Palliative Palliative Medicine: Medicine:

the basicsthe basics

Tara Tucker MD FRCPCTara Tucker MD FRCPC

Lisa Aldridge MD CCFPLisa Aldridge MD CCFP

ObjectivesObjectives

Definition of Palliative CareDefinition of Palliative Care The Role of Palliative MedicineThe Role of Palliative Medicine PainPain ConstipationConstipation NauseaNausea DyspneaDyspnea ETHICSETHICS

Palliative CarePalliative Care

"an approach that improves the "an approach that improves the quality of life of patients and their quality of life of patients and their families facing the problems families facing the problems associated with life-threatening associated with life-threatening illness." WHOillness." WHO

palliative treatments may be used to alleviate the side palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving effects of curative treatments, such as relieving nauseanausea

1967: Dame Cicely Saunders opens 1967: Dame Cicely Saunders opens St. Christopher’s HospiceSt. Christopher’s Hospice

                                                            

                              

1995, first stand alone 1995, first stand alone paediatric paediatric hospice in N.A., hospice in N.A.,

Canuck Place, VancouverCanuck Place, Vancouver

“Dr. Bohen will be out here to talk to you in just a minute – All I can tell you is that your husband’s condition has stabilized!”

We will all face death in our lives We will all face death in our lives and in our work.and in our work.

10% of us will die suddenly…. but 10% of us will die suddenly…. but what about the rest?what about the rest?

Sudden death, unexpected causeSudden death, unexpected cause < 10%, MI, accident, etc < 10%, MI, accident, etc< 10%, MI, accident, etc

Death

Time

He

alth

Sta

tus

Steady decline, short terminal phaseSteady decline, short terminal phase

Slow decline, periodic crises, sudden deathSlow decline, periodic crises, sudden death

End of Life CareEnd of Life Care

Most of us in this room will DO and NEED Most of us in this room will DO and NEED palliative care…palliative care…

220 000 Canadians die each year220 000 Canadians die each year Process and outcome has tremendous effect on Process and outcome has tremendous effect on

others… “collateral suffering”others… “collateral suffering” Only 5% people receive integrated, Only 5% people receive integrated,

multidisciplinary palliative caremultidisciplinary palliative care Cancer patients (25% deaths) receive 90% Cancer patients (25% deaths) receive 90%

palliative carepalliative care Pain and symptoms are poorly controlledPain and symptoms are poorly controlled

Medicine’s Shift in FocusMedicine’s Shift in Focus

Many health care providers feel they Many health care providers feel they have failed if the patient dies… our have failed if the patient dies… our own fear of death may influence how own fear of death may influence how we approach otherswe approach others

To cure sometimesTo cure sometimes To relieve oftenTo relieve often To comfort alwaysTo comfort always

SocratesSocrates

                   

   

                 

   

Where does Palliative Care fit Where does Palliative Care fit in?in?

Disease-focused care

Death Comfort-focused care F/up

The Dying Patient:The Dying Patient:Your RoleYour Role

Relieve sufferingRelieve suffering

Provide Comfort and compassion Provide Comfort and compassion to both the patient and the familyto both the patient and the family

Formulate a Plan for Formulate a Plan for the Dying Patientthe Dying Patient

Pain ControlPain Control Maintain human dignityMaintain human dignity Avoid isolation of patientAvoid isolation of patient Discuss with patients their wishes Discuss with patients their wishes

or refer to advance directiveor refer to advance directive Provide emotional and spiritual Provide emotional and spiritual

supportsupport

Advance Care PlanningAdvance Care Planning Process of making decisions about future Process of making decisions about future

medical care with the help of health care medical care with the help of health care providers, family and loved onesproviders, family and loved ones

Discuss diagnosis, prognosis, expected Discuss diagnosis, prognosis, expected course of illness, treatment alternatives, course of illness, treatment alternatives, risks, benefitsrisks, benefits

In context of patients goals, expectations, In context of patients goals, expectations, values, beliefs and fearsvalues, beliefs and fears

EOL Decision MakingEOL Decision Making People need time to reflect on goals, values, People need time to reflect on goals, values,

beliefsbeliefs

EOL decision making is a process, not a one EOL decision making is a process, not a one time eventtime event

Multidisciplinary team to convey info, discuss Multidisciplinary team to convey info, discuss alternatives, provide emotional and psychological alternatives, provide emotional and psychological support – avoid mixed messagessupport – avoid mixed messages

“What you need, Mr. Terwilliger, is a bit of human caring; a gentle, reassuring touch; a warm smile that

shows concern--all of which, I’m afraid, were not a part of my medical training.”

