patients who receive palliative care as compared with

those who do not.• We believe that you can become leaders in Vietnamese palliative care.• We hope that all of you who participate in these training courses will continue to meet regularly

along with all physicians in Vietnam interested in palliative care, perhaps as a preliminary step to forming a Vietnam Palliative care Association.- We believe that such regular meetings of physicians interested in palliative care will provide

opportunities:• To continue to improve your knowledge and skill in palliative care;• To receive advice for your palliative care projects or research• To share your experiences with your palliative care colleagues, including your successes and

the barriers you have faced as you worked to relieve the suffering of your patients and their families.

• Please take full advantage of this training course by asking many questions and challenging me and the faculty to explain as clearly and fully as possible.

Schedule• New lectures

- Updates on pall care in Vietnam• Especially new opioid prescribing regulations

• New topics• Case presentations• Opportunities for presenting and discussing your successes and challenges in implementing palliative

care in your home institutions and provinces.

Copyright © Massachusetts General Hospital. All rights reserved.

4

Achievements of Palliative Care in Vietnam, Period 2005-2008

1

Achievements of Palliative Care in Vietnam, period 2005 - 2008

Dr. Luong Ngoc KhueVice director – Vietnam Medical Service

Administration

2

1. In 2005:

- The Ministry of Health conducted a rapid situation analysis at 05 provincies and cities on palliative care => Found out the limitations for developing the policies on palliative care.

- The pharmacist law was promulgated by the Government and effect since Oct. 2005 => many improvements in supplying, managing and use of the drugs.

I. Establishment and Implementation of Policy(1)

3

2. In 2006:

- July _ Sept.: Reviewing all documents on supply, management and use opioids in treating pain according to WHO guidelines (Targeting the balance in national policy in opioids controlling) and INCB => find out the shortcomings to overcome.

- Sept: Decision No 3483/QĐ-BYT of the Ministry of Health dated 15th Sept. 2006: “National Guidelines on Palliative Care for HIV/AIDS and cancer patients” and Implementation workshops were implemented in Hanoi and Ho Chi Minh

- Oct.: Developing the palliative care work plan 2007-2008

All the activities were supported (financial and consultants) by VCHAP, FHI, OSI and consultants from PPSG.

I. Establishment and Implementation of Policy (2)

4

3. In 2007

- February :

+ Establishing the committee for revising and editing drug prescribing regulation: Decision No1728/QĐ - BYT on the revision and supplement for drug prescribing regulation and drug selling; implementing the editions and completion.

+ Organizing the workshops on drug prescribing regulation (the 1st in Hanoi on Feb, the 2nd in Nha Trang on August, the 3rd in the Ministry pf Health on Sept, the 4th for the whole country in Hanoi on Dec. 2007)

+ Establishing the committee for developing guidelines on Methadone Substitution therapy

+ Revising and completing the regulation on narcotic management(National drug Administration)

- March: Organizing national workshop on supply, management and use of opioids


5

In cancer hospital

6

5


7 8

3. In 2007 (Cont.)

- Dec.: Decision No 5076/QĐ - BYT of the Ministry of Health dated 12th Dec. 2007 “ Guidelines for Methadone substitution therapy for treating narcotics addicted and implementation of the guidelines”

4. In 2008

- Feb: Decision No 04/2008/QĐ-BYT dated 01 Feb. 2008: Regulation of drug prescription for out patients.

- March and April: Implementation workshops on revised regulation of drug prescription for out patients (on March in Ho Chi Minh for Southern provinces, on April in Hanoi for Northern provincies).


9

4. In 2008(Cont.)- Preparing for pilot program on Methadone

substitution therapy in Hai phong and Ho Chi Minh+ Organizing 2 trainings in Hanoi and Ho Chi Minh+ Preparing for requesting and supplying methadone for pilot sites.


10

1.Train for treating doctors:1.1. In 2007:- March: organizing two training courses for TOTs on

palliative care (2 weeks, total 34 participants)- Oct. and Nov.: Organizing two PC training courses in

Hanoi and Ho Chi Minh (5 days/course)1.2. In 2008:- March: National trainers (three months fellowship

program, March to May 2008)- May 5: Advance palliative care training (module2) in

Hanoi

II. Strengthening Knowledge and Skills on Palliative Care (1)

11 12

1.2. Training for health managers on palliative care at 6 PEPFAR provinces (Provincial health service, provincial drug control bureau, hospital leaders, head of HIV/AIDS and cancer department at the hospital, head of pharmacy departments)

- 02 courses in Quang Ninh and Hai Phong (2007)- 03 courses in Hanoi, Ho Chi Minh and Can Tho 1.3. Developing training materials for doctors and nurses on

palliative care- Directive committee for developing training materials was

established by the MOH.- On going writing the training materials. Training materials

for doctors will be completed on Sept and for nurses will be on Dec. 2008

II. Strengthening Knowledge and Skills on Palliative Care (2)

66


13

III. Activities in 2008(June - December)

1. Monitoring and directing the implementation of palliative care at provinces and fellows host institutions.

2. Organizing module II palliative care training for doctors in Ho Chi Minh and Southern provinces.

3. Organizing palliative care training for health managers in An Giang

4. Completing the three - month training materials for doctors and one month for nurses

14

IV. Developing Palliative Care Network in Vietnam

1. Integrating palliative care in treating cancer patients

2. Integrating palliative care in treating HIV/AIDS patients

3. Establishing palliative care sub groups under Provincial Medicine Associations

4. Promoting collaboration with international and regional countries on palliative care

15

7

Opioid Policy in Vietnam

1

OPIOID POLICY IN VIETNAM

(PRODUCING, PROVIDING, DELIVERING, RETAIL SALE, DISTRIBUTING, PRESCRIPTION FOR PATIENT)

AND

BARRIERS TO PAIN RELIEF IN VIETNAM

2

Questions

• Why opioids are not available for relief of pain?

• What is the role of government drug control policy?

• What are methods to assess and strengthen policy?

3

INCB Conclusion

In many countries, consumption of opioid analgesics remains extremely low in comparison to medical need, and many national governments have yet to address this important deficit.

International Narcotics Control Board (INCB), 1996 and PPSG 2007 4

The International Narcotic Control Board (INCB)

5

1. What is INCB?

INCB is the abbreviation of the International Narcotic Control Board

In Vietnamese: Uỷ ban kiểm soát ma tuý quốc tế

Established in 1968.

Is a fair and independent treaty-based international organization that monitors implementation of the UN drug control conventions

THE INTERNATIONAL NARCOTIC CONTROL BOARD - INCB (1)

6

1. Single Convention on Narcotic Drugs 1961 (amended in 1972)

2. Convention on Psychotropic Substances 1971

3. UN Commitment on combating illegal trade, transportation narcotics and psychotropic substances 1988

UN Conventions on Drug Control and Combat

8


7

2. Functions

a. Advocating for licit manufacture of, trade in and use of drugs

INCB endeavors, in cooperation with Governments, to ensure that adequate supplies of drugs are available for medical and scientific uses and that the diversion of drugs from licit sources to illicit channels does not occur.

INCB also gives guidance to governments for assessing chemicals used in the illicit manufacture of drugs to assist governments in combating the use of illicit chemicals


8

2. INCB functions

b. With regard to illicit production, trade, and use:

INCB identifies weakness of the international and national drug control systems and recommends remedial measures

INCB also has the responsibility to assess chemicals used in illicit drug production to determine whether those chemicals are internationally controlled

THE INTERNATIONAL NARCOTIC CONTROL BOARD – INCB (6)

9

3. INCB responsibilitiesa) Administers a system of estimates for narcotic

drugs and a voluntary assessment system for psychotropic substances and monitors licit activities involving drugs through a statistical returns system, with a view to assisting Governments in achieving, inter alia, a balance between supply and demand.

b) Monitors and promotes measures taken by Governments to prevent the diversion of substances frequently used in the illicit manufacture of narcotic drugs and psychotropic substances and assesses such substances to determine whether there is a need for changes in the scope of control of Tables I and II of the 1988 Convention.


10

3. INCB responsibilitiesc) Analyses information provided by Governments,

United Nations bodies, specialized agencies or other competent international organizations, with a view to ensuring that the provisions of the international drug control treaties are adequately carried out by Governments, and recommends remedial measure.

d) Maintains a permanent dialogue with Governments to assist them in complying with their obligations under the international drug control treaties and, to that end, recommends, where appropriate, technical or financial assistance to be provided

THE INTERNATIONAL NARCOTIC CONTROL BOARD – INCB (5)

11

2. Functions of INCBLaid down in the following treaties:

Single Convention on Narcotic Drugs 1961

Convention on Psychotropic Substances 1971

UN Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988


12

Single Convention 1961Noting that the use of narcotics for medical purposes is still needed to relieve pain and opioids need to be made available for that purpose

Noting that drug addiction is a serious problem for individuals, a socio-economic problem for the society

Recognizing the responsibility to stop and combat this evil

9


13

Single Convention 1961 (con’t)Articles 19,20,21: Nations shall submit annual report and estimation to the INCB on quantity of licit use of narcotics for medical and scientific purposes.Article 29,30: Manufacture, trade and distribution of drugs must be under license. However, this requirement need not to apply to such drugs as physicians may lawfully work with their duly authorized therapeutic functions.

- It is required that written prescriptions must be used dispensing.

- Prescription for drugs in Schedule I should be written on official forms to be issued in the form of counterfoil books by the competent governmental authorities…

14

Single Convention 1961 (con’t)Article 34: Measures of Supervision and Inspection:

a) All persons who obtain license, or who have managerial or supervisory positions in an enterprise shall execute faithfully and effectively provisions of current laws and regulations.

b) Must keep records on all drugs manufacture, trade and use, such records shall respectively be preserved for a period of not less than two years. Where counterfoil books of official prescriptions are used, such books including counterfoil shall also be kept for a period of not less than two years.Article 36: Penal provisions: Any actions contrary to the provisions of this Convention shall be punishable offences (imprisonment or other penalties of deprivation of liberty).

15

2005 United Nations Resolution“Treatment of Pain using Opioids”

Impediments include national drug regulations

Many countries have not examined impediments or removed regulatory barriers

WHO/INCB document “Achieving Balance in National Opioids Control Policy”

ECOSOC 2005

16

ON OPIOID CONTROL

17

Balance

PATIENTS’ACCESS TO

opioid

OpioidCONTROL

18

“Balance” is the Fundamental Principle

National policy should establish a drug control system that prevents diversion and ensures adequate availability for medical use of opioid analgesics

Drug control measures should not interfere with medical access to opioid analgesics

Source: World Health Organization. Achieving balance in national opioids control policy: Guidelines for Assessment. Geneva, Switzerland: WHO; 2000.

10


19

For governments and health professionals

Explains rationale and necessity for opioid availability

16 criteria

Simplified Checklist

22 Languages

Achieving Balance in National Opioids Control Policy: Guidelines for Assessment (2000)

www.painpolicy.wisc.edu20

NARCOTIC & PSYCHOTROPIC DRUGS

ACHIEVING BALANCE IN NATIONAL

OPIOIDSCONTROL POLICYGUIDELINES FOR

ASSESSMENT

WHO/EDM/QSM/2004.4

ENGLISH ONLY

WORLD HEATHL ORGANIZATION

3 Main Parts to Achieving Balanced PolicyWHO, 2000

1. Evaluate national drug control policy

2. Estimate annual requirements; report consumption statistics

3. Administer effective distribution system to patients

21

WHO Criteria for Assessing Policy

1. Opioids absolutely necessary2. Government obligation to ensure availability3. Designate Competent Authority4. Estimate requirements; report statistics5. Address fear of legal sanctions6. Use correct terminology regarding addiction7. Avoid restrictions that limit medical decisions8. Avoid unduly strict prescription requirements9. Cooperation to ensure availability

22

NEEDS AND CURRENT STATUS OF OPIOID USE IN VIETNAM

23

I. OPIOID IS ABSOLUTELY NECESSARY FOR MEDICAL PURPOSES (1)

1. Both list of Essential Drugs (WHO, Vietnam) and list of drugs used in hospital settings have opioids for treatment of pain

2. Some finding in the Palliative Care Rapid Situational Analysis in 5 provinces of Vietnam

(MOH in collaboration with Family Health International, POLICY Project, CDC/VCHAP)

3. MoH issued the National Palliative Care Guidelines for Cancer and AIDS patients.

24

II. FACTORS AFFECTING OPIOIDS AVAILABILITY IN VIETNAM

1. Laws and Regulations. 2. Availability of opioids3. Provision of opioids to patients

a) Manufactureb) Distribution, reservation and sellingc) Prescription

4. Barriers to the availability of opioids

11


25

a) 38 current legal documents related to opioid:• Constitution, article 61.• Law on Illicit drug Control and Combat.• Penal Code• Drug Law• Other guidances under laws:

For the health system, key regulations are those for: narcotics management, psychotropic management, prescription and drugs must be sold with prescriptions.

1. LAWS AND REGULATIONS

26

2. AVAILABILITY OF OPIOIDSStrong opioids:

– Morphine 10mg (injection), cost of one 10mg vial – Morphine 30mg (tablet) (10mg tablet not available)

Morphine is currently not enough in Vietnam and long-acting formulations are not available.

– Pethidine 100mg (injection)/ 2ml vial (at commune level, only used for emergency cases)

– Fentanyl 0,5mg (injection)/10ml vial- 0,1 mg/2ml vial

– Fentanyl (patch) 50 mcg, 25mcg Not very much available due to strict reservation conditions and expensive cost.

– Oxycodone, hydromorphone, hydrocodone, methadone and buprenorphine are not available in Vietnam

Mild opioids: No sand-alone codeine for pain relive

27

3. PROVISION OF OPIOIDS TO PATIENTS

3.1. Procurement, manufacture3.2. Supply, reservation3.3. Prescription3.4. Selling in retail

28

a. Opioid procurementThe Drug Administration of Vietnam (Unit for Controlled Drugs) submit annual evaluation of drug use to the INCB. The evaluation based on consuming of opioids from the previous year.Health Service and centre hospitals send the provide for opioids to Drug Administration of Vietnam from the previous year.

3.1. PROCUREMENT, MANUFACTURE (1)

29

Lượng tiêu thụ morphin toàn cầu năm 2004

0

20

40

60

80

100

120 Global mean 5,67mgmg/người

Nguồn: Ủy ban Kiểm soát ma tuý quốc tế; Niêm giám Dân số của Liên hợp quốcThực hiện bởi: Nhóm nghiên cứu chính sách và thuốc giảm đau – Trường Đại học Wisconsin/Trung tâm hợp tác Tổ chức Y tế thế giới, 2006

Quốc gia (155)Định lượng toàn cầu được tính toán bằng việc thêm vào các dữ liệu mỗi mg trên đầu người cho tất cả các

quốc gia, sau đó đem chia cho tổng số quốc gia

1,0753 mgÁc hen ti na

---Nigeria

0,4001 mgUganda

0,0028 mgSierra Leone

5,67 mgĐịnh lượng toàn cầu

---không báo cáo số liệu

0,0993 mgViệt Nam

0,6261 mgPanama

2,0794 mgSerbia & Montenegro

0,1176 mgColombia

Ác hen ti na

Panama

Uganda

VIệt Nam

Sierra LeoneSerbia &

Montenegro

Colombia

Canada (64,1751 mg)

Hoa Kỳ(48,8145 mg)

Úc

(115,7151 mg)

Ý

(5,3206 Mg)

Nhật Bản(4,7174 mg)

30

12


31

Narcotics use in Vietnam

6

71,150

0

0

900

0

0

1 640

4

2001

31

138,500

0

0

2 160

0

0

2 616

8

2004

000Pholcodine (kg)

000Dihydrocodeine (kg)

37

40,059

0

0

1 395

2 092

4

2003

3549Pethidin (kg)

120,00082,365Fentanyl (g)

00Diphenoxylate (kg)

00Methadone (kg)

1 845900Dextropropoxyphene

2 9681 703Codeine (kg)

12Morphine (kg)

20052002Drug

Total amount of opioids in Vietnam (statistics from INCB)=> Very low in compare to the population and needs of patients

32

Narcotics use of Vietnam and some other countries before 2004 (source: INCB)

0200Hydrocodone (kg)

51300Oxycodone (kg)

00490Pholcodine (kg)017202820Dihydrocodeine (kg)

122

604,480

0

0

0

229

97

Korea

910731Pethidin (kg)

13,280222,262138,500Fentanyl (g)

0320Diphenoxylate (kg)

040Methadone (kg)

002 160Dextropropoxyphene

301892 616Codeine (kg)

18338Morphine (kg)

PhilippinesMalaysiaViệt NamDrug

33

Use by DDD/1,000,000 person/day

302241-Malaysia

315-Việt Nam

2133671Singapore

17779340Korea

1-12Indonesia

1711Philippines

57131China

PethidineMorphineFentanylCodeine

34

b. ManufactureMaterial manufacture: 0 (import 100%)Product manufacture:

- Morphine: 02 enterprises- Codeine : 40 (only in combination forms)- Dextropropoxyphene: 15 (only in combination

forms)- Fentanyl: 0- Pethidine: 0

Manufacturers and companies allowed to produce and sell narcotics are reluctant to produce narcotics. Mostly produce in combination forms below the controlled levels.

3.1. PROCUREMENT, MANUFACTURE (2)

35

3.2. SUPPLYNorthern provinces

Huế

Đà NẵngSouthern-Central provinces and Highland

Southern provinces

Central Pharmaceutical Company # 1



- Provincial Pharm. Companies- Central level Hospitals and Hospitals of other sectors- Research Institutes, Universities, Secondary Schools

Provincial Pharm. CompaniesCentral level Hospitals and Hospitals of other sectorsResearch Institutes, Universities, Secondary Schools

36

3.3. SELLING IN RETAIL

Number of drug stores allowed to sell opioids are different from province to province. Some provinces have only one place (Quang Ninh, Khanh Hoa) There is sill no mandatory or support system for businesses to sell prescribed opioids for therapeutic purposesThe current regulations (issued in 2003) do not allowed private businesses to sell narcotics (conflicted with Drug Law issued in Oct 2005). The provincial pharmaceutical company only sell narcotics in one place depending on the organization and scale of that company.Some provinces add one condition to request the opioidprescription must be approved by the director of the company

13


37

2245,891TP HCM1011

98654321

No.

Hanoi

Tra VinhĐong NaiĐaklakBinh ThuanKhanh HoaHai DuongNam DinhQuang Ninh

Province

1 141,078

4143,145

881,0288112,19314131,710881,115181,12214141,71112141,961

No. of opioidretail outlets

No. of districtsPopulation (in million)

Inappropriate number of retail outlets

Population number from the 2005 Annual Statistics

Data from MoH 2006 monitoring and inspection 38

• Issued with Decision No 04/2008/QD- BYT, Date February 01,2008 of Minister of Health on Prescriptive Regulation for out – patients .

• There are prescription of opioids for pain relief treatment of cancer and AIDS patients from article 11,12,13,16):

3.4. PRESCRIPTION

39

Article 11. Prescription for narcotic drugs

1. Every year, the facilities of curative care and consultation register the signature of prescribers in charge on narcotic drug prescription with narcotic selling facilities;

2. Using “ N” form of prescription;3. Prescription of narcotic drug for acute

diseases should be sufficient and not exceed 7 days.

40

Article 12. Prescription of opioids for pain relief treatment of cancer and AIDS patients

1. Following the regulation item 1; 2 under article 11;

1. Health service facilities which diagnose cancer and AIDS patients will provide a health record book of chronic disease (Using opioids for pain relief ) in which lower level of health service facilities can provide opioids for patients;

1. Dose of opioids will be based on the need of patients. Duration for each prescription is not over 1 month. But at the same time, prescriber has to prescribe 3 prescriptions for 3 stages of treatment ; prescription for each stage of treatment is not over 10 days ( the starting day and the ending day is noted clearly). Prescriber has to guide the member of patient’s family to know: Prescription of patient for treatment of 2nd and 3rd stage is issued or sold with confirmation of health service facility at communal level about patient to be alive. The time for buying or getting drug is one day before of that treatment stage (if meeting holiday, patient buys or gets drug one day before holiday);

41

Article 12. Prescription of opioids for pain relief treatment of cancer and AIDS

patients

4. Cancer and AIDS patients stay at home at the last phase of disease, the assigned health servicer of communal level goes to see and prescribe opioids for patient without exceeding 7 days each time.

5. Prescriber of opioids demand the member of patient’s family to sign a commitment on using opioids with right purposes and having the legal responsibility in case of not using it for treatment of patient.

42

Article 13. The usable value of prescription for buying or getting drug1. The prescription will be usable value for buying

drug at all legal pharmacy in 5 days since day of prescription to be issued.

