Terapi Paliatifpada Keganasan

dr Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit DalamFakultas Kedokteran

Universitas Muhammadiyah Sumatera Utara

Traditional Health Care Model

Curative• The primary goal is cure• The object of analysis is

the disease process• Symptoms are treated

primarily as clues to diagnosis

• Primary value is placed on measurable data

• Tends to devalue information that is subjective, immeasurable, or unverifiable

• Therapy is medically indicated if it eradicates or slows the progression of disease

Symptoms at the End of Life:

Pain 84% 67%Trouble breathing 47% 49%Nausea and vomiting 51% 27%Sleeplessness 51% 36%Confusion 33% 38%Depression 38% 36%Loss of appetite 71% 38%Constipation 47% 32%Bedsores 28% 14%Incontinence 37% 33%

Seale and Cartwright, 1994

Cancer Other

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PALLIATIVE CARE:World Health Organization Definition

Palliative care is an approach that improves the

quality of life of patients and their families facing the

problem associated with life-threatening illness,

through the prevention and relief of suffering by means

of early identification and impeccable assessment and

treatment of pain and other problems, physical,

psychosocial and spiritual.

Palliative Care• Comprehensive care for

patients whose diseases are not responsive to curative treatment

• Care is provided by an interdisciplinary team of physicians, nurses, social workers, chaplains and other health care professionals

• Palliative Care Teams practice in hospitals, nursing homes and in the outpatient setting.

Google Images

History of Palliative Care• Dame Cecily Saunders was the founder of St

Christopher’s Hospice which opened in London in 1967

• Connecticut Hospice- first Modern Hospice in USA in 1974

• Medicare Hospice Benefit introduced in 1983

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General Principles• Patient and family as unit of care• Attention to whole person• Interdisciplinary team approach• Education and support of patient and family• Extends across illnesses and settings• Bereavement Support

National Consensus Project for Quality Palliative Care, 2004

Components of Palliative Care

• Effective symptom control• Effective communication• Rehabilitation – maximising independence• Continuity of care• Coordination of services• Terminal care• Support in bereavement

Domains of Palliative Care• Structure and Processes of Care• Physical Aspects of Care• Psychological and Psychiatric Aspects of Care• Social Aspects of Care• Spiritual, Religious and Existential Aspects of Care• Cultural Aspects of Care• Care of the Imminently Dying Patient• Ethical and Legal Aspects of Care

Clinical Practice Guidelines for Quality Palliative Care, 2004

Structure and Processes of Care

• Comprehensive, interdisciplinary plan of care based on expressed values and goals of patient and family

• Teams have relationships with one or more community hospice programs

• The physical environment in which care is provided meets the needs of the patient and family to the extent possible

• Patients and families have access to palliative care staff 24 hours a day, seven days a week

Physical Aspects of Care• Pain, other symptoms, and side-effects are managed based upon the

best available evidence

Breathlessness AnorexiaInsomnia Fatigue/weaknessAnxiety NauseaDepression Confusion

Constipation

• The outcome of symptom management is the safe and timely reduction of the symptom to a level that is acceptable to the patient

Concept of Total Pain• Physical pain• Anger• Depression• AnxietyAll affect patient’s perception of pain. Needs thorough assessment90% can be controlled with self-administered oral

drugs

Depression

• Loss of social position• Loss of job prestige, income• Loss of role in family• Insomnia and chronic fatigue• Helplessness• Disfigurement

Anxiety

• Fear of hospital, nursing home• Fear of pain• Worry about family and finances• Fear of death• Spiritual unrest• Uncertainty in future

Anger

• Delays in diagnosis• Unavailable physicians• Uncommunicative physicians• Failure of therapy• Friends who don’t visit• Bureaucratic bungling

Treatment options

• Analgesic drugs• Adjuvant drugs• Surgery• Radiotherapy• Chemotherapy• Spiritual and emotional support (total pain)

Analgesic drugs• Mainstay of managing cancer pain• Choice based on severity of pain, not stage

of disease• Standard doses, regular intervals, stepwise

fashion• Non-opiod…weak opioid…strong opiod…

+-adjuvant at any level (WHO analgesic ladder)