CommunicationCommunication

Talk about death – find the wordsTalk about death – find the words ““Hope for the best, plan for the worst”Hope for the best, plan for the worst” Lose the medical jargonLose the medical jargon Being, not doingBeing, not doing Compassion/presence and balanceCompassion/presence and balance Cultural sensitivityCultural sensitivity Collaboration with team membersCollaboration with team members

Phrases to AvoidPhrases to Avoid

““It doesn’t look good”It doesn’t look good” Too vague, be more specificToo vague, be more specific

““Do you want us to do everything?”Do you want us to do everything?” ““We will not do anything extraordinary, We will not do anything extraordinary,

heroic, or aggressive.”heroic, or aggressive.” Implies substandard careImplies substandard care

There’s nothing more that we can do.There’s nothing more that we can do. Implies abandonmentImplies abandonment

Language to describe the goals Language to describe the goals of care…of care…

We want to give the best care possible We want to give the best care possible until the day you die.until the day you die.

We will concentrate on improving the We will concentrate on improving the quality of your child’s life.quality of your child’s life.

We want to help you live meaningfully in We want to help you live meaningfully in the time that you have.the time that you have.

……language to describe the language to describe the goals of caregoals of care

I will focus my efforts on treating your I will focus my efforts on treating your symptoms.symptoms.

Let’s discuss what we can do to fulfill your Let’s discuss what we can do to fulfill your wish to stay at home.wish to stay at home.

Withholding or Withholding or Withdrawing Withdrawing TreatmentTreatment

What does the pt/family know and understand What does the pt/family know and understand about life sustaining Rx – ie: risks and benefitsabout life sustaining Rx – ie: risks and benefits

What are the goals of care/ pt’s wishesWhat are the goals of care/ pt’s wishes Explain how it will be done and what to expectExplain how it will be done and what to expect How will pain/distress be managedHow will pain/distress be managed Pertinent religious/cultural issuesPertinent religious/cultural issues Time limited trials for some interventions ie: Time limited trials for some interventions ie:

dialysisdialysis

“I wish you’d called me sooner, Mrs. Moodie.”

When to call on Palliative When to call on Palliative Medicine Specialist?Medicine Specialist?

Early in the trajectory of life limiting Early in the trajectory of life limiting illness – again, find the words to useillness – again, find the words to use

When major decisions have to made When major decisions have to made re: treatmentre: treatment

When symptom management is When symptom management is problematicproblematic

……

PainPain

““an unpleasant sensory or emotional an unpleasant sensory or emotional experience associated with actual or experience associated with actual or potential tissue damage, or potential tissue damage, or described in terms of such damage”described in terms of such damage”

World Health World Health OrganizationOrganization

PainPain

““a state of distress associated with a state of distress associated with events that threaten the intactness events that threaten the intactness of a person”of a person”

Eric J Cassell. The Nature of Suffering and the Eric J Cassell. The Nature of Suffering and the

Goals of Medicine. NEJM 1982; 306: 639-645Goals of Medicine. NEJM 1982; 306: 639-645

PainPain

Chronic pain serves no Chronic pain serves no physiologic purposephysiologic purpose

Under-treated pain may lead to Under-treated pain may lead to depression and suicidedepression and suicide

physical emotional

social spiritual

e.g. arthritis, bowel spasms, headache caused by CVA

e.g. depression, anxiety, loss of control

Loss of role, loss of social contacts

- search for meaning

Total Pain Pie

Lili/presentations/1999/pie.ppt

Causes of Cancer PainCauses of Cancer Pain

Direct effects of the diseaseDirect effects of the disease Related to disease ie: constipationRelated to disease ie: constipation Secondary to treatment – 20%Secondary to treatment – 20%

SurgerySurgery ChemotherapyChemotherapy RadiationRadiation

Physiological Pain Physiological Pain CategoriesCategories

Nociceptive –localisedNociceptive –localised Somatic: superficial, deepSomatic: superficial, deep

Bone mets, cellulitisBone mets, cellulitis VisceralVisceral

Infiltration, compression, distension of visceraInfiltration, compression, distension of viscera

Neuropathic – may radiate along Neuropathic – may radiate along dermatome, nerve distributiondermatome, nerve distribution

TGN, herpes zosterTGN, herpes zoster

Neuropathic PainNeuropathic Pain

Sympathetic Sympathetic CentralCentral Peripheral (non-sympathetic)Peripheral (non-sympathetic)