2. For narcotic prescription, the time for drug buying or drug getting has to suit with treatment days written in prescription.The time of buying, getting opioids for treatment of 2nd, 3rd stage of cancer or AIDS patients is 1 day before the day of each treatment stage (if meeting holiday, patients buy or get drug 1 day before holiday). Prescription of opioids buy only either at pharmacies where the signature of prescriber has registered or Pharmaceutical Department of hospital where prescription is prescribed ( if pharmacies of local for selling of opioids is not available).

14


43

Article 15. Regulations for narcotic drug issuer and seller based on prescription

1. Every stage of issuing, selling is not over 10 days. The duration of selling narcotic drugs based on prescription follows regulation item 3 under article 12.

2. The drug issuer or seller has to note the duration of drug use in prescription that drug is sold to keep as archives. The prescription as archives has to sufficiency of signature, ID, full name, address of patient. Keeping as archives prescription with the confirmation of health service facility about patient to be alive for 2nd and 3rd stage of treatment.

3. Writing report for getting back narcotic drugs from family member of patient’s if a few of drug were used not as whole.

4. The report is written into 2 copies (1 copy is kept as archives at place of drug issuer or seller; 1copy for family member of patients). The narcotic drugs that get back from patient’s family has to put in a separated place and maintaining, settlement follow the regulation on narcotic drugs management. 44

Article16. Keeping as archives of narcotic drug materials

1. Health service facilities keep as archives the original prescription “N” of narcotic drug materials in duration of 2 years from using date of the last page of prescriptive book “N”. Keeping also as archives the confirmation of families of cancer and AIDS patients on using of opioids in duration 2 years.

2. The facilities of narcotic carry on business preparing, issuing, selling keep as archives the prescriptions “N”following regulations of narcotic drug management.

3. When duration of keeping as archives of narcotic drugs materials come to an end (the original prescriptions “N”, the confirmation of patient’s families on narcotic use), the health service facilities will establish the committee to destroy above materials according to define of regulation on narcotic drugs management.

45

4.1. Legal documentsStill using negative terms referring to opioids in the legal documents.

Example “Controlled substances” including drugs can cause dependence and also essential drugs. Should not identify opioids with social evils, crimes and drug use.

Should use more positive terms, for example: explaining that “opioids are addicting drugs” can be replaced by “opioids are drugs that may cause psychological dependence and can be diversed”Should not regulate to frame all opioid names to avoid the risk of opioid diversionShould confirm that opioids are essential drugs for pain relief.Should have change on assessment for patients’ opioid need? Have clear regulations to submit supplement request or to reduction request for opioid need to INCB

4. BARRIERS TO THE AVAILABILITY OF OPIOID (1)

46

4.2. Opioid availabilityLow quantity produced (amount, various strengths…) low number of suppliers.Additional regulations by other levels of authorities:

- DoHs request to add a regulation: pharm. companies have to approve all opioidprescriptions and collect used empty vials or packages => one more complex step for patients;

- Hospitals or departments request to return used empty vials => physicians are reluctant to prescribe.


47

4.3. Technical, knowledge and education aspects

Technical aspect:- No long-acting morphine produced yet- Lack of formulations and strengths to choose between options

(i.e: only morphine 30mg tablet)- No stand-alone codeine for pain relief

Knowledge and education aspects:- Reluctance of doctors to prescribe and of pharmacists to sell

opioids- Lack of adequate knowledge on appropriate use of opioids for

patients- No national palliative care training for health care workers.


48

Reducing Barriers to Prescribing

Before Recent1. France: 7 days 28 days2. Mexico: 5 days 30 days 3. Italy: 8 days 1 month4. Germany: 1 day no limit 5. Poland: 100 mg 4.0 grams6. Peru: 1 day 14 days7. Romania: 3 day supply 30 day supply8. Vietnam: 7 days 1 month

15

16

The History of the Palliative Care Movement / The Asia Pacific Hospice Palliative Care Network

Copyright © 2007 Cynthia Goh. All rights reserved.


Cynthia R Goh, MBBS, PhD National Cancer Centre Singapore

Objectives

After the lecture, the trainees will be able to: 1. Describe the origins of the modern hospice movement.

2. Describe the development of palliative care worldwide.

3. Understand the Asia Pacific Hospice Palliative Care Network and other resources available to support the development of palliative care in Asia.

Contents

1. Origins of the modern international hospice movement

1.1. Origins of the words “hospice” and “palliative care”

- The word “hospice” is taken from the Latin word “hospitium” which means hospitality. It is the same root from which the English words “hotel”, “hostel” and “hospital” come from.

- In the Dark Ages and Middle Ages in Europe, hospices were places of shelter and safety for travelers journeying across Europe, including pilgrims traveling to a shrine or holy place, often in fulfillment of a vow. Religious orders, such as the Knights Hospitalers and some monasteries, set up hospices which offered hospitality to these travelers, and treatment for injuries and illness.

- When the modern hospice movement started in England, the word “hospice” was chosen because the original concept of a hospice was a place of shelter and hospitality for the terminally ill, who were seen to be journeying from this world to the next.

- However, the word “hospice” had different meanings in other European languages. In modern French, it acquired the meaning of “a poor house or place for the destitute.”

- When Dr Balfour Mount wanted to start hospice care in Montreal in French-speaking Canada, he could not use the word “hospice”. He coined the term “soins palliative” or “palliative care”. The word “palliative” was taken from the Latin word “pallium”, which means “cloak”. The idea was that the patients’ symptoms were covered over, or cloaked, even though the disease could not be cured.



- The words “hospice care” and “palliative care” are often used interchangeably, and indicate the same type of holistic care provided for patients with life-threatening illness. However, there are local preferences for the usage of the two terms. For example, in the USA, the term “hospice care” is used to mean hospice home care, while services in hospital for the same group of patients is termed “palliative care”. In other parts of the world, such as in the UK and Singapore, community services are often called “hospice services” while hospital services are termed “palliative care services”. A stand-alone in-patient facility providing this type of care is often called a hospice.

1.2. Cicely Saunders and St Christopher’s Hospice

- While there were institutions called hospices which looked after the destitute and the dying in various countries in the 19th and early 20th century, the modern hospice movement can be said to have started with the work of Dame Cicely Saunders, who built St Christopher’s Hospice in London, UK in 1967.

- Cicely Saunders (1918-2005) was a remarkable person. She was a student at Oxford University when the Second World War broke out. She gave up her studies to join the war effort in London by training as a nurse at St Thomas’ Hospital in London. She was greatly influenced by her patients, particularly by David Tasma, a Polish refugee in London, with whom she discovered the needs of terminally ill patients. When David Tasma died, he left her all his money, 500 pounds sterling, and asked to be a “window” in her home. After she qualified as a nurse, Cicely Saunders had to give up nursing because of a back injury. She then trained as a lady almoner, nowadays called a medical social worker. She continued to be particularly close to her patients who were dying and to take up their cause. She was advised to study medicine, in order to have a greater influence. So in her mid-thirties, she studied to become a doctor, and ended being triply qualified as a nurse, a social worker and a doctor. Soon after graduating as a doctor, she went to work among nuns looking after terminally ill patients, and was the first to describe and document the use of morphine orally with regular dosing for the control and prophylaxis of chronic pain.

- She gathered round her a group of like-minded people, who spent many years conceptualizing the holistic care needed for terminally ill patients, and gathering enough resources to build a model “hospice”. St Christopher’s Hospice opened its doors to patients in 1967. The word “hospice” was chosen by this Foundation Group at St Christopher’s.

- Through this work, Cicely Saunders was able to demonstrate how good care can be provided for terminally ill patients. She traveled widely and was a charismatic speaker, inspiring a whole generation of doctors, nurses and social workers in many countries to go into this field.

17



- The words “hospice care” and “palliative care” are often used interchangeably, and indicate the same type of holistic care provided for patients with life-threatening illness. However, there are local preferences for the usage of the two terms. For example, in the USA, the term “hospice care” is used to mean hospice home care, while services in hospital for the same group of patients is termed “palliative care”. In other parts of the world, such as in the UK and Singapore, community services are often called “hospice services” while hospital services are termed “palliative care services”. A stand-alone in-patient facility providing this type of care is often called a hospice.

1.2. Cicely Saunders and St Christopher’s Hospice

- While there were institutions called hospices which looked after the destitute and the dying in various countries in the 19th and early 20th century, the modern hospice movement can be said to have started with the work of Dame Cicely Saunders, who built St Christopher’s Hospice in London, UK in 1967.

- Cicely Saunders (1918-2005) was a remarkable person. She was a student at Oxford University when the Second World War broke out. She gave up her studies to join the war effort in London by training as a nurse at St Thomas’ Hospital in London. She was greatly influenced by her patients, particularly by David Tasma, a Polish refugee in London, with whom she discovered the needs of terminally ill patients. When David Tasma died, he left her all his money, 500 pounds sterling, and asked to be a “window” in her home. After she qualified as a nurse, Cicely Saunders had to give up nursing because of a back injury. She then trained as a lady almoner, nowadays called a medical social worker. She continued to be particularly close to her patients who were dying and to take up their cause. She was advised to study medicine, in order to have a greater influence. So in her mid-thirties, she studied to become a doctor, and ended being triply qualified as a nurse, a social worker and a doctor. Soon after graduating as a doctor, she went to work among nuns looking after terminally ill patients, and was the first to describe and document the use of morphine orally with regular dosing for the control and prophylaxis of chronic pain.

- She gathered round her a group of like-minded people, who spent many years conceptualizing the holistic care needed for terminally ill patients, and gathering enough resources to build a model “hospice”. St Christopher’s Hospice opened its doors to patients in 1967. The word “hospice” was chosen by this Foundation Group at St Christopher’s.

- Through this work, Cicely Saunders was able to demonstrate how good care can be provided for terminally ill patients. She traveled widely and was a charismatic speaker, inspiring a whole generation of doctors, nurses and social workers in many countries to go into this field.

18



2. Development of Palliative Care worldwide

2.1. UK

- Following the work of Cicely Saunders, many in-patient hospice facilities sprang up in the UK. These were closely followed by the development of hospice home care services, such as the one at St Christopher’s Hospice which started in 1968. Many communities set up their own in-patient hospices, funded by charitable funds with some input from the National Health Service. Later, hospital palliative care services also developed. Most of these are consultative in nature with no in-patient hospital beds, with the exception of the Supportive Care Unit at the Royal Marsden Hospital, a famous cancer hospital.

- In 1987, Palliative Medicine was recognized as a medical specialty in the UK, and accredited higher medical training of 4 years was established in 1989. By 1995, all consultant staff at National Health Service funded facilities, and medical directors of hospices were required to be accredited specialists in Palliative Medicine.

2.2 Australia and New Zealand

- In Australia, hospices were in existence before the 1960s, but the hospice movement was given a boost by the visit of Cicely Saunders in the mid-1970s. Both Australia and New Zealand have well developed palliative care services and strong professional societies, such as the Australia New Zealand Society of Palliative Medicine, and Palliative Care Australia. Palliative Medicine was recognized as a medical specialty in Australia in 2000, and in New Zealand shortly before that, and accredited training is well established.

2.3 USA

- For many years since the 1970s, hospice home care services were the main services in the USA. Known as “hospice care”, these services to support terminally ill patients at home were given a boost when Medicare funding for them became available in 1982. However, this also brought about constraints, because patients under hospice care had to forgo other treatments such as chemotherapy or radiotherapy. Originally, Medicare funding was available to an individual for 90 days per life-time. This was later amended to 180 days and longer.

- The boost to the development of palliative care in the USA came when the Soros Foundation funded the Project of Death in America from 1994 to 2003, giving US$45 million in grants. Among other things, this project funded scholars in academic institutions to work in the palliative care field and do research. This has given rise to a generation of leaders in palliative care in the USA. Palliative medicine was recognized as a medical subspecialty in 2006, and accredited training is being established.

2.4 Other developed countries

- Palliative care is well developed in Canada where it is funded by the provincial governments. In Western Europe, palliative care development is variable in different countries. The European Association of Palliative Care is active in promoting research and education in Palliative Care.

19



2.5 Eastern Europe and Africa

- In many of the developing nations of Eastern Europe and Africa, palliative care services have developed, supported by philanthropic efforts from developed countries such as the UK and the USA. The Soros Foundation through its arm, the Open Society Institute, has initiated many education efforts in countries in Eastern Europe and Africa. Particularly successful models exist in Romania and in Uganda, which serve as training centres catalyzing the development of palliative care in those regions.

2.6 Worldwide Networking

- There are currently two groups which link individuals and organizations internationally in the field of palliative care. The International Association for Hospice and Palliative Care (IAHPC) has an international membership of individuals and organizations, and focuses on education and professional development. The Worldwide Palliative Care Alliance (WPCA) has a membership of national associations of hospice and palliative care, and focuses on policy issues, advocacy, quality and standards.

3. The Asia Pacific Hospice Palliative Care Network

3.1 Development of hospice & palliative care services in Asia

- There is much variation in the development of palliative care services in the different economies of Asia.

- Some countries, such as Japan, South Korea, Taiwan, Hong Kong, Singapore and Malaysia have well-established services covering a significant portion of their cancer deaths. Many of these services are wholly or partially funded by the government or insurance. Essential drugs are available. Palliative Medicine is recognized as a medical specialty and training is well developed.

- Many less economically developed countries have also started palliative care services. These include Indonesia, Philippines, Thailand, Vietnam, China and India. Services have begun to develop, but coverage of cancer deaths is insignificant. Essential drugs are not easily available.

3.2 History and development of the APHN

- The concept of a network of individuals working in palliative care in the Asia Pacific region originated with Dr Shigeaki Hinohara, a Japanese cardiologist who had access to funding from the Sasakawa Foundation (now known as the Nippon Foundation). In 1995, Dr Hinohara invited the first group of pioneers in hospice care to Tokyo. A series of meetings followed, linked to various regional conferences. By 1999, the group had resolved to form an organization, the Asia Pacific Hospice Palliative Care Network (APHN). A secretariat was set up to oversee its formation and registration as a legal entity in Singapore, which was achieved in 2001. It has 14 Founding sectors, which are: Australia, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, New Zealand, Philippines, Singapore, Taiwan, Thailand and Vietnam. Each of these sectors

20



have the right to appoint one member to the Governing Board of the APHN on a rotating basis. The membership of the APHN includes organizations and individuals. There are currently 1,062 members from 29 countries, of which 165 are organizations.

3.3 APHN Programs include:

• Providing faculty to teach in resource poor countries

• Clinical fellowships in palliative care

• APHN Diploma / Flinders Graduate Certificate Course

• Information service and directory of service providers

• Travel bursaries to the Asia Pacific Hospice Conferences

• Consultancy for service development

3.4 The Asia Pacific Hospice Conferences

- The first conference took place in Singapore in 1989, and the second in 1996. Since 1999, these have been organized by the different sectors of the APHN once every 2 years. These bring together palliative care practitioners throughout the Asia Pacific region. The last conference was held in Manila, Philippines in September 2007, and the next, the 8th Asia Pacific Hospice Conference will be held in Perth, Australia in September 2009.

3.5 Resources available – Useful websites for information on palliative care services, bursaries for travel and courses can be found below:

• International Association for Hospice & Palliative Care: www.hospicecare.com

• Help the Hospices: www.helpthehospices.org.uk

• Hospice Information Service: www.hospiceinformation.info

• National Hospice and Palliative Care Organization: www.nhpco.org

• European Association for Palliative Care: www.eapc.org

• Asia Pacific Hospice Palliative Care Network: www.aphn.org

21



Daily evaluation questions

1. Hospice care and palliative care provide the same type of care to patients.

Yes No

2. Which of the following developing countries have good palliative care services and education?

a) Thailand

b) Romania

c) Uganda

d) Philippines

e) b and c

3. The membership of the Asia Pacific Hospice Palliative Care Network includes both individuals and organizations.

Yes No

22



References (Suggested reading)

Goh CR. The Asia Pacific Hospice Palliative Care Network: Supporting Individuals and Developing Organizations. J Pain Symptom Manage 2007; 33(5):563-67.

References for writing the lecture

Asia Pacific Hospice Palliative Care Network: www.aphn.org

Goh CR. Status of Cancer Pain and Palliative Care in Singapore. J Pain Symp Manage 1993; 8(6):431-433.

Goh CR. Singapore : Status of Cancer Pain and Palliative Care. J Pain Symptom Manage 1996; 12(2):130-132.Goh CR. The Present Status of Hospice in Asia – Singapore. In: Symptom Management in Cancer Patients 2004. Dr Fumikazu Takeda (Editor).

Goh CR. The Asia Pacific Hospice Palliative Care Network – A Network for Individuals and Organisations. J Pain Symptom Manage 2002; 24(2):128-133.

Goh CR and Shaw RJ. Palliative Care Education in Asia-Pacific. In: Palliative Care: Building a Culture of Learning. Bee Wee and Nic Hughes (eds). Oxford University Press 2007.

Hospice Information Service (St Christopher’s Hospice & Help the Hospices): www.hospiceinformation.info

International Observatory on End of Life Care: www.eolc-observatory.net

Saunders C M, Foreword, Oxford Textbook of Palliative Medicine, Third Edition, Doyle D, Hanks G, Cherny N and Calman K (eds), Oxford University Press 2006.

Shaw Rosalie. The Development of Palliative Medicine in Asia. In: Bruera E, Higginson I J, Ripamonti C, von Gunten C (eds). Textbook of Palliative Medicine. Edward Arnold 2006.

23

History of the Palliative Care Movement

1


Associate Professor Cynthia GohSenior Consultant & Head

Department of Palliative MedicineNational Cancer Centre Singapore

The Asia Pacific Hospice Palliative Care Network

Copyright © 2007 Cynthia Goh. All rights reserved.2

ObjectivesAfter the lecture, the trainees will be able to:

1. Describe the origins of the modern hospice movement

2. Describe the recent development of palliative care worldwide

3. Have an understanding of the Asia Pacific Hospice Palliative Care Network and other resources available to support the development of palliative care in Asia

3

The word “hospice” is taken from the Latin word “hospitium” which means “hospitality”.

It is the same root from which the English words “hotel”, “hostel” and “hospital” come from.

HOSPICE

4

The concept of a safe place of refuge for travelers.

Originally for pilgrims traveling across Europe in the Middle Ages.

Monasteries used to look after tired, sick or injured pilgrims & gave them hospitality.

The modern concept of hospice provides care & refuge for travelers journeying from this world to the next.

HOSPICE

5

The word “hospice” in French means a poor house, or place for the destitute.

In French-speaking Canada, Dr Balfour Mount in Montreal invented the word “palliative care” to mean hospice care.

The word “palliative” comes from the Latin word “pallium” which means a cloak.

To palliate is to cover, as with a cloak, over the symptoms.

HOSPICE

6

Hospice = Palliative Care Care

Usually calledthis in theCommunity

Usually calledthis in Hospitals

Common usage of the words:

24


7

Palliative Care has its roots in theInternationalHospice Movement

Cicely Saunders1918-2005

8


• Studied at Oxford University• To help the World War II war

effort, trained as nurse at St Thomas’ Hospital, London.

• Discovered the needs of terminally ill patients, through her patients like David Tasma, a Polish refugee in London.

• When he died, he left her 500 pounds to be a “window” in her home.

9


• Injured her back while nursing and had to give it up.

• Trained as lady almoner, (now called “medical social worker”).

• Was advised that she needed to become a doctor for people to listen to her.

• Trained at St Thomas’ Hospital as a doctor in her mid-thirties.

10


• She was the first doctor to describe and document the use of morphine orally with regular dosing for the control and prophylaxis of chronic pain.

11


• Gathered a group of people to conceptualize the holistic care needed for terminally ill patients.

• St Christopher’s Hospice opened its doors to patients in 1967.

• The word “hospice” was chosen by the Foundation Group at St Christopher’s.

12

1967 St Christopher’s Hospice, London

25


13

Development of Palliative Care Worldwide

UKFollowing the work at St Christopher’s, many in-patient hospice facilities sprang up in the UK.

Hospice home care services followed.

Many communities set up their own in-patient hospice, funded by charitable funds with some input from the government.

14


UKHospital palliative care services developed later.Most provide consultative services with no in-patient hospital beds. The exception was the Supportive Care Unit at the Royal Marsden Hospital, a cancer hospital, which has in-patient hospital beds.

15


UKPalliative Medicine was recognized as a medical specialty in the UK in 1987.

Accredited advanced specialist training of 4 years was established in 1989.

By 1995, all consultant staff at National Health Service funded facilities, and medical directors of hospices were required to be accredited as a specialist in Palliative Medicine.

16


Australia and New ZealandIn Australia, hospices were in existence before the 1960s.

Hospice movement was given a boost by the visit of Cicely Saunders in the mid-1970s.

Both Australia and New Zealand have well developed palliative care services and strong professional societies, such as the Australia & New Zealand Society of Palliative Medicine, and Palliative Care Australia.