Non-opioid drugs

• Paracetamol1g 4 hourly

• NSAIDSIbuprofen 400mg 4 hourlyAspirin 600mg 4 hourly

NB daily maximum doses

Weak opioidsCodeine

60mg 4 hourlyDihydrocodeine

30-80mg tds max 240mg dailyDextropropoxyphene

65mg four hourlyTramadol 50-100mg 6 hourly Prescribing more than the maximum daily dose will

increase s/e without producing further analgesia

Combinations

• Convenient• Care with dosing

• Some combinations e.g co-codamol contain subtherapeutic doses of weak opioid

• Co-proxamol only contains 325mg paracetamol

• Get dosing right before moving on to strong opioids

Strong Opioids

• Morphine• Hydromorphone• Fentanyl• Diamorphine• Buprenorphine

Bone pain

• Paracetamol• Morphine• NSAIDS• Radiotherapy• Bisphosphonates

Neuropathic pain

• Features which suggest neuropathic pain• Burning• Shooting/stabbing• Tingling/pins and needles• Allodynia• Dysaesthesia• Dermatomal distribution

Neuropathic pain• Antidepressant

• Amitriptyline 50mg nocte• Anticonvulsant

• Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine)• Steroids

• Dexamethasone 12mg daily• Antiarrhythmics

• Mexiletine 50-300mg tds (or flecainide or lignocaine)• Anaesthetics

• Ketamine• Nerve blocks and spinal anaesthesia

Neuropathic pain

• Complementary therapies• TENS• Acupuncture• Hypnosis• Aromatherapy• Counselling• Social support

Common mistakes in cancer pain management

• Forgetting there is more than one pain• Reluctance to prescribe morphine• Failure to use non-drug treatments• Failure to educate patient about treatment• Reducing interval instead of increasing

dose

Palliative Care Patient Support Services

• Three categories of support:

1. Pain management is vital for comfort and to reduce patients’ distress. Health care professionals and families can collaborate to identify the sources of pain and relieve them with drugs and other forms of therapy.

Palliative Care Patient Support Services

2. Symptom management involves treating symptoms other than pain such as nausea, weakness, bowel and bladder problems, mental confusion, fatigue, and difficulty breathing

Palliative Care Patient Support Services

3. Emotional and spiritual support is important for both the patient and family in dealing with the emotional demands of critical illness.

1.ILLNESS MANAGEMENT 2. PHYSICAL 3.

PSYCHOLOGICAL

8. LOSS, BEREAVEMENT

7. CAREAT THE END OF LIFE / DEATH MANEGEMENT

4. SOCIAL

5.SPIRITUAL6. PRACTICAL

PATIENT & FAMILY

1. ILLNESS MANAGEMENT

•Primary diagnosis, prognosis, tests•Secondary diagnosis (for example, dementia, psychiatric diagnosis, use of drugs, trauma)•Co-morbid (delirium, attacks, organs failure)•Adverse episodes (collateral effects, toxicity)

2. PHYSICAL•Pain & other symptoms•Conscience level, cognition•Function, safety, materials:•Motor (mobility, shallowness, excretion)•Senses (hearing, sight, smell, taste, touch)•Physiologic (breathing, circulation)•Sexual•Fluids, nutrition, wounds•Habits (alcohol, smoking)

3. PSYCHOLOGICAL•Personality, strengths, behavior, motivation •Depression, anxiety•Emotions (anger, distress, hope, loneliness)•Fears (abandonment, burdens, death)•Control, dignity, independence•Conflict, guilt, stress, assuming answers•Self-image, self-esteem

8. LOSS, BEREAVEMENT•Loss •Pain (for example, chronic acute, anticipatory)•Bereavement planning•Mourning

7. CARE AT THE END OF LIFE/DEATH MANAGEMENT•End of life (businesses ending, relationships closing, to say goodbye)•Delivery of gifts (objects, money, organs, thoughts)•Creation of legacy•Preparation for the awaited death•Anticipation changes in agony•Rituals•Certification•Care of agony•Funerals