Neuropathic PainNeuropathic Pain Spontaneous painSpontaneous pain

DysesthesiaDysesthesia e.g. burninge.g. burning

NeuralgiaNeuralgia e.g. lancinating, “electric shocks”e.g. lancinating, “electric shocks”

Evoked painEvoked pain AllodyniaAllodynia

Pain from a non-painful stimulusPain from a non-painful stimulus HyperalgesiaHyperalgesia

Pain more than expected from a mildly painful Pain more than expected from a mildly painful stimulusstimulus

HyperpathiaHyperpathia Explosive build-up of pain with repetitive stimuliExplosive build-up of pain with repetitive stimuli

Evaluating PainEvaluating Pain

Believe the patientBelieve the patient Initiate discussionsInitiate discussions Detailed pain historyDetailed pain history Careful physical examCareful physical exam InvestigationsInvestigations Monitor results of treatmentMonitor results of treatment

Pain History – the key!Pain History – the key!

P = provokes and palliatesP = provokes and palliates Q = qualityQ = quality R = Radiates - locationR = Radiates - location S = severityS = severity T = time – duration, time of dayT = time – duration, time of day O = other ie: red flagsO = other ie: red flags

Headache + vomitingHeadache + vomiting

Principles of Analgesic Principles of Analgesic TherapyTherapy

By the mouthBy the mouth By the clockBy the clock By the ladderBy the ladder For the individualFor the individual Attention to detailAttention to detail

The ideal treatment for any pain is to The ideal treatment for any pain is to remove the cause.remove the cause.

Treating PainTreating PainUse a Multidisciplinary approachUse a Multidisciplinary approach

MedicationsMedications CounsellingCounselling Physical TherapyPhysical Therapy Nerve blockNerve block SurgerySurgery

WHO Pain LadderWHO Pain Ladder

WHO Pain LadderWHO Pain Ladder

1 Mild

2 Moderate

3 Severe

Morphine

Hydromorphone

Methadone

Fentanyl

Oxycodone

± Acetaminophen

± NSAIDs

± Adjuvants

Acetaminophen + Codeine

Acetaminophen + Oxycodone

± NSAIDs

± Adjuvants

Acetaminophen

NSAIDs

± Adjuvants

NSAIDSNSAIDS

AntiinflammatoryAntiinflammatory Adverse effectsAdverse effects

Gastropathy, renal failure, platelet Gastropathy, renal failure, platelet inhibition, cardiacinhibition, cardiac

Risk factorsRisk factors Age, PUD, cachexia, dehydration, steroids, Age, PUD, cachexia, dehydration, steroids,

comorbid conditionscomorbid conditions

Combination Combination medicationsmedications

Percocet (oxycodone and tylenol)Percocet (oxycodone and tylenol) Tylenol #3 (Codeine and tylenol)Tylenol #3 (Codeine and tylenol) Limited by dose of acetaminophenLimited by dose of acetaminophen

Opioids:choosing the Opioids:choosing the right drugright drug

Morphine is first lineMorphine is first line

Morphine metabolites will accumulate Morphine metabolites will accumulate in renal failure patients; suggest in renal failure patients; suggest fentanyl or hydromorphonefentanyl or hydromorphone

Do NOT use meperidine (Demerol) due Do NOT use meperidine (Demerol) due to metabolites causing adverse effectsto metabolites causing adverse effects

Opioids – choosing the right Opioids – choosing the right drugdrug

Pt’s previous experience with Pt’s previous experience with opioidsopioids

ComplianceCompliance Fears and myths – pt + MD!Fears and myths – pt + MD! Physician comfort + experiencePhysician comfort + experience

Opioids – choosing the right Opioids – choosing the right dosedose

Opioid naïve patientOpioid naïve patient Morphine 2.5 - 5 – 10 mg po q4hMorphine 2.5 - 5 – 10 mg po q4h Hydomorphone 0.5 – 1 mg po q4hHydomorphone 0.5 – 1 mg po q4h Oxycodone 2.5 - 5 mg po q4hOxycodone 2.5 - 5 mg po q4h

PercocetPercocet Some references give higher starting Some references give higher starting

doses – CAUTION! doses – CAUTION!