17


Australia and New ZealandPalliative Medicine was recognized as a medical specialty in Australia in 2000 and in New Zealand shortly before that.Accredited specialist training is well established.Government funding of palliative care services are well established.

18


USASince the 1970s, hospice home care services were the main services in the USA. Known as “hospice care”, these services support terminally ill patients at home. Medicare funding for these services became available in 1982.

However, patients under Hospice Care had to forgo other treatments such as chemotherapy or radiotherapy.

Medicare funding was originally available to an individual for 90 days per life-time. This was later amended to 180 days and longer.

26


19


USA

From 1994 to 2003, the Soros Foundation funded the Project of Death in America, giving US$45 million in grants. This charitable project funded scholars in academic institutions to work in the palliative care field and do research, giving rise to a generation of leaders in palliative care in the USA.

In 2006, Palliative Medicine was recognized as a medical subspecialty, and accredited training was established in 2008.

20


Other developed countriesPalliative care is well developed in Canada where it is funded by the provincial governments.

In Western Europe, palliative care development is variable in different countries.

The European Association of Palliative Care is active in promoting research and education in Palliative Care.

21


Eastern Europe and AfricaMany developing nations of Eastern Europe and Africa have palliative care services, supported by philanthropic efforts from the UK and the USA. The Soros Foundation, through its arm the Open Society Institute, has initiated many education efforts in countries in Eastern Europe and Africa.

Particularly successful models exist in Romania and in Uganda, which serve as training centres catalyzing the development of palliative care in those regions.

22


Worldwide NetworkingThere are currently two groups which link individuals and organizations internationally.

The International Association for Hospice and Palliative Care (IAHPC) has an international membership of individuals and organizations and focuses on education and professional development.

The Worldwide Palliative Care Alliance (WPCA) has a membership of national associations of hospice and palliative care which focuses on policy issues, advocacy with governments, quality and standards.

23

The Asia PacificHospice Palliative Care Network

APHN

24

Palliative care services are in various stages of development in Asia

JapanSouth KoreaTaiwanHong KongSingaporeMalaysia

Services are fairly well developed.Some payment by govt or insurance.Essential drugs available.Education well developed.Recognition as a specialty.

Hospice home care in Singapore Mackay Hospice in Taipei

27


25

Palliative Care Services are in Various Stages of Development in Asia

PhilippinesIndonesiaThailandVietnamMyanmarChinaIndia

Services are starting up.Coverage by palliative care services

patchy or minimal.Essential drugs not easily available. Much to be done in education

Home care in Myanmar Benh Vien K in Hanoi26

The Asia Pacific Hospice Palliative Care NetworkA Network of Individuals & OrganisationsNow has 1,062 members in 29 Countries

165 Organisations / 897 Individuals

27

• The concept of a network of individuals working in palliative care in the Asia Pacific originated with Dr Shigeaki Hinohara, a Japanese cardiologist.

• In 1995, he invited the 1st group of pioneers in hospice care to Tokyo.

• After several meetings, in 1999 the group resolved to form an organisation, the Asia Pacific Hospice Palliative Care Network (APHN).

Dr Shigeaki HinoharaPatron

APHN - History and Development

28

Objective: To promote the development

of hospice palliative care in the Asia Pacific region

Prof Young-Seon Hong Chairman

Legally registered in 2001Secretariat in SingaporeRun by Council of 20 Sector Representatives

Asia Pacific Hospice Palliative Care Network

APHN

29

AustraliaHong KongIndiaIndonesia JapanKoreaMalaysia MyanmarNew Zealand Philippines SingaporeTaiwan ThailandVietnam

14 Founding Sectors of the APHN

30

APHN Programs

• Provides faculty to teach in resource poor countries.• Training of trainers courses in Vietnam & Thailand.• Clinical fellowships in palliative care.• APHN Diploma / Flinders Graduate Certificate Course.• Information service and directory of service providers.• Travel bursaries to the Asia Pacific Hospice

Conferences.• Consultancy for service development.

28


31

The Asia Pacific Hospice Conferences • The first conference took place in Singapore in 1989.• Followed by the second in Singapore in 1996.• Since 1999, these have been organized by the

different sectors of the APHN once every 2 years.• The conferences bring together palliative care

practitioners throughout the Asia Pacific region.• Last conference Manila, September 2007.• Next conference: 8th Asia Pacific Hospice Conference

Perth, Australia, September 2009.

32

Linking individuals & organisations….

Spinning a web….

Dr Rosalie ShawExecutive Director

APHN

The Asia Pacific Hospice Palliative Care Network

33

Useful ResourcesUseful websites for information on hospice services, bursaries for travel or courses include:International Association for Hospice & Palliative Care: www.hospicecare.com

Help the Hospices: www.helpthehospices.org.uk

Hospice Information Service : www.hospiceinformation.info

National Hospice and Palliative Care Organization: www.nhpco.org

Asia Pacific Hospice Palliative Care Network: www.aphn.org

29

Palliative Care for Patients with Heart / Lung Disease Part A: Congestive Heart Failure

Copyright © 2008 Massachusetts General Hospital. All rights reserved.


F. Amos Bailey, MD University of Alabama at Birmingham School of Medicine

Eric L. Krakauer, MD, PhD Harvard Medical School & Massachusetts General Hospital

Objectives

After the lecture, the trainees will be able to: 1. Describe the role of palliative care in congestive heart failure (CHF).

2. Describe the common physical symptoms and the common emotional, social and spiritual problems of patients with CHF.

3. Prescribe the best treatment to relieve symptoms associated with CHF.

4. Describe an interdisciplinary team approach to relieving psycho-social and spiritual distress.

Content

1. Typical symptoms of patients with late-stage congestive heart failure (CHF): • Dyspnea• Pain in the chest, abdomen, and legs • Weakness• Fatigue• Edema • Insomnia • Anorexia• Wasting• Anxiety

2. Principles of palliative care for patients with CHF: 2.1. Disease-modifying and palliative care for CHF are inseparable and often indistinguishable.

• With the exception of cardiac transplantation and a few other invasive interventions, almost all standard treatments of heart disease and CHF could be described as palliative.

2.2. The initial palliative care assessment and, if needed, intervention, should occur at the time of diagnosis or as soon as possible thereafter (Figure 1).2.3. Palliative care is applicable early in the course of congestive heart failure along with standard treatments such as:

30



o Diuretic therapy o Angiotensin converting enzyme (ACE) inhibitors o Low dose beta blocker therapy

2.4. Palliative care is especially important in advanced CHF when symptoms may be severe and disabling and may not be adequately controlled by standard cardiac medications.

o Dyspnea at rest or minimal exertion o Chest pain at rest or minimal exertion o Paroxysmal nocturnal dyspnea o Refractory lower extremity edema o Confined to bed or able to move only from bed to chair due to fatigue and/or above

symptoms

2.5. Palliative care attends to distress from psychosocial or spiritual problems. • The physical symptoms of pain, dyspnea and fatigue make it difficult for CHF patients to be

independent in their own self care. This dependence on others, particularly family, may lead to emotional distress, depression, financial difficulty for the patient and family.

• Some patients and families may struggle to find reasons for the illness that has affected them. This search for meaning at the end-of-life is determined by the patient’s family and spiritual background and personal history.

2.6. A palliative care assessment or re-assessment is indicated whenever death in the next 6 months would not be surprising.

• Prognosis is difficult to determine for patients with CHF. o Most patients with CHF are at risk for sudden cardiac death due to arrhythmia. o Others will survive for years with intermittent exacerbations. However, preventing or

controlling physical symptoms may prevent crisis and improve quality and even quantity of life

2.7. After the patient’s death, palliative care provides bereavement support to the family.

*******************************************************************************

Figure 1: Diagram of palliative care throughout the course of illness and bereavement.

Disease-specifictreatment

Diagnosis Death

PALLIATIVE CARE BereavementSupport

31



3. Palliative care interventions for patients with CHF 3.1. Aggressive relief of pain and any other symptoms

• Training patients and their families to use standard cardiac medications properly can improve symptom control.

• Use of diuretics such as furosemide to prevent symptomatic fluid overload is a key to controlling dyspnea.

• Determine a “dry weight” for the patient. Then arrange for the patient to be weighed daily on the same scale and adjust the diuretic dose upward or downward if the patient gains or loses more than 1 kilogram. In this way, both symptomatic fluid overload and dehydration can be avoided.

• The use of low dose spironolactone 25 mg daily by mouth along with furosemide can improve survival. The reason for the survival benefit may be a reduction in risk of hypokalemia and thus of arrhythmias.

• Use of an ACE inhibitor with a goal of low-normal blood pressure can improve symptoms and survival. However, some patients have allergic reactions or persistent cough with ACE inhibitor therapy, and some patients cannot tolerate ACE inhibitors due to renal insufficiency.

• A cardiac-selective beta blocker such as carvedilol or metoprolol, started at a low dose and increased as tolerated, can help to prevent tachycardia, chest pain and arrhythmias.

• Aspirin 81 to 325mg per day helps reduce acute coronary syndromes and other problems due to platelet aggregation.

• Some patients with coronary artery disease and angina may benefit from nitrate therapy such as oral isosorbide dinitrate. However, nitrates often have side effects such as headache

• When prescribing a CHF regimen, keep in mind complexity of the regimen and the availability and cost of medications.

• When chest pain, dyspnea, or other symptoms are not controlled with the above strategies, low dose opioid therapy can be beneficial.

o Opioid such as morphine can be given either intermittently of by-the-clock depending on the consistency and severity of the symptoms.

• The patient and family should be educated or reminded about salt restriction and avoidance of tobacco and alcohol, particularly if the patient is not having an optimal response to standard medical therapy.

3.2. Non-pharmacologic interventions • An electric fan or a breeze from an open window can help to relieve dyspnea. • Proper positioning of the patient can reduce dyspnea and help to prevent pressure ulcers. For

example, some patients will sleep better in an upright position. • Assistance with self care such as food preparation, bathing, or dressing can allow a patient to

conserve energy for other activities.

3.3. Psychological and social supports: • Depression can occur when patients lose their strength, vitality, work, family roles, and control

of bodily functions. • Open discussion about the psychological effects of the patient’s illness can be helpful, and

patients can be helped to develop coping and reframing strategies. • Some patients may benefit from anti-depressant medication. • Some patients need help to access clinical services and to remain adherent to standard therapies

32



for heart disease. • The patient’s family also can be helped to cope, both during the patient’s illness and during

bereavement. Families can be encouraged to seek support from family and friends and from any spiritual support practices that are a part of the family’s beliefs.

3.4. Anticipation of potential future symptoms and psychosocial problems. • CHF typically has a relapsing and remitting course. Recurrences of dyspnea, pain, or other

symptoms should be expected, and plans should be made to relieve them quickly whenever and wherever they occur, including in the home.

• Some patients have a period of hours or days during which they are actively dying and need opioid and other therapies around-the-clock to relieve intolerable symptoms.

• Despite excellent medical therapy for CHF, some patients experience sudden cardiac death. Some families, and even some patients, may wish to be informed of this possibility. Care should be taken in discussing bad news so as to minimize emotional distress for the patient and family.

3.5. Protection of the patients from unwanted or inappropriate medical interventions such as treatments that unduly sustain life.

• Life-sustaining treatments such as mechanical ventilators, non-invasive ventilatory support, and hemodialysis are becoming more available in Vietnam.

o These treatments can save lives but also can cause pain and suffering. o As these treatments become more available, decisions will be required more frequently

about the relative benefits and burdens of specific life-sustaining treatments for individual patients.

o In end-stage heart disease, these interventions have a low likelihood of benefit and are not routinely recommended.

• Palliative care never intends to hasten death, but it also does not try to unduly prolong the dying process.

3.6. Comprehensive palliative care is best provided by an interdisciplinary team with the patient at the center. Ideally, the team should include:

• Healthcare workers: o Physician (or Assistant Physician in some settings) o Nurseo Community health workers

• Family members o Will require training and psychosocial support

• Peer supporters and/or volunteers o May require training.

33




1. Since most treatment for heart disease is not curative, it could be considered palliative care. True False

2. Palliative care in end-stage heart disease would:

a. Maximize the effectiveness of standard treatment for CHF.

b. Use daily weight measurement and adjust medications as needed.

c. Use opioids for intractable symptoms.

d. All of the above.

e. b and c only

3. Standard therapy for CHF includes several classes of medication including angiotensin converting enzyme inhibitors, beta blockers, aspirin, and _______________. Diuretics

4. Depression, which is common in patients with heart disease,

a. negatively impacts quality of life.

b. has no effect on adherence to treatment.

c. can be trated with anti-depressant medication.

d. a and c

e. All of the above

34




Pantilat SZ, Steimle AE Palliative care for patients with heart failure JAMA. 2004; 291:2476-82.


Bhatia, R.S., Tu, J.V., Lee, D.S., et.al. (2006). Outcome of Heart Failure with Preserved Ejection Fraction in a Population-Based Study. New England Journal of Medicine, 355 (3), 260 -269.

Birks, E.J., Tansley, P.D., Hardy, J. (2006). Left Ventricular Assist Device and Drug Therapy for the Reversal of Heart Failure. New England Journal of Medicine, 355 (18), 1873-84.

Curtis, J.R., Rubenfeld, G.D. (2005). Improving Palliative Care for Patients In The Intensive Care Unit. Journal of Palliative Medicine, 8 (4), 840-854.

Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine ,3nd ed. Oxford: Oxford University Press, 1998.

End-of-Life Physician Education Resource Center. Available at http:/www.eperc.mcw.edu

Innovations in End-of-Life-Care (electronic journal). Available at http:/www.edc.org/lastacts/

International Society of Nurses in Cancer Care. End-of-Life Nursing Education Consortium (ELNEC) Project. Available at http:/www.aacn.nche.edu/elnec

Last Acts. Available at http:/www.lastacts.org

Pantilat SZ, Steimle AE Palliative care for patients with heart failure JAMA. 2004; 291:2476-82.

Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2008 Jan 15;148(2):I42

Thomas, J.R., von Gunten, C.F. (2003). Management of Dyspnea. Journal of Supportive Oncology, 1 (1), 23-34.

World Health Organization. National Cancer Control Programmes: World Health Organization. Palliative Care: Symptom Management and End-of-Life Care / Integrated Management of Adolescent and Adult Illness. Geneva: World Health Organization, 2004.

35

Palliative Care for Patients with Heart / Lung Disease Part B: Chronic Lung Disease



Eric L. Krakauer, MD, PhD Harvard Medical School & Massachusetts General Hospital

Objectives

After the lecture, the trainees will be able to: 1. Describe standard treatment for chronic obstructive pulmonary disease (COPD).

2. Describe the role of palliative care for patients with end-stage lung disease.

3. Prescribe the best treatment regimen for patients with end-stage chronic lung disease and dyspnea.

4. Discuss ethical issues in the palliative care of patients with end-stage lung disease.

Contents

1. Chronic Obstructive Pulmonary Disease (COPD)

1.1. COPD is the most common cause of end-stage lung disease.

1.2. This condition is due to loss of lung tissue and obstruction of airflow on exhalation. Air becomes trapped in the damaged lung, areas of the lung are no longer ventilated, and the lung volumes increase. As lung damage progresses, blebs or large areas of non-ventilated “dead space” develop. All of this results in decreased expiratory flow rates (decreased forced expiratory volume in one second or FEV1). Ultimately this illness can progress to chronic hypoxia and hypercapnia, pulmonary hypertension, right heart failure, chronic and acute respiratory failure and death.

1.3. The most common cause of this illness is smoking. Air pollution also plays an important causative role.

2. Restrictive Lung disease

2.1. Interstitial lung diseases such as idiopathic pulmonary fibrosis and sarcoidosis cause inflammation and scarring of the lung. When severe, this results in decreased expandability or stiffness of the lungs (restriction), impaired gas exchange, and dyspnea. Some interstitial lung diseases, including sarcoidosis, can cause both restrictive and obstructive lung disease.


36


2.2. Interstitial lung disease may be immune mediated or due to environmental exposures to inhaled pollutants. Examples of the latter are silicosis and asbestosis.

2.3. As interstitial lung disease progresses, both chronic and acute respiratory failure may occur.

3. Differential diagnosis of chronic lung disease

3.1. Destruction of pulmonary tissue may be caused by many diseases in addition to those mentioned above. These include primary or metastatic cancer, chronic or recurrent infections such as bacterial pneumonia, pulmonary tuberculosis (TB), or recurrent OI’s such as pneumocystis carinii pneumonia (PCP) or fungal pneumonia.

3.2. All can lead to progressive destruction of lung tissue and impairment of pulmonary function and result in chronic and acute respiratory failure and death.

3.3. Other conditions that cause chronic dysnea can mimic chronic lung disease. These include chronic pulmonary edema due to left-sided congestive heart failure or oliguric renal failure and severe asthma. Often patients have multiple causes of lung disease or dyspnea.

4. Prevention of chronic lung disease

4.1. Prevention of chronic and life-threatening illnesses including HIV/AIDS, cancer, and chronic lung disease is an important task for healthcare workers at all levels and in all fields including palliative care.

4.2. Chronic lung diseases can be prevented in many ways: • COPD and lung cancer, as well as other cancers, can be prevented by educating patients and the

public about the danger of smoking, encouraging young people not to smoke, and encouraging those who do smoke to stop.

o Even though COPD is not cured by smoking cessation, the rate of progression of the disease to death is slowed dramatically.

o Patients can be aided to stop smoking with counseling and psychological support, particularly during nicotine withdrawal.

o Smoking cessation programs that combine counseling, peer support, and nicotine therapy have been shown to be effective in rich countries.

• Early diagnosis and treatment of infectious diseases such at TB and OI’s associated with HIV/AIDS can greatly reduce lung damage.

• Air pollution and environmental lung toxins such as silicon and asbestos can both cause and exacerbate chronic lung disease. Therefore, public health initiatives are needed to:

o Educate the public about the dangers of air pollution o Advocate for reduction of exposure of workers and the public to air pollution and

environmental lung toxins.


37


5. Approach to the patient with chronic lung disease

5.1. Dyspnea, the subjective sensation of breathlessness, is common in chronic lung disease. Although pain, anorexia, fatigue and many other symptoms also are common, dyspnea is often the most disabling. Dyspnea often causes extreme distress, anxiety. Thus, it is imperative to relieve dyspnea effectively to improve the quantity and quality of life of individuals living with advanced chronic lung disease. (See syllabus on “Dyspnea Assessment and Treatment”.)

5.2. A Functional Dyspnea Scale can be used to quantify the severity of chronic lung disease• 0 = No dyspnea • 1 = Dyspnea when walking up incline • 2 = Dyspnea when walking on level • 3 = Dyspnea when moving from bed to chair or with other minimal activity • 4 = Dyspnea at rest • Patients with a Functional Dyspnea Score of 3 or 4 have very limited function, will have the

most limited prognosis, and would benefit most from aggressive palliative care interventions.

6. Palliative treatment for patients with chronic lung disease

6.1. There is no contradiction between standard, disease-modifying treatment of COPD and other chronic lung disease and palliative care. The best treatment plan for any patient may include disease-modifying therapy, curative treatment for acute complications, and palliative care.

• In the later stages of chronic lung disease, many patients will have an increasing need for palliative care including comprehensive symptom control and psychosocial support.

6.2. Consider treating any potentially treatable cause of dyspnea such as pulmonary TB (which can mimic chronic lung disease), COPD exacerbation, pneumonia caused by bacteria, fungus, virus, or parasite, pleural effusion, etc.

• With such treatment, the patient often feels better and has improved quality and quantity of life. In addition, for contagious diseases such as pulmonary TB there is the public health benefit of reduction of transmission to health care workers and the community.

6.3. Standard treatments for COPD: • Beta-agonist such as albuterol:

o Long-acting beta-agonist (salmeterol) in combination with inhaled corticosteroid for maintenance therapy.

o Short-acting beta-agonist via inhaler for mild exacerbations o Short-acting beta-agonist via nebulizer for more severe exacerbations

• Anticholinergic such as ipatropium via inhaler or nebulizer • Corticosteroid:

o Inhaled as maintenance therapy only. Not for acute exacerbations. o Oral or intravenous corticosteroid for exacerbations or for comfort in dying patients.

Chronic oral steroid should be used only in patients with very severe disease because of serious side effects with prolonged use.


38


In patients with very severe disease or with only a few months to live, the benefits of chronic corticosteroids may justify the risk of side effects.

• Oxygen therapy: o As chronic therapy for patients with chronic hypoxia (Pa02<55) to prolong survival by

preventing pulmonary hypertension and more rapid decline. o As acute therapy for dyspnea. However, care must be taken when giving oxygen to

patients who are chronically hypercapneic and whose primary stimulus to breathe is hypoxia. In these patients, oxygen can cause respiratory failure or arrest.