Opioids – choosing the right Opioids – choosing the right schedule schedule

Immediate Release (IR)Immediate Release (IR) Q4h dosing – straightQ4h dosing – straight Prn q1-2h at 10% of daily dosePrn q1-2h at 10% of daily dose

Sustained release (the Contins)Sustained release (the Contins) Q12h, prn IR 10% daily doseQ12h, prn IR 10% daily dose

Opioids – adverse eventsOpioids – adverse events

CommonCommon Constipation is easier to prevent than Constipation is easier to prevent than

treattreat Softener + laxativeSoftener + laxative

Nausea (tolerance develops)Nausea (tolerance develops) Maxeran, HaldolMaxeran, Haldol

Sedation (tolerance develops)Sedation (tolerance develops) Dry mouthDry mouth

Opioids - Adverse eventsOpioids - Adverse events

Less commonLess common Urinary retentionUrinary retention PruritisPruritis DeliriumDelirium MyoclonusMyoclonus Psychotomimetic effectsPsychotomimetic effects Postural hypotensionPostural hypotension VertigoVertigo

Opioids – adverse eventsOpioids – adverse events

RareRare AllergyAllergy

Codeine allergy most common, unlikely Codeine allergy most common, unlikely cross-reactivity with other opioidscross-reactivity with other opioids

Respiratory depressionRespiratory depression

Fentanyl PatchFentanyl Patch

See table for equianalgesic dosesSee table for equianalgesic doses For stable painFor stable pain Dosage increases in 2-3 day Dosage increases in 2-3 day

intervalsintervals Careful in opioid naïve patients!Careful in opioid naïve patients!

25 mcg/hr= 90 mg/d morphine = 18 25 mcg/hr= 90 mg/d morphine = 18 mg/d hydromorphonemg/d hydromorphone

Withdrawal…Withdrawal…

Tachycardia, hypertension, diaphoresis, Tachycardia, hypertension, diaphoresis, pilo-erection, N, V, diarrhea, body pilo-erection, N, V, diarrhea, body aches, abdo pain, psychosis, aches, abdo pain, psychosis, hallucinationshallucinations

Opioids and ToleranceOpioids and Tolerance

Characterized by decreased efficacy Characterized by decreased efficacy and duration of action with and duration of action with prolonged repeated use of the drugprolonged repeated use of the drug

Need for higher doses to maintain Need for higher doses to maintain same level of analgesiasame level of analgesia

Normal pharmacological responseNormal pharmacological response

Opioids and Psychological Opioids and Psychological DependenceDependence

AddictionAddiction Characterized by craving for the drug Characterized by craving for the drug

and a preoccupation for itand a preoccupation for it Rarely occurs in cancer patientsRarely occurs in cancer patients Beware of labeling a patient who Beware of labeling a patient who

actually has uncontrolled painactually has uncontrolled pain Screening for addiction potential Screening for addiction potential

(CAGE)(CAGE)

“I hate to tell you this, but I’ve still got the headache.”

Anti-convulsantsAnti-convulsants

Carbamazepine Carbamazepine Block Sodium channelsBlock Sodium channels Reduce hyperexcitabilityReduce hyperexcitability

GabapentinGabapentin Action unclear, ? Ca channels Action unclear, ? Ca channels

SE: dizziness, sedationSE: dizziness, sedation

Tri-cyclic Tri-cyclic antidepressantsantidepressants

Nortriptylline 10 mg po qHS Nortriptylline 10 mg po qHS Inhibit serotonin and NE reuptakeInhibit serotonin and NE reuptake Block Sodium channelsBlock Sodium channels

SE: dry mouth, sedation, SE: dry mouth, sedation, hypotensionhypotension

ConstipationConstipation

DebilityDebility Decreased fluids and foodDecreased fluids and food Metabolic: hypothyroid, Metabolic: hypothyroid,

hypokalemia, hypercalcemiahypokalemia, hypercalcemia DRUGSDRUGS Autonomic dysfunction: DM, CA, Autonomic dysfunction: DM, CA,

SCCSCC ObstructionObstruction

DRUGSDRUGS

Anticholinergics: ex TCAsAnticholinergics: ex TCAs AntacidsAntacids IronIron ZofranZofran DiureticsDiuretics AnticonvulsantsAnticonvulsants NSAIDSNSAIDS ChemotherapyChemotherapy

OPIOIDSOPIOIDS

Increase Bowel toneIncrease Bowel tone Decrease pancreatic and biliary Decrease pancreatic and biliary

secretionssecretions Delay Gastric emptyingDelay Gastric emptying Decrease peristalsisDecrease peristalsis Increase transit timeIncrease transit time Decrease the urge to defecateDecrease the urge to defecate