6.4. In the case of primary or secondary (metastatic) lung cancer causing dyspnea or complicating chronic lung disease, palliative radiation and less commonly palliative chemotherapy sometimes can reduce symptom burden. However, these interventions can cause severe side effects. Thus the potential benefits and burdens of such disease-modifying treatments for cancer must be weighed carefully in light of the patient’s goals of care.

6.5. Opioid Therapy • In patients who have a Functional Dyspnea Score of 3 or 4 despite treatment for reversible

causes such as infection or COPD exacerbation and despite oxygen therapy will benefit from opioid.

o Opioid also can be given temporarily to reduce dyspnea while waiting for treatment of potential reversible causes of dyspnea to take effect.

• Opioid not only can relieve dyspnea but also can relieve cough and improve exercise tolerance. • As a general rule, a goal of opioid therapy is to relieve dyspnea enough to make the patient

comfortable.o When a patient is tachypneic or laboring to breath and is unable to speak or

communicate, a general goal of opioid therapy is to reduce respiratory rate to 15 – 20 breaths / minute. This rate permits more effective gas exchange

• In opioid-naive patients, opioid should be started at a low dose. For example, morphine 5 mg orally or 2 mg IV/SC every 2 hours as needed or both every 4 hours by-the-clock and every 2 hours as needed.

• Respiratory drive is strong, so low-dose, short-acting opioids can reduce dyspnea without causing dangerous respiratory depression.

6.6. Benzodiazepines should be used only if opioid is not effective at relieving anxiety due to dyspnea or when the patient clearly has an anxiety disorder in addition to lung disease. It can be used in combination with opioid.

6.7. If possible, all patients with chronic lung disease should receive an annual vaccination for influenza and a vaccination for pneumococcus every 5 years.

7. Ethical issues in opioid therapy for patients with advanced chronic lung disease

7.1. Physicians, nurses, and other members of the medical team as well as patients and families may have unrealistic fears that use of opioids will cause or hasten death in patients with dyspnea and end-stage lung disease


39


• This may come from experience caring for patients who have accidentally overdosed on heroin or other illicit drugs.

7.2. Opioid therapy for patients with advanced chronic lung disease and dyspnea almost always will help them to breathe more comfortably. And as long as the Vietnam national Guidelines on Palliative Care are followed, there is virtually no danger of causing significant respiratory depression or hastening death. In fact, effective symptom relief can increase not only quality of life but also quantity of life.

7.3. In very rare cases when the pain or dyspnea of a dying patient is extremely severe and very high doses of opioid are required to relieve the symptoms, there may be a risk that opioid therapy can hasten death. According to the Principle of Double Effect, the physician must never intend to hasten death. However, for a dying patient who does not want to suffer, it is ethical for the physician to treat severe distress with any dose of opioid and/or other medication needed to relieve the suffering even at the risk of foreseeable but unintended hypotension, respiratory depression, and hastened death. (See syllabus on “Ethical Issues in Vietnamese Palliative Care.”)

8. Non-pharmacological relief of symptoms in chronic lung disease

8.1. Dyspnea sometimes can be reduced: • With a cool breeze from a fan or open window. • With removal of smoke or dust from the air. • With changes in position. • With a change to quieter or more comforting surroundings such as the home.

9. Relief of psychological, social, and spiritual distress

9.1. With chronic lung disease, as with any chronic life-threatening illness, patients may suffer from isolation, financial problems, grief, or spiritual distress such as worry about the afterlife.

9.2. Psycho-social and spiritual supports can: • Help patients to live as actively as possible. • Help patients to access clinical services and remain adherent to disease-modifying therapies. • Help dying patients to prepare for death. • Help the patient’s family cope during the patient’s illness and during bereavement. •

9.3. Psycho-social and spiritual supports are best provided by an interdisciplinary team with the patient at the center that includes:

• Healthcare workers: o Physician (or Assistant Physician in some settings) o Nurseo Community health workers

• Family members • Peer supporters and/or volunteers


40


10. End-stage lung disease

10.1. When patients with chronic lung disease begin an active dying process, the benefits of standard therapies often are reduced and the burdens are increased.

10.2. It is both medically and ethically correct to withhold or withdraw treatments that are ineffective and burdensome by the patient’s criteria.

10.3. Life-Sustaining Treatments: • In late-stage chronic lung disease, cardio-pulmonary resuscitation (CPR) in the event of cardiac

arrest seldom is successful in the sense of allowing patients to survive without intensive life-sustaining treatment. Thus, CPR usually is not recommended in this situation due to burden of treatment being greater than benefit.

• Some patients with late-stage chronic lung disease and respiratory failure without cardiac arrest may benefit from a limited trial of mechanical ventilation if they have a potentially reversible condition such as a COPD exacerbation or pneumonia and if they or their spokesperson request such treatment.

• Many patients with very late stage lung disease do not want aggressive life-sustaining treatment such as mechanical ventilation for a prolonged period, and some will not want it at all.

• Clarification of the goals of care can help clinicians to decide whether or not to offer or recommend aggressive life-sustaining treatments such as CPR and mechanical ventilation.

• In cases where aggressive life-sustaining treatment is being provided, palliative care can reduce or relieve discomforts caused by this treatment.

10.4. Anticipation of potential future symptoms • In Vietnam, most patients prefer to die at home. But patients with end-stage lung disease are at

high risk for sudden or severe dyspnea that may require frequent and high doses of opioid for relief. Thus, strategies are needed in Vietnam for making available to patients at home aggressive relief of dyspnea with oral and injectable opioid.


41



1. COPD can be a progressive and terminal disease.

Yes No

2. Goals of management of COPD and other end-stage lung disease is:

a. Educate patients and family about non-pharmacological interventions that can be helpful.

b. Use disease-modifying treatment in the most effective way.

c. Use low dose opioid for dyspnea that is not responsive to other treatments.


e. b and c

3. Patient most stop smoking in order to receive palliation for end-stage lung disease.

Yes No

4. Patients, family members, and medical staff often have unrealistic and unnecessary fear of use of morphine for dyspnea in patients with end-stage lung disease. True False

5. In patients with end-stage lung disease, opioid:

a. Can be used safely to control dyspnea.

b. May also relieve cough.

c. Should be started at a low dose in opioid-naïve patients.

d. b and c only

e. All of the above

6. As a general rule, opioid therapy for a dyspneic and tachypneic patient with end-stage lung disease can be titrated to a respiratory rate of _________ breaths per minute. 15-20


42



Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):I42


American Thoracic Society, American Thoracic Society Documents. (2005). Statement on Home Care for Patients with Respiratory Disorders. American Journal of Respiratory Critical Care Medicine, 171, 1443-1464.

Curtis, JR. Palliative and End-of-Life Care for Patients with Severe COPD European Respiratory Journal 2007 Nov 7

Curtis, J.R., Rubenfeld, G.D. (2005). Improving Palliative Care for Patients In The Intensive Care Unit. Journal of Palliative Medicine, 8 (4), 840-854.

Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine ,3nd ed. Oxford: Oxford University Press, 1998.

End-of-Life Physician Education Resource Center. Available at http:/www.eperc.mcw.edu

Freeman D, Price D. ABC of chronic obstructive pulmonary disease: primary care and palliative care.BMJ.2006 Jul 22;333(7560):188-90.

Harris S. COPD and coping with breathlessness at home: a review of the literature. Br J Community Nurs. 2007 Sep;12(9):411-5. Review. PMID: 18026004

International Society of Nurses in Cancer Care. End-of-Life Nursing Education Consortium (ELNEC) Project. Available at http:/www.aacn.nche.edu/elnec

Last Acts. Available at http:/www.lastacts.org

Lindenauer, P.K., Pekow P., Gao, S., et al. (2006). Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Annals of Internal Medicine, 144 (12), 894-903.

Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):I42

Rocker GM, Sinuff T, Horton R, Hernandez P. Advanced chronic obstructive pulmonary disease: innovative approaches to palliation. J Palliat Med. 2007 Jun;10(3):783-97.


43


Thomas, J.R., von Gunten, C.F. (2003). Management of Dyspnea. Journal of Supportive Oncology, 1 (1), 23-34.

World Health Organization. Achieving Balance in National Opioids Control Policy. Geneva: World Health Organization, 2000.

World Health Organization. Palliative Care: Symptom Management and End-of-Life Care / Integrated Management of Adolescent and Adult Illness. Geneva: World Health Organization, 2004.


44

Palliative Care for Patients with Congestive Heart Failure or Chronic Lung Disease

1

Palliative Care for Patients with Congestive Heart Failure or

Chronic Lung DiseaseF. Amos Bailey MD FACP

University of Alabama at BirminghamDirector, Safe Harbor, Birmingham VAMC


Copyright © 2007 Massachusetts General Hospital. All rights reserved2

Objectives• After the lecture, trainees will be able to:

– Describe the role of palliative care for patients with congestive heart failure (CHF) and for patients with end-stage lung disease.

– Describe the common physical symptoms and psycho-social and spiritual problems of patients with CHF and end-stage lung disease.

– Prescribe the best treatment to relieve symptoms of patients with end-stage CHF or lung disease.

– Describe an interdisciplinary team approach to relieving psycho-social and spiritual distress.

3

Palliative Care for Patients with Congestive Heart Failure

4

Common Symptoms in Late-Stage CHF

• Dyspnea• Pain (chest, abdomen, legs)• Edema• Weakness• Fatigue• Insomnia• Anorexia• Wasting• Anxiety

5

Principles of Palliative Care for the Patients with CHF

• Disease-modifying and palliative care for CHF patients are inseparable and often indistinguishable– Most treatments for heart disease could be

considered palliative.• Initial palliative care assessment at time of

diagnosis.• Palliative care is especially important in

advanced CHF• Attention to psycho-social & spiritual distress• Bereavement support

6

Palliative Care Interventions in CHF• Aggressive relief of dyspnea and any other symptoms

– Diuretic therapy: furosemide• Determine “dry weight”• Then use daily weight to adjust diuretic dose• Add spironolactone

– Reduces risk of hypokalemia– Start with 25 mg orally once daily

– Angiotensin converting enzyme (ACE) inhibitor• Afterload reduction (arterial vasodilatation)• In general, titrate to low-normal blood pressure• Side effects: cough, tongue swelling, renal failure

continued…

45


7

– Cardiac-selective beta-blocker (carvedilol, metoprolol)• Start with low dose, increase as tolerated• Reduces risk of cardiac ischemia, arrhythmia

– Aspirin 81 to 325 mg daily• Reduces risk of acute coronary syndrome and

ischemic stroke– Nitrates (isosorbide dinitrate)– Diet:

• Salt restriction• Avoid nicotine, alcohol

– If standard therapy does not control chest pain or dyspnea, add opioid (standard doses)

8

• Non-Pharmacologic Interventions– Electric fan or breeze from open window– Optimal positioning– Assistance with self-care

• Psycho-social support– Loss of social, familial, and bodily function can

produce depression• Open discussion of psycho-social effects of CHF can

be helpful• Some patients benefit from anti-depressants

– Help with access to treatment and adherence– Support for family– Comprehensive palliative care best provided by

interdisciplinary team

9

• Anticipation of potential future symptoms and psychosocial problems– CHF usually has relapsing and remitting

course, often with sudden exacerbations and many hospitalizations

– Some patients have sudden cardiac death– Others have distressing symptoms for hours

or days before death

10

• Protection of patients from unwanted or inappropriate medical interventions such as treatments that unduly sustain life– Life-sustaining treatment are becoming more

available in Viet Nam• CPR• Mechanical ventilation• Hemodialysis

– Can save lives but also cause or exacerbate pain and suffering.

– Potential benefits and burdens must be weighed for each patient and clinical situation.

– In end-stage heart failure, these interventions likely to be more burdensome than beneficial.

– Palliative care avoids unduly prolonging the dying process.

11

Palliative Care for Patients with Chronic Lung Disease

12

Differential Diagnosis of Chronic Lung Disease

• Destruction of lung tissue has many causes:1. Chronic Obstructive Pulmonary Disease (COPD):

• Most common cause of end-stage lung disease

• Combination of loss of lung tissue and airway obstruction

• Air trapping, increased “dead space”• Pulmonary function testing: decreased

expiratory flow rate (FEV1) and increased lung volume (TLC, RV)

• Caused by smoking, air pollutioncontinued….

46


13

2. Restrictive lung disease• Most common types are interstitial lung diseases

– Idiopathic pulmonary fibrosis– Sarcoidosis– Inhaled toxins: silicosis, asbestosis

• Can result in both chronic and acute respiratory failure

3. Primary lung cancer or lung metastases4. Chronic or recurrent infection

• TB• OIs such as PCP or fungal pneumonias• Bacterial pneumonias

– Conditions that mimic chronic lung disease:• Pulmonary edema• Severe asthma

– Often patients have multiple causes of lung disease or dyspnea

14

Prevention of Chronic Lung Disease• Educate patients about the danger of smoking

and encouraging them not to smoke.– Progression of COPD to death is slowed

dramatically. – Patients can be aided to quit smoking:

counseling, peer support, nicotine therapy• Early diagnosis and treatment of TB and other

infectious diseases reduces lung damage.• Support of initiatives to:

– Protect workers from lung toxins such as asbestos and silicates.

– Reduce exposure to air pollution.

15

Approach to the Patient with Chronic Lung Disease

• Dyspnea:– Definition: the subjective sensation of

breathlessness– Often disabling– Often causes extreme distress and anxiety– Very important to treat well to improve both quality

of life

continued…

16

Functional Dyspnea Scale– 0 = No dyspnea– 1 = Dyspnea when walking up incline– 2 = Dyspnea when walking on level ground– 3 = Dyspnea when moving from bed to chair or with

other minimal activity– 4 = Dyspnea at rest

– Patients with Functional Dyspnea Score of 3 - 4:• Have very limited function and prognosis• Would benefit most from aggressive palliative

care

17

Palliative Treatment for Patients with Chronic Lung Disease

– No contradiction between standard, disease-modifying treatment for COPD and other chronic lung disease and palliative care.

• Consider treating any potentially reversible cause of dyspnea such as COPD exacerbation, TB and other lung infections, pleural effusion, etc.

18

Standard Treatment for COPD• Beta agonist

– Long-acting (salmeterol) combined with inhaled steroid for maintenance therapy

– Short-acting drug (albutrerol) via inhaler for mild exacerbations

– Short-acting drug via nebulizer for more severe exacerbations

• Anticholinergic (ipatropium) via inhaler or nebulizer• Corticosteroid:

– Inhaled as maintenance therapy– Oral or IV for exacerbations and for dying patients– Chronic use only for patients with very severe disease

• Oxygen– For patients with chronic hypoxia (Pa02<55) to

prolong survival by preventing pulmonary hypertension.

– For acute dysnea, CAREFULLY.

47


19


• Opioid Therapy– Beneficial when patients have Functional Dyspnea Score

of 3 – 4 despite treatment for reversible causes and oxygen.

– Benefits:• Relieves dyspnea• Relieves cough• Improves exercise tolerance

– Can be given temporarily while treating potentially reversible causes of dyspnea.

– For patients unable to communicate with tachypnea or labored breathing, usual goal is respiratory rate of 15 – 20 breaths / minute.

– Starting dose in opioid-naïve patient:• 5 mg orally every 4 hours and/or every 2 hours as needed• 2 mg IV/SC every 4 hours and/or every 2 hours as needed

– Unlikely to cause dangerous respiratory depression at usual doses.

20


• Benzodiazepines should be used only:– If opioid not fully effective at relieving anxiety due

to dyspnea (can be combined with opioid).– If patients has anxiety disorder distinct from lung

disease.• Dyspnea from advanced primary lung cancer or

pulmonary metastases:– Consider palliative radiation or chemotherapy– Weigh potential benefits and burdens carefully

• Vaccinations– Influenza (annual)– Pneumococcus (every 5 years)

21

Ethical Issues in Palliative Treatment of Chronic Lung Disease: Opioid Therapy• Physicians, nurses, other members of the medical

team, patients, and families may have unrealistic fears that opioids will hasten death in patients with dyspnea and end-stage lung disease– This may come from experience with people who have

accidentally overdosed on heroin.• In very rare cases when pain or dyspnea of a dying

patient is extremely severe and very high doses of opioid are required, there may be risk of hastening death.

• Following the Principle of Double Effect:– Physicians must never intentionally hasten death.– For a dying patient who wants relief from suffering, it is

ethical to treat with any dose of opioid needed to relieve suffering even at the risk of foreseeable but unintended hypotension, respiratory depression, or hastened death.

22

Ethical Issues in Palliative Treatment of Chronic Lung Disease:Life-Sustaining Treatment

• It is both medically and ethically correct to withhold or withdraw life-sustaining treatments that are ineffective or burdensome by the patient’s criteria.

• For patients with end-stage chronic lung disease:– CPR for cardiac arrest rarely allows the patient to recover

enough to leave the hospital.– Limited trial of mechanical ventilation may provide

benefit if there is a potentially reversible condition.– Clarification of the goals of care can help clinicians

decide whether to recommend life-sustaining treatments such as CPR, mechanical ventilation, and hemodialysis.

48

49

Day 2

50

51

Neurobiology of Pain



Gary J. Brenner, MD, PhD & Eric L. Krakauer, MD, PhD Harvard Medical School & Massachusetts General Hospital

Objectives

After the lecture, the trainees will be able to: 1. Describe the basic neuro-anatomy of the pain system.

2. Define basic concepts in the neurobiology of pain including:

- Neural plasticity

- Peripheral sensitization

- Central sensitization

3. Diagnose hyperalgesia, allodynia, and spontaneous pain when it occurs in patients.

Contents

1. Introduction: One of the most important functions of the nervous system is to provide information regarding potential and actual bodily injury.

2. Definitions:

2.1. Nociception: Nearly a century ago, Sir Charles Sherrington (1906) defined nociception as the sensory detection of a noxious event or potentially harmful environmental stimulus. He explicitly distinguished nociception from pain, a complex human experience that involves sensory, psychological and cognitive components.

2.2. Pain: Currently defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

3. Components of the pain system:

• Nociceptors, the specialized receptors in the peripheral nervous system that detect noxious stimuli. Primary nociceptive afferent fibers, normally A-delta and C-fibers, transmit information regarding noxious stimuli to the dorsal horn of the spinal cord.

• Ascending nociceptive tracts, e.g., the spinothalamic and spinohypothalamic tracts, which convey nociceptive stimuli from the dorsal horn of the spinal cord to higher centers in the CNS.

52



• Higher centers in the CNS that are involved in pain discrimination, affective components of pain, memory components of pain, and motor control related to the immediate aversive response to painful stimuli.

• Descending systems that allow higher centers of the CNS to modify nociceptive information at multiple levels.

4. Nociceptors (Primary Afferent Fibers or Sensory Neurons)

4.1. Although somewhat confusing, the term nociceptor is used to refer both to the free nerve terminals of primary afferent fibers that respond to painful, potentially injurious stimuli, as well as to the entire primary afferent fiber (sensory neuron) capable of transducing and transmitting information regarding noxious stimuli. We will use the term “nociceptor” to refer to the entire nociceptive primary afferent. Free nerve terminals contain receptors capable of transducing chemical, mechanical, and thermal signals. Recently, for example, a membrane receptor that responds to noxious heat has been cloned (it has been designated TRPV1), and interestingly this receptor is also stimulated by capsacin, the molecule responsible for the “hot” sensation associated with hot peppers. Nociceptive terminals innervate a wide variety of tissues and are present in both somatic and visceral structures including the cornea, tooth pulp, muscles, joints, respiratory system, cardiovascular system, digestive system, urogenital system, and meninges, as well as skin. 4.2. Nociceptors may be divided according to three criteria:

• Degree of myelination • Type(s) of stimulation that evokes a response • Response characteristics

There are two basic classes of nociceptors based on their degree of myelination and conduction velocity. A-delta fibers (Aδ) are thinly myelinated and conduct between 2 to 30 meters per second. C fibers are unmyelinated and conduct at a velocity of less than 2 meters per second (Figure 1).

Figure 1: Diagram of nociceptors and the spinal cord.

53



4.3. Aδ and C nociceptors can be further divided according to the stimuli they sense. They may respond to mechanical, chemical or thermal (heat and cold) stimuli, or a combination (polymodal). For example, C-fiber mechano-heat receptors respond to noxious mechanical stimuli and intermediate heat stimuli (41-49°C), have a slow conduction velocity, and constitute the majority of nociceptive afferent fibers. 4.4. Aδ mechano-heat receptors can be divided into two subtypes.

• Type I receptors have a high heat threshold (>53°C) and conduct at relatively fast velocities (30-55 m/sec). These receptors detect pain sensation during high-intensity heat responses.

• Type II receptors have a lower heat threshold and conduct at slower velocity (15 m/sec). Some receptors respond to both warmth and thermal pain. There are also both C and Aδ fibers which are mechanically insensitive but respond to heat, cold, or a variety of chemicals, e.g., bradykinin, hydrogen ions, serotonin, histamine, arachidonic acid, prostacyclin, etc.