Managing ConstipationManaging Constipation

PRIVACYPRIVACY Increase fluids and activityIncrease fluids and activity R/O obstruction, with an Xray if R/O obstruction, with an Xray if

necessarynecessary All patients starting on Opioids need All patients starting on Opioids need

laxativeslaxatives

Suggested Laxative Suggested Laxative RegimeRegime

Start:Start:Stimulant: Senokot 2-4 tabs po qhs andStimulant: Senokot 2-4 tabs po qhs andSoftener: Colace 200mg po dailySoftener: Colace 200mg po daily

If needed add:If needed add:Osmotic agent: Lactulose 30 cc po BID prn or M of Osmotic agent: Lactulose 30 cc po BID prn or M of

M 60 mls/ dayM 60 mls/ day

If needed:If needed:Rectal agents: Bisocodyl supp and/ or Fleet enemaRectal agents: Bisocodyl supp and/ or Fleet enema

Warning… Warning…

Fiber + no water = cementFiber + no water = cement

DELIRIUM: DELIRIUM: Common and under-Common and under-recognizedrecognized

A Disturbance in consciousnessA Disturbance in consciousness

Characterized by:Characterized by:

decreased attention, acute onset & decreased attention, acute onset & fluctuationfluctuation

Causes of Delirium Causes of Delirium

Metabolic: Metabolic: Hypoxemia, Hypoglycemia, Hypoxemia, Hypoglycemia, Hypothyroid, Thiamine def’nHypothyroid, Thiamine def’n

Electrolyte AbN: Electrolyte AbN: High Na++, Ca++, or Mg+High Na++, Ca++, or Mg+++

Drugs and toxins: Drugs and toxins: opioids, anticholinergics, opioids, anticholinergics, withdrawalwithdrawal

Organ failure: Organ failure: RF, Liver, CHF, CO2, sepsisRF, Liver, CHF, CO2, sepsis

Brain: Brain: tumor, infection, vascular events, tumor, infection, vascular events, seizuresseizures

ManagementManagement

Determine WHO is at riskDetermine WHO is at risk Screen with MMSEScreen with MMSE Find underlying causeFind underlying cause Obtain collateral historyObtain collateral history

Consent when deliriousConsent when delirious

You may use : ”substituted You may use : ”substituted judgment” – if you know the patient judgment” – if you know the patient wellwell

Use a substitute-decision maker Use a substitute-decision maker otherwiseotherwise

Treat without consent if in an Treat without consent if in an emergencyemergency

Treatment for DeliriumTreatment for Delirium

Haldol or atypical antipsychotic Haldol or atypical antipsychotic (olanzapine, risperidone)(olanzapine, risperidone)

NO AtivanNO Ativan

Causes of NauseaCauses of Nausea GI: gerd, motility, tumor, gastritis, GI: gerd, motility, tumor, gastritis,

obstructionobstruction BRAIN: High ICP, tumor, anxiety BRAIN: High ICP, tumor, anxiety EAR: Vestibular disturbancesEAR: Vestibular disturbances DRUGSDRUGS SYSTEMIC: infection, toxins, uremiaSYSTEMIC: infection, toxins, uremia CANCER: paraneoplastic syndromes, ov CANCER: paraneoplastic syndromes, ov

caca

Treatment – mechanistic Treatment – mechanistic approachapproach

Drugs, toxins, metabolic (CRTZ)Drugs, toxins, metabolic (CRTZ) Anti-dopaminergic: maxeran, haldolAnti-dopaminergic: maxeran, haldol

Vestibular Vestibular anticholinergic, antihistamines anticholinergic, antihistamines

Chemo/radiation - ondansetronChemo/radiation - ondansetron

DyspneaDyspnea

Treat the causeTreat the cause O2 if helpful or hypoxicO2 if helpful or hypoxic OpioidsOpioids

Double EffectDouble Effect

Appropriate treatment of pain is Appropriate treatment of pain is morally acceptable even if it hastens morally acceptable even if it hastens death as long as there was no death as long as there was no intention to do so.intention to do so.

Physician Assisted Physician Assisted SuicideSuicide

The physician supplies the patient The physician supplies the patient with the means, usually medication, with the means, usually medication, to end their life. Not legal in Canada.to end their life. Not legal in Canada.

EuthanasiaEuthanasia

The physician administers a The physician administers a medication with the intent of medication with the intent of causing death. Also not legal in causing death. Also not legal in Canada.Canada.

Speak gently, treat Speak gently, treat aggressivelyaggressively

“SAVE the patient you idiot!! I said we’ve got to do whatever we can to SAVE the patient!!”