4.5. The neural impulses originating from the free endings of nociceptors are transmitted via primary afferent nerves to the spinal cord (Figure 1), or via cranial nerves to the brain stem if from the head and neck. 4.6. Most primary afferent fibers innervating tissues below the level of the head have cell bodies located in the dorsal root ganglion (DRG) of spinal nerves. Primary afferent fibers of cranial nerves V, VII, IX, and X (the sensory cranial nerves) have cell bodies in their respective sensory ganglia. 4.7. The majority of nociceptors are C-fibers, and 80 - 90% of C fibers respond to nociceptive input. The differences in conduction velocities and response characteristics of A delta and C fibers may explain the typical subjective pain experience associated with a noxious stimulus: a first pain (so-called epicritic pain) that is rapid, well-localized, and pricking in character (A delta), followed by a second pain (so-called protopathic pain) that is burning and diffuse (C fiber).

4.8. Visceral afferent nociceptive fibers (Aδ and C) travel with sympathetic and parasympathetic fibers; their cell bodies are also found in the DRG.

4.9. Muscle is also innervated by both Aδ and C fibers and interestingly, muscle pain appears to be limited in quality to that of a cramp.

5. Dorsal horn synapses 5.1. Primary afferent nociceptors enter the spinal cord via Lissauer’s Tract and synapse on neurons in the dorsal horn (Figure 1). Lissauer's tract is a bundle of predominately (80%) primary afferent fibers, consisting mainly of A-delta and C fibers that penetrate the spinal cord en route to the dorsal horn. 5.2. After entering the spinal cord, A-delta and C fibers run up or down one or two segments before synapsing with second-order neurons in the dorsal horn. The dorsal horn synapse is an important site of further processing and integration of the incoming nociceptive information.

• The dorsal horn may be a point at which nociceptive information is conducted to higher centers, or at which nociceptive information is inhibited by descending systems.

• The responsiveness of dorsal horn neurons may change in response to prior noxious afferent input, particularly repetitive input (central sensitization).

54



6. Biochemical mediators in dorsal horn synapses 6.1. Numerous neurotransmitters and other biochemical mediators are released in the dorsal horn. These substances are derived from three main sources:

• Primary afferent fibers • Interneurons • Descending fiber systems

6.2. The neurochemistry of the dorsal horn is complicated and there are qualitative differences between the pharmacology of acute pain and that of the facilitated pain states associated with chronic noxious stimulation.

6.3. Some neurochemical mediators can be categorized as either excitatory or inhibitory, although many serve complex and mixed functions. For example, the endogenous opioid dynorphin may be inhibitory or excitatory depending of the state of the nervous system. The following are examples of excitatory and inhibitory substances active in the dorsal horn.

6.4. Excitatory neuromediators:

• The excitatory amino acids glutamate and aspartate • The neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) • Growth factor brain-derived neurotrophic factor (BDNF) • Bradykinin

6.5. Inhibitory neuromediators:

• Endogenous opioids such as enkephalin and ß-endorphin • Gamma-aminobutyric acid (GABA) • Glycine

6.6. Cells of the dorsal horn possess specific receptors for the substances listed above, as well as receptors for a multitude of other neurochemicals (some probably undiscovered). Of particular note is the receptor for glutamate, the N-methyl-D-aspartate (NMDA) receptor, which is widely distributed in the dorsal horn. There are now extensive experimental data implicating the NMDA receptor in the generation and maintenance of facilitated pain states. 7. Peripheral sensitization

7.1. Prolonged noxious stimulation can sensitize nociceptors. Sensitization refers to a decreased threshold as well as an increased response to suprathreshold stimulation. 7.2. Peripheral sensitization can occur following direct nerve injury or inflammation and is the result of a complex set of transcriptional and post-translational changes in the nociceptor. 7.3. Sensitization of the entire nociceptive pathway (from the free nerve terminal of the nociceptor to the brain) can arise due to certain changes in the central nervous system (CNS) called central sensitization or to peripheral sensitization. Once sensitization occurs, it is often impossible clinically to distinguish

55



central from peripheral contributions to the process of sensitization. 8. Hyperalgesia 8.1. Tissue damage results in activation of nociceptors. If the damage is prolonged and intense, it can generate a state in which there is a lowered threshold to painful stimuli. This state is termed hyperalgesia. 8.2. In hyperalgesic areas one can clinically observe an increased response to noxious stimuli. There are alterations in both the subjective and the neurophysiological responses to stimuli. The subjective re-sponse is characterized by a lowered pain threshold and an increase in pain response, while nociceptors demonstrate a corresponding decreased threshold and increased response. 8.3. Primary hyperalgesia is hyperalgesia at the site of injury; secondary hyperalgesia refers to hyperalgesia in the surrounding the injured tissue. 8.4. Secondary hyperalgesia is thought to reflect changes occurring in the central nervous system, and would thus be an example of central sensitization.

9. Allodynia

9.1. In addition to the development of a lowered threshold for noxious stimuli following tissue damage (hyperalgesia), sometimes a post-injury state occurs in which normally innocuous stimuli are perceived as painful. This phenomenon is termed allodynia. For example, very light touch in the area of a burn or a previous episode of shingles can generate excruciating pain.

9.2. Like hyperalgesia, allodynia is likely caused by plastic changes in both primary sensory fibers and spinal cord neurons.

10. Inflammation

10.1 Inflammation is the characteristic reaction to injury and typically results in redness, heat, pain, swelling, and loss of function. During an inflammatory response, activation of nociceptive pathways can lead to sensitization resulting clinically in spontaneous and increased stimulation-induced pain (i.e., hyperalgesia and allodynia). 10.2. Release of prostaglandins, cytokines, growth factors, and other mediators by inflammatory cells can directly stimulate nociceptors. The precise nature of this interaction between the immune and nervous systems and the manner in which this can lead to pathological pain states, however, remains to be clarified. The critical observation is that inflammation is an important cause of both acute and chronic alteration in pain processing and sensation.

56



11. Nerve injury 11.1. Direct neural trauma can also lead to pathological pain states characterized by spontaneous pain (i.e., pain occurring in the absence of any stimulus), hyperalgesia, and allodynia.

11.2. Such neuropathic pain states can arise following injury to peripheral or central elements of the pain system.

11.3. A clinical example of this is Complex Regional Pain Syndrome Type I (CRPS I), formerly called Reflex Sympathetic Dystrophy (RSD), in which an apparently minor injury can lead to sensitization of pain processing in a region including but not limited to that involved in the injury.

12. Ascending nociceptive pathways 12.1. Topographical arrangement of the dorsal horn (Rexed's laminae)

• The gray matter of the spinal cord can be divided into ten laminae (I-X) (the Rexed laminae) based on the histologic organization of the numerous types of cell bodies and dendrites. The dorsal horn is composed of laminae I-VI (Figure 2).

Figure 2: Rexed’s laminae of the spinal cord.

57



• The majority of nociceptive input converges on lamina I (marginal zone), lamina II (substantia gelatinosa), and lamina V in the dorsal horn. However, some primary visceral and somatic nociceptive afferent fibers synapse in other laminae.

• Cutaneous mechanoreceptor A-delta afferent fibers synapse in laminae I, II, and V; visceral mechanoreceptor A-delta fibers synapse in laminae I and V; cutaneous nociceptor C fibers synapse in laminae I and II; and visceral nociceptive C fibers synapse in many laminae including I, II, 1V, V, and X.

• The ascending spinal pathways involved with nociceptive transmission arise mainly from laminae I, II, and V (Figure 3). These pathways include the spinothalamic tract, spinohypothalamic tract, spinoreticular tract, and spinopontoamygdala tract.

Figure 3: Ascending nociceptive pathways.

58



12.2. Dorsal horn projection neurons • The second order neurons in the pain pathway are the dorsal horn projection neurons (or their

equivalent in cranial pathways). They have their cell bodies in the spinal cord (or cranial nerve nuclei in the head and neck), and are classified according to their response characteristics.

o High-threshold (HT, also called nociceptive specific – NS) cells respond exclusively to noxious stimuli; these cells receive input only from nociceptors (i.e., Aδ and C fibers). Their receptive fields are small and organized somatotopically, being most abundant in lamina I.

o Other cells respond to a range of stimuli from innocuous to noxious; they are called wide dynamic range (WDR) cells and integrate information from Aβ (non-noxious stimuli), Aδ, and C fibers. These cells have larger receptive fields, are the most prevalent cells in the dorsal horn, and are found in all laminae, with a concentration in lamina V.

• The convergence of sensory information onto a single dorsal horn neuron is critical for the coding of stimulus intensity in terms of output frequency by these second-order neurons.

12.3. Spinothalamic tract • The spinothalamic tract (STT) is the most important of the ascending pathways for the

transmission of nociceptive stimuli and is located in the anterolateral quadrant of the spinal cord. • The cell bodies of STT neurons reside in the dorsal horn; most of their axons cross midline in the

ventral white commissure of the spinal cord to ascend in the opposite anterolateral quadrant, however, some do remain ipsilateral.

• Neurons from more distal regions of the body (i.e., the sacral region) are found more laterally and neurons from more proximal regions (i.e., the cervical region) are found more medially within the spinothalamic tract as it ascends.

• Spinothalamic tract neurons segregate into medial and lateral projections to the thalamus (see Limbic System below).

o Neurons that project to the lateral thalamus arise from laminae I, II, and V, and from there synapse with fibers that project to the somatosensory cortex. The fibers are thought to be involved in sensory and discriminative aspects of pain.

o Neurons projecting to the medial thalamus originate from the deeper laminae VI and IX. The neurons send collateral projections to the reticular formation of the brain stem and midbrain, the periaqueductal gray matter and the hypothalamus, or directly to other areas of the basal forebrain and somatosensory cortex. They are thought to be involved with autonomic reflex responses, state-of-arousal, and emotional aspects of pain.

12.4. Spinohypothalamic Tract (SHT)

• Nociceptive and non-nociceptive information from neurons within the dorsal horn is conveyed to diencephalic structures, such as the hypothalamus, directly by a recently discovered pathway--the spinohypothalamic tract. This pathway projects to the region of the brain (the hypothalamus) that is involved in autonomic functions such as sleep, appetite, temperature regulation, stress response, etc. In fact, the majority (60%) of SHT neurons project to the contralateral medial or lateral hypothalamus and, therefore, are presumed to have a significant role in autonomic and neuroendocrine responses to painful stimuli. Thus, the SHT appears to form the anatomic substrate that coordinates reflex autonomic reactions to painful stimuli. Some of its connections, e.g., to the suprachiasmatic nucleus which partly controls the sleep/wake

59



pattern, may account for behaviors such as difficulty in sleeping with painful conditions, particularly chronic pain.

• The majority of SHT neurons respond preferentially to mechanical nociceptive stimulation, and a smaller number to noxious thermal stimulation.

• The fibers of the SHT cross midline in the supraoptic decussation. • The spinoreticular tract (SRT) and the spinaoponoamygdala tract are also likely involved with

state of arousal and emotional aspects of pain.

12.5. Cranial nerves • The transmission of pain in the head and neck has many of the same characteristics as the

nociceptive system which has first-order synapses in the dorsal horn of the spinal cord. • The face and oral cavity are richly innervated with nociceptors. The primary nociceptive afferent

fibers for the head originate mainly from cranial nerve V, but also from cranial nerves VII, IX, and X, and from the upper cervical spinal nerves.

• The primary afferent fibers of the cranial nerves project mainly to nuclei of the trigeminal system, whereas the upper cervical nerves project to second order neurons in the dorsal horn of the spinal cord. From there, projections continue to the supraspinal systems.

12.6. The trigeminal system (Cranial Nerve V or CN V)

• The trigeminal system receives afferent input from the three divisions of the trigeminal nerve (ophthalmic, maxillary, and mandibular) which serve the entire face as well as the dura and the vessels from a large portion of the anterior two thirds of the brain.

• The trigeminal nerve has three sensory nuclei, all of which receive projections from cells which have cell bodies located within the trigeminal ganglion, a structure similar to DRG. The three nuclei are the mesencephalic, the main sensory, and the spinal trigeminal nuclei.

o The spinal trigeminal nucleus is further divided into the subnucleus oralis, the subnucleus interpolaris, and the subnucleus caudalis. The subnucleus caudalis (also known as the medullary dorsal horn) extends caudally from the medulla to the level of the upper cervical segments of the spinal cord (C3-4).

• The trigeminal nuclei give rise to several ascending pathways. o The axons of cell bodies in the main sensory nucleus and subnucleus oralis project either

ipsilaterally, forming the dorsal trigeminothalamic tract, or contralaterally, in the ventral trigeminothalamic tract. Both tracts terminate in the thalamus.

o The subnucleus caudalis contributes as well to the trigeminothalamic tracts, but also has direct projections to the thalamus, reticular formation, and hypothalamus.

12.7. The glossopharyngeal nerve (CN IX)

• The glossopharyngeal nerve conveys impulses concerned with tactile sense, thermal sense and pain from the mucous membranes of the posterior third of the tongue, tonsil, posterior pharyngeal wall and Eustacian tubes.

12.8. The vagus nerve (X)

• The vagus nerve conveys impulses concerned with tactile sense from the posterior auricular skin and external auditory meatus, visceral sensation from the pharynx, larynx, trachea, esophagus, and thoracic and abdominal viscera via the spinal trigeminal tract and the fasciculus solitarius (sensory tract of VII, IX and X).

60



13. Central sensitization

13.1. Just as prolonged noxious stimulation of nociceptors can result in altered pain states (peripheral sensitization), so can repetitive stimulation of second order (and higher) neurons alter pain processing (central sensitization). 13.2. Hyperalgesia and allodynia are manifestations of central as well as peripheral sensitization (see Sections 8 and 9). 13.3. The ability of the neural tissue to change in response to various incoming stimulae is a key function of the nervous system and termed neural plasticity. Presumably this function has some evolutionary or protective advantage, although in clinical pain practice we often see a disadvantage - the development of chronic pain. 13.4. Both short term and long term plastic changes occur in the dorsal horn. 13.5. Wind-up is an increase in the ratio of outgoing to incoming action potentials of a dorsal horn neuron with each successive nociceptive stimulus. It occurs in response to repetitive C-fiber stimulation, and is reversed as soon as the stimulation ceases. This is an example of a short-term plastic change. 13.6. Central sensitization (including wind-up) is associated with NMDA receptor activation. In the case of persistent states of sensitization, various mechanisms are likely involved including the induction of novel patterns of gene expression.

14. Supraspinal systems: integration and higher processing

14.1. Integration of pain in higher centers is complex and poorly understood. At a basic level the integration and processing of painful stimuli may fall into the following broad categories:

• Discriminative component: This is somatotopically specific and involves the primary (S I) and secondary (S II) sensory cortex. This level of integration allows the brain to define the location of the painful stimulus. Integration of somatic pain, as opposed to visceral pain, takes place at this level. The primary and secondary cortices receive input predominantly from the ventrobasal complex of the thalamus, which is also somatotopically organized.

• Affective component: The integration of the affective component of pain is very complex and involves various limbic structures. In particular, the cingulate cortex is involved in the affective components of pain (receives input from the parafascicular thalamic nuclei and projects to various limbic regions). The amygdala is also involved in the integration of noxious stimuli.

• Memory components of pain: Recent evidence has demonstrated that painful stimuli activate CNS regions such as the anterior insula.

• Motor control and pain: The supplemental motor area is thought to be involved in the integration of the motor response to pain.

61



14.2. Thalamus (Figure 4)

Figure 4: The thalamus and its nuclei.

• The thalamus is a complex structure that acts as the relaying center for incoming nociceptive stimuli.

• Two important divisions of the thalamus receive nociceptive input. o First is the lateral division, formed by the ventrobasal complex in which nociceptive

specific input from NS and WDR neurons synapses. It is somatotopically organized and projects to the somatosensory cortex.

o Second is the medial division, which consists of the posterior nucleus and the centrolateral nucleus. It is thought that these nuclei project to limbic structures involved in the affective component of pain, since there is no nociceptive-specific information conveyed by them to higher cortical regions.

• The medial and intralaminar nuclei receive input from many ascending tracts, in particular the spinothalamic tract, and the reticular formation. There is little evidence of somatotopic organization of these nuclei.

• The ventrobasal thalamus is organized somatotopically and can be further subdivided into: o The ventral posterior lateral nucleus, which receives input mainly from the

spinothalamic tract but also from the dorsal column system and somatosensory cortex, to which it projects, and

o The ventral posterior medial nucleus, which receives input from the face via the trigeminothalamic tract and projects to the somatosensory cortical regions of the face.

62



• Input to the posterior thalamus comes mainly from the spinothalamic tract, spinocortical tract, and dorsal column nuclei. The receptive fields are large and bilateral and lack somatotopic organization. The posterior nuclei project to the somatosensory cortex and appear to have a role in the sensory experience of pain.

• The spinothalamic tract also sends projections to the centrolateral nucleus, an area that is involved in motor activity.

14.3. Hypothalmus • The hypothalamus receives innocuous and noxious stimuli from all over the body, including

deep tissues such as the viscera (see spinohypothalamic tract above). • The hypothalamic neurons are not somatotopically organized and therefore do not provide

discriminatory aspects and localization of pain. • Some hypothalamic nuclei send projections to the pituitary gland via the hypophyseal stalk, brain

stem, and spinal cord. The gland regulates both the autonomic nervous system and neuroendocrine response to stress, including pain.

14.4. The limbic system • The limbic system consists of subcortical regions of the telencephalon, mesencephalon, and

diencephalon. Specifically, it includes the following subcortical nuclei: amygdala, septal nuclei, hypothalamus, anterior thalamic nuclei, and nuclei in the basal ganglia.

• The limbic system also has a cortical component that includes the subcallosal, cingulate, and parahippocampal gyri and hippocampal formation.

• The limbic system receives input from the spinothalamic tract, the thalamus, and reticular formation, and it projects to various parts of the cerebral cortex, particularly the frontal and temporal cortex.

• The limbic system receives both sensory and cortical impulses and activates visceral and somatic effectors; it contributes to the physiologic expression of behavior and emotion.

• It is involved in the motivational and emotional aspects of pain, including mood and experience.

14.5. Cerebral cortex • The somatosensory cortex and cingulate cortex are involved in pain. The somatosensory cortex is

the most important area for nociception and is located posterior to the central sulcus of the brain. It receives input from the various nuclei of the thalamus, particularly the ventral posterior lateral and medial nuclei and the posterior thalamus.

• The sematosensory cortex is cytoarchitecturally organized and therefore has an important role in the discriminatory aspect and localization of pain.

• Efferent fibers from the somatosensory cortex travel back to the thalamus and contribute to the descending nociceptive system.

14.6. The cingulate cortex • The cingulate cortex is a component of the limbic system. Recent work has demonstrated that the

cingulate gyrus is activated in humans by painful stimuli. Cingulate cortex lesions have been used in an attempt to alleviate pain and suffering.

63



15. Pain modulation

15.1. The evidence for descending modulation of nociceptive information came from two basic observations. The first observation, in the late 1960s, was that neurons in the dorsal horn of decerebrate animals are more responsive to painful stimuli with spinal cord blockade. The second observation, in the late 1980s, was that electrical stimulation of the periaqueductal gray matter profoundly relieved pain in animals. So great was the stimulation-produced analgesia that surgery could be performed on these animals without apparent pain. Furthermore, the animals behaved normally in every other way and there was no observed effect on other sensory modalities. These studies were pivotal in demonstrating an anatomic basis for the "natural equivalent" of stimulation-induced analgesia. Furthermore, subsequent studies demonstrated that small concentrations of morphine, when injected into regions such as the periaqueductal gray matter, produced significant analgesia. Interestingly, both stress-induced analgesia and stimulation-induced analgesia can be reversed by opioid antagonists. 15.2. There are a number brain centers that are involved in the intrinsic modulation of noxious stimuli. These include the somatosensory cortex, the hypothalamus (paraventricular nucleus, lateral hypothalamus), the midbrain periaqueductal gray matter, areas in the pons including the lateral tegmental area, and the raphe magnus. Electrical stimulation of these regions in humans (some cases) and in animals produces analgesia.

• Fibers from these central structures descend directly or indirectly (e.g., periaqueductal gray matter to raphe magnus) via the dorsolateral funiculus to the spinal cord and send projections to laminae I and V.

15.3. Activation of the descending analgesic system has a direct effect on the integration and passage of nociceptive information at the level of the dorsal horn. Blockade of the dorsolateral funiculus (with cold or sectioning) increases the response of nociceptive second order neurons following activation by painful stimuli. 15.4. Descending systems The descending system appears to have three major functionally interrelated components: the opioid, noradrenergic, and serotonergic systems.

• The opioid system: The opioid system is involved in descending analgesia. Opioid precursors (proopiomelanocortin, proenkephalin, and prodynorphin) and their respective peptides (beta-endorphin, met- and leu-enkephalin, and prodynorphin) are present in the amygdala, the hypothalamus, the periaqueductal gray matter, the raphe magnus, and the dorsal horn. With the recent advent of opioid receptor cloning, knowledge is steadily increasing about the action sites of the various opioids (i.e., on mu, delta, and kappa receptors).

• The noradrenergic system: Noradrenergic neurons project from the locus caeruleus and other noradrenergic cell groups in the medulla and pons. These projections are found in the dorsolateral funiculus. Stimulation of these areas produces analgesia, as does the administration (direct or intrathecal) of an alpha2-receptor agonist such as clonidine.

• The serotonergic system: Many neurons in the raphe magnus are known to contain serotonin (5-hydoxytryptamine or 5-HT), and they send projections to the spinal cord via the dorsolateral funiculus. Pharmacologic blockade, or lesioning, of the raphe magnus can reduce the effects of morphine and administration of 5-HT to the spinal cord produces analgesia.

64



15.5. Projections to the dorsal horn The nerve fibers that originate in nuclei that are involved in pain modulation terminate in the dorsal horn predominately in laminae I and II, but also in other laminae, including IV, V, VI, and X.

16. Conclusion The neuroanatomy and neurochemistry of the pain system is extremely complex. Unfortunately, we have only a basic understanding of the physiology of pain processing and an even more incomplete knowledge of the mechanisms through which pathology of the nervous system results in persistent hyperexcitable states. Neuroanatomic techniques have taught us a great deal about the "connectivity" of the system. Newer techniques have enabled the study of individual cells and specific cell populations in an attempt to elucidate roles in both ascending and descending systems. Sophisticated imaging, e.g., functional MRI and PET have allowed investigation of in vivo brain activity in the presence of acute and chronic pain. Thus, fundamental neuroscientific and clinical studies hold the promise of a better understanding of the pain system in both resting and pathologic states.

65




1. Most primary afferent sensory nerve fibers below the head have cell bodies located in the dorsal root ganglion of spinal nerves and synapse with second order neurons in the ____________________ of the spinal cord. dorsal horn

2. Neural plasticity is the ability of neural tissue to change biochemically and anatomically in response to incoming stimulae. True False

3. Examples of neural plasticity are:

a. Peripheral sensitization

b. Central sensitization

c. Both

d. Neither

4. Hyperalgesia can be defined as “the development of a lowered pain threshold following tissue injury” or as “development of an increased sensation of pain due to a stimulus that normally would not be as painful.” True False

5. Allodynia can be defined as “pain due to a stimulus that normally would not be painful.” For example, very light touch in the area of a burn or a previous episode of shingles can generate excruciating pain. True False

6. Spontaneous pain can be defines as “pain that occurs without any stimulus.” True False

7. Hyperalgesia, allodynia, and spontaneous pain are examples of:

a. Nociceptive pain

b. Neuropathic pain c. Both

d. Neither

66




Brenner, G.J. and Woolf, C.J. Mechanisms of Chronic Pain. In: Longnecker DE, Brown, DL, Newman, MF and Zapol, WM, editors. Anesthesiology. New York: McGraw Hill Companies, Inc; 2008. p. 2000-2019.


Brenner, G.J. and Woolf, C.J. Mechanisms of Chronic Pain. In: Longnecker DE, Brown, DL, Newman, MF and Zapol, WM, editors. Anesthesiology. New York: McGraw Hill Companies, Inc; 2008. p. 2000-2019. Fields, H.L. Pain: Mechanisms and Management, 2nd edition. New York: McGraw-Hill, 2002. Kruger, L. (ed.) Pain and Touch. San Diego: Academic Press, 1996. Scarry E. The Body in Pain: The Making and Unmaking of the World. Oxford: Oxford University Press, 1985. Sherrington, C.S. The Integrative Action of the Nervous System. New York: Scribner, 1906. Simone, D.A. Peripheral Mechanisms of Pain Perception. In: Stephen E. Abram (ed), The Atlas of Anesthesia, Pain Management. Philadelphia: Churchill Livingston, 1998. Pp. 1.1-1.11.

Waldman, S.D. and Winnie, A.P. (eds) Part I: Anatomy and Physiology of Pain: Clinical Correlates. In: Interventional Pain Management. Philadelphia: W.B. Saunders Company, 1996. Pp. 1-72.

Wall, P.D and Melzack, R. (eds) Textbook of Pain. Philadelphia: Churchill Livingstone, 1999. Woolf, C.J. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic

Management. Ann. Intern. Med. 2004;140:441-451.

67


1

Gary J. Brenner, M.D., Ph.DDept. of Anesthesia and Critical Care

Massachusetts General HospitalHarvard Medical School

Copyright © Massachusetts General Hospital. All rights reserved.


2

Goals

• To understand the basic neuro-anatomy and neuro-chemistry of the pain system.

•To understand the most important concepts in the neurobiology of pain.

• To distinguish between 3 types of pain.

3

Neurobiology of Pain:Basic Concepts

• Plasticity is an essential feature of the pain system: anatomic and chemical changes can occur in the nervous system as a result of pain.

• Pain can be physiological (protective) or pathological(serving no helpful function).

• Different types of pain require different treatments.• Future therapy must be mechanism-based.

4

Basic Physiology of Pain Perception

• Transduction• Transmission• Modulation• Perception• Interpretation• Behavior

Injury

Descending Pathway

PeripheralNerve

Dorsal RootGanglion

C-Fiber

A-beta Fiber

A-delta Fiber

AscendingPathways

Dorsal Horn

Brain

Spinal Cord

5

Pain Pathways

6

68


7 8

9 10

RECEPTOR

11

plasmamembrane

TRPVs ASICsTRPV1

TRPMsTRPA1

GPCRs TyrosineKinases

?ASICs?TRPA1?TREK-1

G

(Primary afferent peripheral terminal)

Purinoceptors

H+

MechanicalforceProtonsHeatColdHistamine ATPNGF

Transduction by specific receptors

12

There are specific sensory afferents for sensory detection:

A delta (Aδ) – fast, well localized painC-fibers – slow, diffuse pain

A beta (Aβ) - touch

69


13

EP-R

PGE2

PKC

PKA

Nav1.8/1.9

TRPV1

Nociceptorperipheralterminal

Inflammation

Macrophage

B1/B2

Bradykinin

TrkA

NGF

MastCell

TNFα &IL1β

COX2

NociceptorSensitizers

Peripheral sensitization(a form of “modulation”)

14

allodynia: pain from a stimulus that does not normally evoke pain(e.g., light touch after sunburn)

hyperalgesia: exaggerated response to a normally painful stimulus

spontaneous pain vs. evoked pain

Sensitization can lead to pain hypersensitivity ofvarious types:

15

Dorsal horn of thespinal cord

16

Spinal cord dorsal horn afferent inputs

- Sensory signal integration occurs here…

17

NMDAGlutamate

AMPA

Central Terminal of

Primary Sensory Neuron

Dorsal Horn Neuron

mGluRSub PNK1

Excitation

Inhibition

Opioid

Presynaptic Postsynaptic

CB1

GABAA

GABAB

Glycine R

Voltage-gatedcalcium channel

α2δ

GIRK

Pain processing occurs in the spinal cord.There is plasticity in the dorsal horn.

18

Activityin nociceptor

BDNF Src

PKC

Sub P

Glutamate Ca2+

Central terminal of nociceptor

Dorsal horn neuron

IP3

Trk B

NMDA

NK1

mGluR

AMPA

AMPA

PKA

ERK

Central sensitization(Allodynia, hyperalgesia, spontaneous pain)

70


19

Brain

20

Peripheral & Central Sensitization =Plasticity-dependent pain

•Pain detection (transduction) is dependent on specific receptors in specific neurons

•There is processing of pain information at all levels of the nervous system

•Processing of pain can be altered by past experience including injury: “plasticity”

•Plasticity can lead to clinical pain hypersensitivity (allodynia/hyperalgesia)

21

• Nociceptive pain

• Inflammatory Pain

• Neuropathic Pain

Pain Types

22

Nociceptive Pain

No pathologyRequires an ongoing noxious stimulusA high threshold (Aδ, C) protective alarm system

23

Inflammatory Pain

Tissue injury with inflammationAllodynia, hyperalgesia, spontaneous painA low threshold protective system that

promotes healing/repair

24

Peripheraldiabetic neuropathy

Neuropathic Pain

Post-Herpetic Neuralgia

PNS or CNS lesionsAllodynia, hyperalgesia, spontaneous pain,

negative symptomsLow threshold – pathological/maladaptive

Spinal cord

injury

Thalamic

stroke

71


25

- 3 Basic Types of Pain -

High Threshold

Protective

Acute traumaProcedural pain

Pathological

Postoperative painArthritis

Protective during healing/repair

Low Threshold

Inflammatory PainNociceptive Pain Neuropathic Pain

Diabetic neuropathyPostherpetic neuralgia

HIV, d4T, INHTumor injury to nerve

Thalamic stroke

(Allodynia and hyperalgesia)(normal pain)26

WHY DO WE CARE ABOUT PAIN?

• A major source of suffering for patients.

• A major burden for society.

• Current therapeutic options are quite limited.

27

First-line Pharmacologic Treatment Recommendations for Neuropathic Pain

Anticonvulsants (Gabapentin)Tricyclic Antidepressants

(Amitryptyline)Opioid Analgesics (morphine)Local anesthetics (Lidocaine Patch 5%)

Dworkin RH, et al. Arch Neurol. 2003;60:1524-1534. 28

SPINALCORD

BRAIN

Pharmaco-therapeutics and the Nervous System

CN

S

Descending Modulation

PeripheralSensitization

Central Sensitization

PNS

Local AnestheticsTopical AnalgesicsAnticonvulsantsTricyclic AntidepressantsOpioids

AnticonvulsantsOpioidsNMDA-Receptor AntagonistsTricyclic/SNRI Antidepressants

AnticonvulsantsOpioidsTricyclic/SNRI Antidepressants

29

Problem with current therapeutics:

Do not specifically target underlying mechanism(s) of pain hypersensitivity

Thus, frequently –Poor efficacySubstantial side effects

72

Review of Key Concepts in Pain Assessment and Treatment

1

Review of Key Concepts in Pain Assessment and

Treatment



General Principles of Pain Relief• Assessment:

– Chronology– Location– Severity– Character– Mediating factors (What makes it better or worse?)– Previous treatments

• Differential diagnosis• Management

– pharmacologic– nonpharmacologic

3

Figure 1. The WHO Three-step AnalgesicLadder

Pain ReliefPainpersisting or increasing

Painpersisting or increasing

3SEVERE

PAIN

Strong Opioid+/- Non-opioid+/- Adjuvant

2MODERATE

PAIN

Weak Opioid+/- Non-opioid+/- Adjuvant

Non-opioid +/- Adjuvant

1 MILD PAIN

Adapted from World Health Organization. Cancer Pain Relief. Geneva: WHO, 1990.

4

Opioid tolerance: over time, a fixed dose produces a decreased effect

5

WHO Step 3: Strong OpioidsRoutine Oral Dosing

• Morphine– Oral route is preferred except:

• When patient unable to swallow or absorb oral medications• When patient has very severe pain

– Start with 5 mg orally (for opioid-naïve patient)• Reassess after 30 minutes

– For chronic pain, dose every 4 hours (if renal function normal)

– If pain remains unrelieved after 30 minutes, repeat same dose or increase by 50% – 100%

– If pain disturbs sleep, consider doubling the evening dose.

6

Parenteral• Morphine SC, IV

– Starting dose 2-5 mg IV or SC in opioid-naïve patient with normal renal function

– For persistent pain, dose every 3–4 hours– Peak effect reached in 15 minutes– If pain remains unrelieved after 15 minutes,

repeat same dose or increase by 50%–100%

73


7

Useful definitions:• Around-the-clock dosing: pain medication

given regularly at fixed dosing intervals

• Breakthrough pain: transitory flare of pain

• Rescue dose: an extra dose of pain medication to treat breakthrough pain

8

Breakthrough pain should be treated with a rescue dose

• How to calculate the rescue dose:– 5%–10% of 24-hour dose

• Give the rescue dose and reassess in 15 minutes if IV/SC or 30 minutes if oral

– If pain unchanged: double the dose– If pain decreased by <50% : repeat same

dose

9

To change opioids:• For example: codeine is not adequately

effective for your patient and you want to use morphine

1) Calculate the dose of codeine the patient is taking

2) Use the equianalgesic table to convert this dose to morphine

10

Equianalgesic Tableused to convert from one opioid to

another

120mg every 3-4 hours


Codeine *


30 mg every 3-4 hours

Morphine

ParenteralOral

Approximate equianalgesicdose

Drug

*Available only in fixed dose tablet combination with acetaminophen or aspirin.

11

Reduce the new dose by 33%• Cross-tolerance

– The molecular structure of each opioid is different

– When changing from one opioid to another, the patient is not 100% tolerant to the new opioid

– Start with 67% of standard equianalgesicdose

12

Morphine pharmacokinetics• Metabolized by the liver to active and inactive

metabolites• Excreted mostly by kidneys• Liver disease:

– Mild (no change on prothrombin time): no change in dose– Severe (increase in prothrombin time): lengthen dosing

interval to every 6 or 8 hours• Renal failure:

– Increase dosing interval or decrease dose size– If anuria renal failure develops, stop routine dosing of

morphine and use only as needed– Treat symptomatic myoclonus with benzodiazepine or by

changing to another opioid, if possible

74


13

Important Concepts• Opioid physical dependence• Opioid psychological dependence

(addiction)• Pseudoaddiction

14

Physical dependence• A normal process of neuro-adaptation• Abruptly reducing or stopping opioid

therapy may cause withdrawal syndrome• If dose reduction required, reduce by no

more than 50% every 2–3 days

15

Psychological Dependence (Addiction)

• Compulsive use even when continued use creates problems in patients work or personal life

• Loss of control over drug use• Loss of interest in pleasurable activities• A rare outcome of pain management

– particularly, if no history of substance abuse

continued…

16

• Differential diagnosis of addictive behavior…– substance use (true addiction)– pseudoaddiction (undertreatment of pain)– behavioral / family / psychological disorder– drug diversion

17

Pseudoaddiction• Drug-seeking behavior that results from

inadequate treatment of pain• Resolves when pain is adequately treated• Must be distinguished from true addiction

75

Death and Dying in Vietnamese Culture and Buddhism


Tran Quynh Thai, MD Hanoi Center for HIV/AIDS Treatment

I. Purpose of this lecture:

- To introduce traditional Vietnamese ideas about death and dying according to Confucianism - To introduce Buddhist ideas about death and dying according to the Mahayana Sutra

• Most of the Vietnamese people are affected by the traditional culture of the Confucianism spirit and are of the Buddhist faith

• When the patients and their families do not have consensus on which action to take, the trainees, based on their understanding of death and dying, help them have a state of “peace” psychologically

II. Theoretical background:

- This lecture approaches death and dying from an anthropological perspective (which is the study of human socio-cultural variation) for Vietnamese people

• According to Confucianism, what is a good death, what is a bad death • According to Buddhism, when it comes to dying state, what happens to the spirit

- A commonly shared idea among these two religions is humans have two dimensions:

• Physical/material dimension: Confucianism calls it figure, sound and the five inner parts (five innards) while Buddhism calls it the five aggregate body (form, feeling, perception, reaction, consciousness

• Spiritual dimension: (Soul or spirit)

- A new commonly shared idea among the two religions is that when a human dies: • The physical body really dies and is disintegrated after that • The spiritual part continues to exist after the physical death

- According to Confucianism, the spiritual part exists forever and is attached to old body (old living body) but in another world (Cảnh giới khác) with practical evidence such as votive objects for worshiping, construction of tombs with house structure, the deceased’s former objects (photos) which are kept to worship, things the deceased liked (especially

76


food) which are placed for worshiping on the annual anniversary of the death, etc. Also there is a common saying (folklore saying) that the death reflects how the person lived or the life in hell reflects that on earth. - According to Buddhism, the spiritual part is “sheltered” in the former figure within 49 days after death. After 49 days, the spiritual part becomes attached to a new body in a new world. Within 49 days after death, the spiritual part is presented in front of Pluto’s palace in order to consider the person’s merits and sins when he/she was alive and then the Pluto will decide which world the person will reincarnate into, in the next birth (Go to heaven, back to human life, become ghosts and devils or go to the hell, etc). Therefore, there is a tradition to worship for 49 days after death (7 weeks) and to worship one month after a baby is born in order to inform that that baby now has a clean body and is no longer covered with the parents’ smelly and dirty fluid from the pregnancy and delivery. - In order to approach the human spiritual part after death, the living (usually family members together with shamen) often carry out worshiping rituals to guide the spirit (soul, manes) to reach the other world such as praying through worshipping documents, even praying in whisper (like real talking with the dead) and burning votive objects. The nature of the work varies by age, sex, region and religion, etc. - 09 center guides the dead’s spirit to reach the other world, frequently on the first and the fifteenth day of the lunar months by reciting the Buddhist scriptures - In order to help patients and their families maintain stable psychological state (peaceful) when the death is approaching (dying) and when the death comes, the trainees need to have firm knowledge about dying or what a bad death and what a peaceful death is (stable psychologically). III. General ideas about death and dying, a good death or a bad death

1. A good death and dying

• Dying at an advanced or middle age (60-70 years old) • Dying with many surviving children and grandchildren though particularly a son

and grandson • Dying quickly and painlessly and without torment • Dying in his/her home or the family’s home • Dying with the body intact, without losing the body and with the body quite

clean… • Dying with traditional funeral rituals such as being laid in coffin and buried • Dying when important things and wishes in life are relatively completed (Getting

married, building house, having children, repaying people for their kindness...) • Receiving medical care, being mentally encouraged and consoled by family

members and society when approaching the death.

77


2. A bad death and dying:

Opposite to the above If the person dies a good death, the spirit (soul) will be gently released from the body. The evidence is the person’s face, figure and complexion are quite balanced compared to those when the person is alive (some of the dead even look like they are smiling or sleeping…). In this case, for the family, the death is the comfort and consent. The evidence is during the funeral, the family sticks some paper to wish the dead well. Some families talk about the dead in an exciting manner and are proud of the dead. If the person dies a bad death, the spirit will flee from the body in a panic. 09 center has been providing medical care and giving mental encouragement and consolation since the patients here are special ones. For example we talk about causal relationships in the Buddhist prayer-book when the patients are approaching their death. 3. Spirit ( soul, nature...)

- This is a real and very important part in humans, even though it is inaudible and invisible by touching or modern facilities. The evidence is no one can say that he or she doesn’t have a spirit, a person can even hear his spirit pushing him to do something or think about something. Some pregnant women say it seems that their babies are whispering to their mothers. Some people while standing before their family members’ graves seem to talk with the person inside the grave even though he or she died a long time ago. This spiritual part can only be sensed from the depth of consciousness (according to Buddhism, it is located in the great eight types of consciousness (Đại Bát Thức) -The living body shelters the spiritual part. It is integrated within the human consciousness but does not depend on it, but rather decides the mentally balanced state of humans. The evidence is that when human beings are able to help others, they will be in high spirits, thus body actions will be quicker. During pagoda festivals or tet holidays, Vietnamese people are high spirited. When the spiritual part is hurt or when the person is angry or scared, he will wear a melancholy face or do things unconsciously (this is commonly seen in diseases of psychiatry and mental illness department)

- According to Buddhism, the spiritual dimension has two components:

• The good is the basic and primitive one transmitted from generation to generation, from one world to the other world. It is deeply located in Đại Bát Thức (in Thư Lăng Nghiêm Sutra) and is inversely relates to age (the older, the worse).

• The evil is attached partly to the good (like becoming infected, the degeneration of the good. The reason is conflicts of life or death arise in daily life while the mind is greedy or deluded which infringes the space for the good in Đại Bát Thức (For example, the capacity of computers is limited so this part will take up space of another part). This is discussed in detail in the causal relationship section, the twelve predestined affinity in Sutra of the Great Decease.

78


- According to Confucianism, the spiritual dimension also has two components:

• The good is innate, thus in the manual composed of sentences of three words, there is a sentence: the nature of the newborn babies is good.

• The evil becomes impregnated in life. The evidence is ‘Some special children in family having few children are sold to the pagoda or temple. However, when they are 13 years old (girls) or 16 years old (boys), they are redeemed out because of the feudal idea that at those ages, they can get married, thus the bad thing is likely to come out, they are no longer as pure as small children.

- The old often move to pagodas to do penance (repair) for the bad things arising in life. - Another shared idea among Confucianism and Buddhism is the good and the evil are invisible and inaudible by common sense. But the person who does bad things can sense it. The evidence is people themselves plead guilty before legal institutes and pagodas/temples, before parish priests and heads of a clan, etc. Clearly, the bad things hurt the basic spiritual dimension that they are able to sense and the person is so tormented that he has to plead guilty himself. It is necessary to counsel and encourage patients close to the death but in miserable and tormented mood (09 center has been doing so, especially for female patients infected with HIV due to their being sex workers) - If a person dies a bad death, the spirit will be hurt deeply in various manners and it will be difficult to be released to the other world. For example, if a person dies in a war without finding the body, his family (even his country) will spend a large amount of money finding the dead body (even though he might have died a long time ago). The purpose is to make the spirit release. Example: If a person drowns or dies with a lost body, there is a tradition to sacrifice materials to make an overpass so that the spirit will be released and won’t come back to the family to interrupt the living (rites to avoid repetition of funerals, amulets and incantations, etc). - The final shared idea among Confucianism and Buddhism is if a person dies a good death or a bad death but there are sufficient rites such as praying, doing penance, etc, the spirit will likely cross to the other world in a peaceful and stable manner, and will continue to remain happily. The evidence is in Thư Lăng Nghiêm Sutra, section 1, 3, 4 and 6 in chapter VI. Another piece of evidence is the saying “If abstaining from something, there will be good things”. A fact is that in families which have their members dying a bad death, if necessary rites are carried out to release the spirit, those families will have a balanced state in terms of psychology and health, even prosper in their business. Thus, people call “peaceful graves and tombs”.

79


IV. Causes of human suffering and misfortune in life 1. According to Confuciansim:

• Due to fate, the evidence is astrology, book of changes, and other types of fortune telling

• Due to not good repair of fate, for example, the ancestor or the dead’s graves or the house are not put in a good position accroding geomancy. Due to names or colors of clothes unsuitable with the five basic elements in human fate. Due to a careless choice of marriage because of greed

• Due to the actions of gods or spirits • Due to unrighteousness in study or work, illegal activities or actions against

family faith.

Thus, there is a saying “sow the wind and reap the whirlwind”. 2. According to Buddhism:

• Due to internal feeling or external feeling (clearly stated in section 3, chapter VI of Thư Lăng Nghiêm Sutra)

• The actions of gods and spirits For example: some people doing sacrilege will suffer from retribution, some are under a spell by ghosts, their spirits are in a panic (these are cases clearly stated in sudden death cases in the Buddha of Medicine scriptures, causal relationships in Sutra of the Great Decease, etc)

V. Summary:

• Death is the end of a living body • When a person dies, the spiritual dimension still remains in the other world

The spirit exists forever. For example: when one is ten years old, one sees the sun rise in the east. When one is 20 years old, one sees the same thing. When one is at an advanced age, nothing is changed. Even though from young to old, the physical dimension of the living body is dying gradually (degeneracy), the knowledge that the sun rises in the east remains forever (good mind).

• The spiritual dimension is the most important factor of a living body because it makes the body live a real life (live with one’s ideas, live healthily but purely, live meaningfully, live to benefit the community, etc)

• The living try every way to orient the patients very close to the death and until they die (death management). This is spiritual palliative care for patients.

80

Death & Dying in Vietnamese Culture


Shaun K Malarney, PhDAssociate Professor of Anthropology

International Christian UniversityTokyo, Japan

1

Objectives• To introduce traditional Vietnamese ideas about death

and dying.• To help participant’s to reflect about their own

understandings of death and dying.• To prepare participants to:

– Discuss preferences for end-of-life care with their patients and their patient’s families in a non-judgmental way

– To understand these preferences– To help their patients and their patients families to achieve a

good death as they understand it

2

Theoretical Background• This lecture approachs death & dying from an

anthropological perspective.• Anthropology: the study of human socio-

cultural variation.• The goal of anthropology: to clarify and

explain how other societies and cultures understand “reality”

• Fundamental assumption: different societies and cultures have different ideas about the nature of “reality”, what is “real”, what exists.

3

Examples of Different Cultural Realities

• Example 1: Sorcery in Cebu in the Philippines– Magical powers “exist” and humans can use them

to bring benefits to themselves or harm to others

• Example 2: Cholera epidemics in the early 20th century in Vietnam– Cholera epidemics were caused by a spirit,

referred to as thần dịch tả.– This spirit ravaged the Vietnamese countryside

bringing cholera to the people.– October 20, 1937, Việt Báo newspaper reporting

from Kiến An: 98 người bị thần tả đem đi.– This spirit therefore “existed” and was very “real”

to rural Vietnamese.

4

Examples of Different Cultural Realities

• Example 3: 1902 plague epidemic in Hanoi

– Hanoi residents asked permission from the colonial government to light firecrackers to scare off the angry spirits causing the epidemic.

– For Hanoi residents, these spirits were “real” and existed.

5

Guiding Questions to UnderstandDeath and Dying in Vietnamese Culture

1) What is a good death? What is a bad death?2) What constitutes the person?

• Specifically, what are its physical and spiritual dimensions?

3) What part of the person lives on after death?4) What happens to the soul after death?5) What are the responsibilities of the living to the

dead?6) How can the dead achieve lasting peace?

• How can the living help the dead achieve peace?

7) What are the causes of suffering and misfortune?

6

81


1) What is a good death? What is a bad death?

• Every culture has these ideas.

• Commonly shared ideas: A good death is often one at an advanced age, dying quickly and painlessly.

• A bad death involves dying young, dying due to violence, or after a long, painful illness.

7

A Good Death in Vietnam1) Dying at an advanced age

2) Dying with many surviving children, though particularly a son

3) Dying quickly and painlessly

4) Dying in the home, preferably near the ancestral altar

5) Dying with the body intact

8

A Bad Death in Vietnam1) Dying young and without children

2) Dying slowly and painfully

3) Dying from violence or in an accident

4) Dying away from home

5) Dying when the body or parts of it are lost or missing

9

2) What constitutes the person?• Good & bad deaths are related to the

concept of the person.• The person has two main dimensions:

1) The physical/material dimension• The flesh and bones of the living person

2) The spiritual dimension: two componentsa) The spirit essence (vía)

– Variation by sex: men have seven, women have nine– This component is linked to popular ideas of wellness.

For example, the vía can flee the body due to a strong fright, bringing on psychological problems.

b) The soul (linh hồn) – Every person is born with one soul.

10

3) What part of the person lives on after death?

• Two of the three components of the body cease to exist with death:– The physical body– The spirit essence (vía)

• However, the soul (linh hồn) continues to exist.– Physical death does not terminate its

existence.

11

4) What happens to the soul (linhhồn) after the body’s death?

• Despite a degree of general agreement, there are multiple answers to this question.– Variation by age, region, and religion.– Thus the following explanation is a generalization.

• At death, the soul (linh hồn) is released from the body, but it remains in the area around the deceased’s body for an indeterminate period of time.– Generally thought to be a few days or so, but

opinions do vary.

12

82


The Soul (Linh Hồn)• Special characteristics of the soul (linh hồn)

– It is “alive” and human-like.– It can think, experience emotions (contentment,

desire, fear, anger), move from place to place, even intervene in the lives of the living.

• The way the person dies is very important for what happens to the soul (linh hồn)– If the person dies a good death, the soul (linh hồn)

is gently released from the body.– Such a death is not shocking for the soul (linh

hồn) and it remains calm.– It is further comforted by being in familiar

surroundings, especially the family home.

13

The Soul (Linh Hồn)• If a person dies a bad death, the soul’s (linh

hồn) release from the body is frightening and traumatic.– If the person dies young, violently, or in an

accident the soul (linh hồn) is more likely to be upset and angry.

– If the soul (linh hồn) finds itself in a strange or unfamiliar environment, it may to flee and become difficult to locate.

14

5) What are the responsibilities of the living to the dead after they die?• Immediately after death, the soul (linh hồn) remains

in the world of the living.• However, the “other world” (thế giới khắc) is where

the soul (linh hồn) can find its final peace.• Therefore, with death one of the greatest

responsibilities of the living emerges: to facilitate the transition of the soul (linh hồn) from this world to the “other world” (thế giới khắc).

15

Getting to the Other World (ThếGiới Khắc)

• In the Vietnamese conception, the world of the living and the “other world” (thế giới khắc) are almost identical.

• This is evident in the existence of votive paper items (hàng mã).– These take the form of such everyday items as clothes,

money, televisions, motorcycles and helmets, etc.• In order for the soul (linh hồn) to cross to the “other

world” (thế giới khắc), the living must conduct the appropriate funeral rites such as the burning of paper votives (hàng mã).– The nature of these rites vary by region, religion, and other

factors.

16

Getting to the Other World (Thế GiớiKhắc)

• A good death facilitates the soul’s (linh hồn) crossing to the “other world” (thế giới khắc) through the proper funeral rites.

• A bad death, however, makes the crossing more difficult. For example:– A young, violent or accidental death that causes the soul to

be angry may make it flee and become difficult to locate.– Dying away from home also can make it more difficult for

the living to locate the soul and bring it to the place (family home) where it can be sent off.

– Especially a missing body or missing body parts can prevent the soul from ever making the transition to the “other world”.

• This problem has been acutely visible in the search for the remains of war dead. Families have spent time and money to bring back the bones of their missing loved ones so they can be given the proper burial rites and sent to the “other world”.

17

Getting to the Other World (Thế GiớiKhắc)

• In all of these cases, the danger is that instead of becoming a benevolent family ancestor at peace, the soul will become an angry ghost (con ma).

• And without the proper rites, ghosts are doomed to roam the world of the living.– They will never find eternal peace and will never be

able to have their living family members properly care for them.

18

83


6) How can the dead find lasting peace?

• Answers will vary based upon such factors as age, region, and religion. However, two factors are critical:– The dead must die in a way that they and their

family members consider a “good death”.– The living must perform the appropriate religious

or ritual practices to help the deceased to make the transition to the “other world” and there find peace.

19

7) What are the causes of suffering and misfortune in life?

• There are multiple possibilities:– “Fate” (số phận)– “Chance” (may dùi)– The actions of gods or spirits– Others

• Awareness of a patient’s or family’s way of explaining misfortune can help us to understand how they respond to it:– Anger– Efforts to influence gods or spirits to improve their fortune– Sadness– Resignation– Acceptance

20

Summary• The physical death of the body is but one stage in a

longer process of transition.• Death does not represent the complete termination of

existence, but instead a transformation in the nature of existence.

• Although the physical body ceases to function, the spiritual components remain.

• The surviving spiritual component, the soul (linh hồn), is dependent upon the living to give it peace in the afterlife.

• The living can help by:– Creating the conditions for what the dying person

considers a “good death” (palliative care may be able to help with this).

– Caring for the soul after death.

21

84

85

Palliative Care for Patients with End-stage Kidney Disease, End-stage Liver Disease, and Massive Hemorrhage




Eric L. Krakauer, MD, PhD

Harvard Medical School & Massachusetts General Hospital

Objectives

After the lecture, the trainees will be able to: 1. Describe the role of palliative care for patients with end-stage kidney disease (ESKD).

2. Describe the role of palliative care for patients with end-stage liver disease (ESLD).

3. Describe the role of palliative care for patients with massive hemorrhage.

Contents

1. Palliative Care for patients with end-stage kidney disease (ESKD). 1.1. Prevention of kidney disease is an important task for physicians who care for patients with many chronic diseases including HIV/AIDS, cancer, diabetes mellitus, and hypertension.

• Avoid or minimize use of nephrotoxic medications. • Avoid intravascular volume depletion due to:

o Excessive fluid loss from diarrhea or vomiting o Low oncotic pressure from poor nutrition or liver failure o Inadequate oral fluid intake or artificial hydration

• For patients with diabetes mellitus: o Strict control of blood sugar level o Use of angiotensin converting enzyme (ACE) inhibitor or angiotensin II inhibitor

• For patients with hypertension: o Strict blood pressure control

• For patients with genito-urinary, gynecologic, and other cancers: o Avoid or rapidly reduce hydronephrosis

1.2. Chronic kidney disease (CKD) often is asymptomatic until a very late stage. 1.3. Serum creatinine is an imperfect measure of loss of renal function.

86



• The glomerular filtration rate (GFR) can be estimated by calculating the Creatinine Clearance:o 24 hour urine collection is the most accurate way to measure the Creatinine Clearance:

(Urine creatinine (mg/dL) x total urine volume in 24 hours) / serum creatinine (mg/dL) x time (1,440 minutes) Normal values:

• Male: 100-125 ml/min • Female: 85-105 ml/min

o Easier method: Male: [(140 – age) x weight (kg)] / [serum creatinine (mg/dL) x 72] Female: [(140 – age) x weight (kg)] / [serum creatinine (mg/dL) x 72] x 0.85

1.4. Symptoms due to end-stage kidney disease

• Prevention and relief of symptoms often become the most important goals of care when the Creatinine Clearance of patients with CKD remains below 10 ml/min and:

o Hemodialysis is not available or planned.o Hemodialysis will be discontinued

• Fatigue is one of the most common symptoms associated with CKD even before it reaches the terminal phase.

o This often is due in part to anemia. Reduction in endogenous production of erythropoietin often occurs by the time the serum creatnine reaches 300 μmol/L.

o Erythropoietin replacement therapy can prevent anemia and improve quality of life. However, erythropoietin replacement therapy is very expensive.

o Iron supplementation should be given with erythropoietin only if there is evidence of iron deficiency because iron overload can occur.

o Fatigue also can be due to fluid overload, to uremia itself, and to concomitant failure of other organs.

• Dyspnea and peripheral or generalized edema due to fluid overload often occurs when patients with end-stage kidney disease (ESKD) have oliguria or anuria.

o If the renal failure is associated with proteinuria, the patient may develop anasarca due to low albumin level (low oncotic pressure).

o Early in the course of CKD, it is very important to avoid intravascular volume depletion because poor renal perfusion can cause more rapid progression of renal failure. However, for patients dying of ESKD with oliguria or anuria, it is crucial to avoid fluid overload and resultant dyspnea.

o Daily weights and careful measurement of output and intake maybe needed to careful balance the fluid status in patients with worsening renal failure

• Anorexia, nausea and vomiting are common gastro-intestinal symptoms in patients with ESKD. These symptoms often worsen as uremia progresses.

o Haloperidol in low doses often relieves nausea due to uremia and other endogenous or exogenous emetogenic toxins that stimulate the chemoreceptor trigger zone in the brain.

• Delirium and agitation may occur and worsen as uremia progresses. Some patients eventually become comatose.

o Haloperidol is useful to reduce delirium and relieve agitation while minimizing sedation. • Pruritis (itching) is a very common symptom due to the uremia.

o A moisturizing skin lotion may help.

87



o Anti-histamines may be useful but also may cause or exacerbate delirium and sedation. Therefore, they should be used with caution.

1.5. Many medications are cleared from the blood by renal excretion of the drug itself or of physiologically active metabolites of the drug. In patients with ESKD, the effects of these medications will be increased or prolonged, and the risk of toxicity will increase. Morphine is an example.

• The morphine metabolite morphine-6-glucuronide is physiologically active: it binds to opioid receptors and can relieve pain and dyspnea. It also can cause typical side effects of morphine including nausea, myoclonus, sedation, and respiratory depression. In renal failure, the plasma halflife of morphine-6-glucuronide increases and can cause cumulative toxicity unless the dose or the dosing frequency are decreased.

• Some other opioids, such as hydromorphone, do not have as much cumulative toxicity in patients with renal failure. When these opioids become available in Vietnam, they will be better choices for relieving pain or dyspnea in patients with renal failure.

1.6. Hemodialysis

• Many patients with severe acute renal failure have the potential to recover adequate renal function to sustain life. These patients may benefit from a brief course of hemodialysis to give their kidneys a chance to recover.

o This is true both for patients with CKD and for those who had normal renal function prior to developing acute renal failure.

• For patients with ESKD, hemodialysis as a “destination therapy” or life-long therapy can improve the quality and quantity of life. This is particularly true for patients whose baseline performance status is good.

• Informed consent should be obtained from patients and their families before hemodialysis is initiated.

• If the burden of continuing hemodialysis becomes greater than the benefit achieved, it is ethical to recommend that hemodialysis be stopped and that all further care be palliative.

o Most hemodialysis-dependant patients die within 7-14 days after discontinuing hemodialysis.

o When hemodialysis is stopped, the physician should anticipate the typical symptoms associated with ESKD (described above) and should be prepared both to prevent them and to relieve them if they occur.

1.7. There is no contradiction between treatment of ESKD and palliative care. A balance always should be sought between disease-modifying therapy and palliative care.

• Every effort should be made to prevent and slow the progression of CKD to ESKD. • Pain, dyspnea, and other distressing symptoms, whether caused by the disease or side effects of

medications, should be treated at any stage of CKD. • In the later stages of progressive CKD, many patients will have an increasing need for palliative

care including comprehensive symptom control and psychosocial support. 2. Palliative Care for patients with end-stage liver disease (ESLD)

2.1. Most patients have liver disease and some degree of cirrhosis for years before they develop

88



symptoms of end-stage liver disease (ESLD). • Many patients will be unaware that they have liver disease until symptoms occur.

2.2. Typical symptoms of ESLD include:

• Abdominal distention due to portal hypertension with resultant ascites. • Peripheral edema. • Abdominal pain:

o From stretching of the peritoneum by massive ascites. o From liver capsule stretch due to growing tumor (metastasis or primary hepatocellular

carcinoma), acute infection, hepatic vein thrombosis, bleeding, or other causes. • Jaundice • Fatigue • Anorexia • Nausea • Pruritis (itching) • Tremor • Confusion (hepatic encephalopathy) • Bleeding (especially hematemesis and epistaxis)

2.3. Prognostication can be difficult with ESLD. However, some important signs suggest a short life expectancy:

• Sudden esophageal or GI bleeding, • Spontaneous bacterial peritonitis • Intractable ascites despite diuretic therapy • Recurrent hepatic encephalopathy • Hepato-renal syndrome

2.4. Relief of pain and other symptoms in patients with ESLD

• Prevention and relief of physical symptoms can improve both the quality and quantity of life for the patient.

• Control ascites and edema: o Diuresis with spironolactone (start with 50-100mg/day orally) and furosemide (start with

40 mg/day orally). Monitor the weight and potassium closely at least initially. Determining a “dry weight” (normal weight) for the patient. Weigh the patient daily on the same scale. Adjust the diuretics up or down in order:

• Achieve ideal weight. • Maintain potassium in the normal range. • Avoid intravascular volume depletion that could cause acute renal failure

and hepato-renal syndrome. o Low-sodium diet o Elevate legs whenever possible to reduce edema.

• Prevent bleeding from esophageal varices or peptic ulcers. o Prescribe a low-dose systemic beta blocker such as propranolol (10 mg orally twice per

day) to reduce portal hypertension.

89



o Prescribe a histamine type 2 receptor blocker such as ranitidine or a proton pump inhibitor such as omeprazole to reduce the risk of gastritis, esophagitis, and peptic ulcer.

o Avoid aspirin due to increase risk of bleeding. o Avoid NSAIDS due to risk of bleeding and renal failure.

• Prevent and treat spontaneous bacterial peritonitis (SBP): o If there are 250 or more polymorphonucleosites/mcL of peritoneal fluid, or if there is

strong clinical suspicion (fever, abdominal pain, worsening encephalopathy in a patient with ascites), antibiotic therapy should be provided for at least 5 days:

Cefotaxime 2 g IV every 8–12 hours for at least 5 days, or Ceftriaxone 2 gm IV every day, or Ofloacin 400 mg orally twice daily, or Ciprofloxacin, 500 mg orally twice daily.

o For primary or secondary prophylaxis: Ciprofloxacin 750 mg orally once per week, or Cotrimoxazole 1 double-strength tablet five times a week.

• Prevent and treat hepatic encephalopathy o Low protein diet o Minimize sedating medications o Lactulose 15-30 ml orally 1-4 times per day as needed o Antibiotoics:

Neomycin 500 mg orally 2-4 times per day (not absorbed), or Rifaximin 1200 mg orally once per day (not absorbed), or Metronidazole 250 mg orally three times per day.

• Prevent and treat delirium and agitation o Use same methods as for hepatic encephalopathy. o When these methods are inadequate, use haloperidol 0.5-2 mg orally, SC, or IV every 4-8

hours as needed and/or around the clock. o Avoid benzodiazepines unless needed for alcohol withdrawal

• Treatment of pain o Acetaminophen should be used only in low doses or not at all to prevent worsening of

liver damage. o Avoid NSAIDS o Morphine can be used.

Use the lowest possible dose to minimize the risk of delirium. In severe liver failure, or liver failure combined with renal failure, use only short-acting morphine and either reduce the dose or lengthen the dosing interval.

o Therapeutic paracentesis can reduce pain from tense ascites. • Treatment of dyspnea:

o Diuresis and therapeutic paracentesis can be helpful in some patients. o Use morphine as above.

2.5. Psycho-social supports

• Depression related to lost of strength, vitality and role in family or work may affect many patients.

o Some patients can be helped to develop coping and reframing strategies. o Some patients may benefit from anti-depressant medication.

90



• Home healthcare workers can help the patient’s family cope during the patient’s illness and during bereavement by providing emotional support.

3. Palliative care for patients with massive hemorrhage

3.1. Conditions with highest risk for sudden hemorrhage: • Lung cancers located centrally near major vessels and airways • Invasive cancers of the head and neck, particularly those near the carotid artery and jugular vein • Advanced liver disease with coagulopathy and esophageal varices • Renal and bladder cancers with hematuria • Pulmonary tuberculosis or aspergillosis not responding to treatment

3.2. Prevention of hemorrhage • Identify patients who are at risk for hemorrhage • Make sure the patient is not taking aspirin or an NSAID that:

o Inhibit platelet function o Can cause gastritis and peptic ulcers o Can cause or exacerbate renal failure and uremia further impairs platelet function

• Patients with lung, head and neck, and some other cancers may benefit from palliative radiation to reduce bleeding or bleeding risk.

o Patients who have not already received radiation often benefit from high dose low fraction treatments to the most likely source of the bleeding.

o If patients have already received radiation but not the maximum dose, they may still benefit from a brief second course.

o Treating cough with opioid can reduce the risk of bleeding from lesions along the airways in the lungs and neck.

• Patients with cirrhosis and esophageal varices: o Prescribe a low-dose systemic beta blocker such as propranolol (10 mg orally twice per

day) to reduce portal hypertension. o Elevate the head of the bed if possible to further reduce the pressure in esophageal

varices and to reduce esophageal reflux. o Prescribe a histamine type 2 receptor blocker such as ranitidine or a proton pump

inhibitor such as omeprazole to reduce the risk of gastritis, esophagitis, and peptic ulcer. • Patients with urinary tract bleeding may form clots that cause bladder outlet obstruction and

pain. o A bladder catheter may be necessary to relieve painful obstruction.

The catheter may require frequent irrigation to keep prevent clots from obstructing it. For patients at home, the family can be instructed to do this. For massive bleeding, a large double-lumen catheter can be required that allows for continuous irrigation of the bladder to prevent frequent obstruction.

• For some patients with mucosal bleeding, 6-aminocaproic acid (Amicar) can be used to temporarily prevent mild bleeding from becoming a massive.

o The dose is 4 gm orally, followed by 1 gm oirally every hour as needed. o 6-aminocaproic acid can increase the risk of deep venous thrombosis and of clot

formation in urinary tract hemorrhage.

91



3.3. Treatment of massive hemorrhage• Advise the patient or family about the risk of massive bleeding and make a treatment to be used

if it occurs. • Prepare the family and staff to use universal precautions to reduce the risk of transmission of

HIV, viral hepatitis, or other blood-borne infections during bleeding. o Have surgical or water-proof gloves available.

• Massive hemorrhage often is extremely upsetting to the patient and to the family and even to clinicians. First, reassure everyone that the situation is under control.

• If the bleeding is causing severe dyspnea or is associated with severe pain, give morphine intravenously or subcutaneously every 15 minutes until the patient is comfortable.

o Even if the bleeding is not causing dyspnea or pain initially, dyspnea and chest pain often occur as the patient exsanguinates.

• Benzodiazepine also can be given to treat anxiety or to sedate the patient while exsanguination occurs.

• Have green, blue, or dark colored towels and bedding available such as that used in the operating room.

o These towels and sheets make the redness of the blood less visible and thereby reduce the emotional shock for the patient, family, and staff.

o Have many of these towels available to cover and absorb the blood, and remove the soaked towels frequently.

• In the hospital, suction can be used to clear blood from the mouth and airway. • Have bowls or basins available to collect vomited or expectorated blood or melena. Cover the

bowel with a dark towel or sheet and remove it from the room. • If the bleeding is witnessed by the family, bereavement support should be offered if possible.

92




1. Fatigue and anorexia are common symptoms of patients with end-stage kidney disease.

Yes No

2. Palliative care for patients with end-stage kidney disease includes:

a. Weighing the benefits and burdens of hemodialysis.

b. Avoiding both intravascular volume depletion and symptomatic fluid overload.

c. Using low doses of an opioid for dyspnea that is not relieved by other treatments.


e. b and c

3. Uremia can contribute to which of the following symptoms

a. itching

b. bleeding

c. delirium

d. A and c

e. all of the above

4. In patients with renal failure:

a. Morphine should be avoided.

b. Morphine will have a longer highlife due to prolonged clearance.

c. Morphine is not effective.

d. Toxic metabolites of morphine may cause myoclonus and delirium

d. A and C

e. B and D

5. Palliative care for patients with cirrhosis includes:

a. Use of diuretics to reduce ascites and peripheral edema.

b. Obtaining a daily weight to help reduce the risk of excessive diuresis and renal failure.

c. Use of a beta blocker to reduce portal hypertension.


e. a and b

93



6. Patients at most at risk for massive hemorrhage usually can be identified in advance.

Yes No

7. NSAIDS should be avoided in patients with end-stage liver disease or other bleeding risks because they:

a. Inhibit platelet function

b. Reduce the production of clotting factors by the liver.

c. Increase risk of gastric ulceration.


e. a and c

8. Preparation for massive hemorrhage might include:

a. Reducing the patient’s cough by using an opioid.

b. Informing the family of the possibility of hemorrhage.

c. Suggesting using dark towels and bedding.

d. a and b

e. All of the above.

11. When counseling family members about massive hemorrhage, they should be taught to use ___________________________ to reduce their risk of acquiring a blood-borne infection such as HIV. universal precautions

94




Cohen LM, Moss AH, Weisbord SD, Germain MJ. Renal palliative care. J Palliat Med. 2006 Aug;9(4):977-92. Sanchez W, Talwalkar JA. Palliative care for patients with end stage liver disease ineligible for liver transplantation. Gastroenterol Clin North Am. 2006 Mar;35(1):201-19 References for writing the lecture Chater S, Davison SN, Germain MJ, Cohen LM. Withdrawal from dialysis: a palliative care perspective. Clin Nephrol. 2006 Nov;66(5):364-72. Cohen LM, Moss AH, Weisbord SD, Germain MJ. Renal palliative care. J Palliat Med. 2006 Aug;9(4):977-92. Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine ,3nd ed. Oxford: Oxford University Press, 1998. Droney J, Levy J, Quigley C Prescribing opioids in renal failure. J Opioid Manag. 2007 Nov-Dec;3(6):309-16. Emanuel LL, von Gunten CF, Ferris FD, eds. The Education in Palliative and End-of-life Care (EPEC) Curriculum: © The EPEC Project, 1999, 2003. Available from http://www.epec.net End-of-Life Physician Education Resource Center. Available at http:/www.eperc.mcw.edu Gagnon B, Mancini I, Periera J, et al. Palliative management of bleeding events in advanced cancer patients. J Palliative Care 1998 ;14:15-54. Hudson M, Weisbord S, Arnold R. Prognostication in patients receiving dialysis: fast fact #191. J Palliat Med. 2007 Dec;10(6):1402-3. International Society of Nurses in Cancer Care. End-of-Life Nursing Education Consortium (ELNEC) Project. Available at http:/www.aacn.nche.edu/elnec Last Acts. Available at http:/www.lastacts.org Murtagh FE, Addington-Hall J, Higginson IJ The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis. 2007 Jan;14(1):82-99. Murtagh FE, Addington-Hall JM, Edmonds PM, Donohoe P, Carey I, Jenkins K, Higginson IJ. Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med. 2007 Dec;10(6):1266-76.

95



Murtagh FE, Murphy E, Shepherd KA, Donohoe P, Edmonds PM. End-of-life care in end-stage renal disease: renal and palliative care. Br J Nurs. 2006 Jan 12-15;15(1):8-11. Sanchez W, Talwalkar JA. Palliative care for patients with end stage liver disease ineligible for liver transplantation. Gastroenterol Clin North Am. 2006 Mar;35(1):201-19.

96

Palliative Care for Patients with End-Stage Kidney and Liver Disease and Massive Hemorrhage

11

Palliative Care for Patients with End-stage Kidney and Liver

Disease and Massive Hemorrhage F. Amos Bailey MD FACP

University of Alabama at BirminghamDirector, Safe Harbor Birmingham VAMC

Eric L. Krakauer, MD, PhDHarvard Medical School & Massachusetts

General Hospital


Objectives• After the lecture, trainees will be able to:

– Describe the role of palliative care for patients with end stage kidney or liver disease and those who have massive hemorrhage.

– Prescribe the best treatment to relieve symptoms of patients with end stage kidney or liver disease or massive hemorrhage.

3

Palliative Care for Patients with End-Stage Kidney Disease

(ESKD)

Chronic Kidney Disease (CKD)• Often asymptomatic until very advanced or

even near need for hemodialysis• Creatinine is an imperfect measure of

renal function and often does not indicate the severity of CKD

• Glomerular filtration rate (GFR) can be estimated by calculating creatinineclearance .

4

Calculation of CreatnineClearance

Male: (140 – age) x weight (kg)Serum creatinine (mg/dL) x 72

Female: (140 – age) x weight (kg)Serum creatinine (mg/dL) x 72 x 0.85

Normal Values – Male: 100-125 ml/min– Female: 85-105 ml/min

5

Prevention of Progression of Chronic Kidney Disease (CKD) to ESKD

• Avoid /minimize use of nephrotoxic medications• Avoid intravascular volume depletion

– Inadequate fluid intake– Excessive fluid loss (due to diarrhea, vomiting)

• For patients with diabetes mellitus:– Strict blood sugar control– Use of angiotensin converyig enzyme (ACE) inhibitor

• For patients with hypertension: strict blood pressure control

• Avoid or rapidly treat obstruction hydronephrosis6

97


7

Principles of Palliative Care for the Patients with ESKD

• Disease-modifying and palliative care for ESKD patients are inseparable and often indistinguishable.– Most treatments for ESKD could be considered palliative.

• Prevention and relief of symptoms often become the most important goals of care when creatinineclearance remains below 10 ml/min and:– Hemodialysis is not available or planned.– Hemodialysis will be discontinued

• Many patients also will benefit from efforts to relieve psycho-social and spiritual distress, and grieving families may benefit from bereavement support.

8

Common Symptoms in End-Stage Kidney Disease (ESKD)

• Dyspnea• Weakness• Fatigue• Edema• Anorexia• Nausea• Pruritis (itching)• Pain (often diffuse)• Anxiety

Symptom Relief for Patients with ESKD• Fatigue

– May be due to anemia from to decreased erythropoetin production.

• Fatigue due to aneamia can be relieved by erythropoietin replacement.

– Very expensive and requires repeated injections• Treat with iron only when iron deficiency is confirmed

because of the risk of iron overload.– May be due to uremia and/or failure of other

organs at the same time.

9

Edema• Patients at highest risk for fluid overload and

resultant edema and dyspnea:– Those with oliguria or anuria;– Those who have heart or liver failure in addition to ESKD.

• While avoidance of intravascular volume depletion is important earlier in the course of CKD, it becomes more important in the terminal phase of ESKD to avoid fluid overload.– Daily weights and careful monitoring of fluid intake and

output.– Diuretics as needed.

10

Pain and Dyspnea• Morphine is effective for both symptoms.

However, it must be used more cautiously in patients with CKD.– Metabolized in the liver– One metabolite, morphine-6-glucuronide (M6G), is

physiologically active and is renally cleared.– In ESKD, renal clearance is reduced and the risk

increases of toxic side effects such as myoclonus, delirium and sedation.

– Use lower doses and/or longer dosing intervals.• Other opioids are safer to use in patients with

renal failure but are not yet available in Vietnam.11

Anorexia, Nausea, Delirium

• Anorexia and nausea often are related to uremia– Low dose haloperidol often relieves nausea due to

endogenous or exogenous emetogenic toxins.• Delirium

– Uremia can cause both delirium and agitation.– Low dose haloperidol often relieves both symptoms

and causes minimal sedation.– In the very late stages of uremia, the patient may

become comatose.

12


98

Pruritis

• Pruritis (itching) is a very common symptom due to the uremia.– A moisturizing skin lotion may help.– Anti-histamines may be useful but also may

cause or exacerbate delirium and sedation. Therefore, they should be used with caution.

13

Hemodialysis• Can be provided transiently for patients with acute

renal failure to give kidneys a chance to recover.• In ESKD, hemodialysis is a “destination therapy”

or life-long therapy.– May improve the quality and quantity of life, especially

when the baseline performance status is good.– Can be discontinued if the burden of treatment is

greater than the benefit.– When hemodialysis is stopped:

• Most patients die in 7-14 days• The physician should be prepared to both prevent and

treat uncomfortable symptoms.14

1515

Palliative Care for Patients with End-stage Liver Disease

(ESLD)

Clinical Course of ESLD• Patients may have cirrhosis for many years before

they develop symptoms of ESLD. When symptoms occur:– It is often too late for any treatment of the underlying

liver disease.– Patients and families are often surprised by the

diagnosis and poor prognosis.• Precise prognostication is often difficult with ESLD.

Howere, some signs suggest a short life expectancy:– Sudden esophageal or GI bleeding,– Spontaneous bacterial peritonitis – Intractable ascites despite diuretic therapy– Recurrent hepatic encephalopathy– Hepato-renal syndrome 16

Symptoms of ESLD

• Abdominal distention due to ascites• Peripheral edema• Abdominal pain:

– From stretching of the peritoneum by ascites.– From liver capsule stretch due to growing

tumor, acute infection, hepatic vein thrombosis, bleeding, or other causes.

• Jaundice

17

Symptoms of ESLD• Fatigue• Anorexia• Nausea• Pruritis (itching)• Tremor• Confusion (hepatic encephalopathy)• Bleeding (especially hematemesis and

epistaxis)18

99


Ascites and Edema • Elevate legs whenever possible to reduce edema• Low-sodium diet• Diuresis

• Spironolactone (start with 50-100mg/day orally)• Furosemide (start with 40 mg/day orally)• Determine a “dry weight” (normal weight) for the patient.• Monitor the weight and potassium closely at least

initially, if possible. Use the same scale to weigh the patient every day.

• Adjust the diuretics up or down in order to:– Achieve ideal weight.– Maintain potassium in the normal range.– Avoid intravascular volume depletion that could cause

acute renal failure and hepato-renal syndrome. 19

Prevention of GI Bleeding– Prescribe a low-dose systemic beta blocker

such as propranolol (10 mg orally twice per day) to reduce portal hypertension.

– Prescribe a histamine type 2 receptor blocker such as ranitidine or a proton pump inhibitor such as omeprazole to reduce the risk of gastritis, esophagitis, and peptic ulcer.

– Avoid aspirin due to increase risk of bleeding.– Avoid NSAIDS due to risk of bleeding and

renal failure.20

Spontaneous Bacterial Peritonitis (SBP)

• Diagnosis of SBP:• > 250 granulocytes / mcL of peritoneal fluid• Clinical suspicion: fever, abdominal pain or worsening

encephalopathy in a patient with ascites)• Antibiotic therapy should be provided for at least 5

days:• Cefotaxime 2 g IV every 8–12 hours at least 5 days, or• Ceftriaxone 2 gm IV every day, or• Ofloacin 400 mg orally twice daily, or• Ciprofloxacin, 500 mg orally twice daily.

• For primary or secondary prophylaxis:• Ciprofloxacin 750 mg orally once per week, or• Cotrimoxazole 1 double-strength tablet five a week

21

Hepatic Encephalopathy • Low protein diet• Minimize sedating medications• Lactulose 15-30 ml orally 1-4 times per day as

needed• Antibiotics:

– Neomycin 500 mg orally 2-4 times per day (not absorbed), or

– Rifaximin 1200 mg orally once per day (not absorbed), or– Metronidazole 250 mg orally three times per day.

• For delirium and agitation:– Treat for hepatic encephalopathy as above.– Haloperidol 0.5-2 mg orally, SC, or IV every 4-8 hours as

needed and/or around the clock.– Avoid benzodiazepines unless needed for alcohol

withdrawal. 22

Pain and Dyspnea• For treating pain:

– Avoid aspirin and NSAID– Use paracetamol only when necessary and only in

low doses to avoid further liver damage.• Morphine can be used for both pain & dyspnea:

– Use lowest possible dose to reduce risk of delirium.– When liver failure is severe or combined with renal

failure, reduce dose and/or lengthen dosing interval.• Therapeutic paracentesis may help pain and

dyspnea.23

Psycho-Social Support• Depression due to lost of strength, vitality and

role in family/work affects many patients.– Some patients can be helped to develop coping and

reframing strategies.– Some patients may benefit from anti-depressant

medication. • Home healthcare workers can help the patient’s

family cope during:– The patient’s illness – During bereavement by providing emotional support.

24

100


Palliative Care for Patients with Massive Hemorrhage

25

Risk Factors for Sudden Hemorrhage

• Lung cancer near major vessels and airways.• Pulmonary tuberculosis or aspergillosis not

responding to treatment.• Invasive cancers of the head and neck, especially

when near the carotid artery or jugular vein.• Advanced liver disease with coagulopathy and

esophageal varices• Renal and bladder cancers with hematuria.

26

Prevention of Hemorrhage • Identify patients at high risk.• Stop any NSAID or aspirin therapy.• For patients with lung cancers or head and neck

cancers, consider radiation.• For patients with cirrhosis and esophageal varices,

propranolol and H2 blockers or PPI (omeprazole).• In patients with urinary tract bleeding:

– May use bladder catheter to relieve painful obstruction by clots.

– Catheter may require frequent flushing to keep it open. The family can be trained to do this.

• Prevention is not always effective or possible.27

Massive Hemorrhage• Advise the patient or family about the risk of

massive bleeding and treatment plan to be used if it occurs.

• Universal precautions to reduce the risk of transmission of blood borne disease. – Have surgical or water-proof gloves available.

• Massive hemorrhage often is extremely upsetting to the patient and to the family and even to clinicians.– First, reassure everyone that the situation is under

control.28

Massive Hemorrhage• If the patient has dyspnea or pain, give

morphine intravenously or subcutaneously every 15 minutes until the patient is comfortable.– Even if there is no dyspnea or pain initially, dyspnea

and chest pain often occurs with exsanguination.• Benzodiazepine may be given to treat anxiety or

to sedate the patient while exsanguinationoccurs.

• In the hospital, suction can be used to clear blood from the mouth and airway.

29

Massive Hemorrhage• Have green, blue, or dark colored towels and

bedding available such as that used in the operating room.– These towels and sheets make the redness of the blood

less visible and reduce the emotional shock.– Have many of these towels available to cover and absorb

the blood, and remove the soaked towels frequently.• Have bowls or basins available to collect vomited or

expectorated blood or melena. Cover the bowel with a dark towel or sheet and remove it from the room.

• If the bleeding is witnessed by the family, bereavement support should be offered if possible.

30

101

Participant’s Projects:Development of Palliative Care Services or Research in Home Institutions

1

1

Participant’s Projects:Development of Palliative Care Services or Research in Home

InstitutionsNguyen Phi Yen, MDBui Bich Thuy, MD

Eric L. Krakauer, MD, PhDFaculty, Vietnam Fellowship in Palliative Medicine


Objectives• To discuss and identify palliative care

clinical services, training programs, research projects, or other interventions that participants could implement in their home institutions.

3

1) Clinical Services• Inpatient palliative care ward• Inpatient palliative care consultation

service• Palliative care outpatient clinic• Palliative care community outreach or

home-care• Palliative care volunteer or peer-support

program

4

2) Training Programs• Provide palliative care training for:

– Physician colleagues• Training courses (1 – 5 days)• Regularly scheduled (monthly, quarterly)

– Lectures– Case discussions– Journal club

– Residents– Medical students– Nurses– Pharmacists– Community healthcare workers

• Work with So Y Te or NGO• Curriculum development

5

3) Research Projects• Prevalence, incidence, or severity of:

– Pain– Other symptoms– Psycho-social problems

• Availability of palliative care services– Clinician training– Essential medications (IAHPC)

• Palliative care knowledge / attitudes / practice patterns of clinicians

• Intervention study (more complex & difficult)– Treatment of pain or other symptoms– Effect of palliative care on adherence to ARV or cancer

therapy– Effectiveness of training program

6

4) Other Palliative Care Interventions• Design history and physical examination

forms with palliative care content?• Design method for estimation of institutional

opioid need?• Propose guidelines for use of life-sustaining

treatment?• Assist with development of national

palliative care association?

102

Palliative Care Module II Advanced & Refresher Course, faculty and trainees. Hanoi, Vietnam, May 2008.

Palliative Care Module II Advanced & Refresher Course, faculty and trainees.Ho Chi Minh City, Vietnam, October 2008.

Copyright © 2009. Massachusetts General Hospital. Developed by Eric L. Krakauer. All rights reserved.

MASSACHUSETTSGENERAL HOSPITAL