4. SOCIAL•Values, cultural, beliefs, practices•Relations, roles with the family, friends, community•Isolation, abandonment, reconciliation •Safe, comforting environment•Privacy, intimacy•Routines, rituals, leisure, vocations•Financial resources, expenses•Legal (powers of attorney for businesses, health attention, advanced directives, last desire/testament beneficiaries)

5.SPIRITUAL•Significance, value•Existential, transcendental•Values, beliefs, practices, affinities•Spiritual advisors, rituals•Symbols, icons

6. PRACTICAL•Everyday activities (personal care, home work)•Dependents, pets•Access to telephone, transport•Care

PATIENT & FAMILYCharacteristicsDemographic (age, sex, race, contact information)Culture (ethnic, language, nurture)Personal values, beliefs, practices, strengthsDevelopment status, education, alphabetizationDisabilities

Psychological and Psychiatric Aspects of Care

• The interdisciplinary team includes professionals with training and skills in the psychological consequences and psychiatric co-morbidities of serious illness

• Appropriate pharmacologic and non-pharmacologic therapies are initiated for depression, anxiety, insomnia or other symptoms

• Bereavement support is available for up to 13 months

Cancer and Palliative Care• It is generally estimated that roughly 7.2 to 7.5 million

people worldwide die from cancer each year.

•  More than 70% of all cancer deaths occur in developing countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent.

• More than 40% of all cancers can be prevented. Others can be detected early, treated and cured. Even with late-stage cancer, the suffering of patients can be relieved with good palliative care.

Palliative Care and Cancer Care

• Palliative care is given throughout a patient’s experience with cancer.

• Care can begin at diagnosis and continue through treatment, follow-up care, and the end of life.

Social Aspects of Care• Comprehensive interdisciplinary assessment

identifies the social needs for patients and their families

• Referrals to appropriate services are made that meet identified social needs:Access to care Transportation

Rehabilitation Medications Counseling Community resources

Equipment AdvocacyHelp in the home, school or work

Spiritual, Religious and Existential Aspects of Care

• Professionals with expertise in assessing and responding to spiritual and existential issues are included on the interdisciplinary team

• Regular ongoing exploration of spiritual and existential concerns occurs as appropriate

• Contacts with spiritual/religious communities, groups, or individuals as desired by the patient and/or family are facilitated

• Religious or spiritual rituals as desired by the patient and/or family are supported

Cultural Aspects of Care• The Palliative Care team assesses and attempts to meet

the culture-specific concerns of patients and their families

• Communications are respectful of cultural preferences regarding disclosure, truth-telling and decision-making

• The program attempts to respect and accommodate the range of language, dietary, and ritual practices of patients and their families

Care of the patient who is imminently dying

• Signs and symptoms of impending death are recognized and communicated and appropriate care is provided to the patient and family based on their preferences

• End-of-life concerns, hopes, fears and expectations are addressed openly and honestly in the context of social and cultural customs

Ethical and Legal Aspects of Care• Care is consistent with the professional code of ethics

for all involved disciplines

• The team aims to prevent, identify and resolve ethical dilemmas related to specific interventions • withholding or withdrawing treatments• instituting DNR orders • use of sedation

• Team members are knowledgeable about legal and regulatory aspects of palliative care

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NON-SPECIFIC INTERVENTIONS NON-SPECIFIC INTERVENTIONS FOR SUFFERINGFOR SUFFERING

1.1. Non-pharmacologicalNon-pharmacological• TalkTalk about death and dying about death and dying• Calm reassuranceCalm reassurance• Emotional and spiritual supportEmotional and spiritual support

2.2. PharmacologicalPharmacological• Opioids, other analgesics and adjuvants (eg/ Opioids, other analgesics and adjuvants (eg/

gabapentin)gabapentin)• SedativesSedatives

— Neuroleptics – CPZ, methotrimeprazineNeuroleptics – CPZ, methotrimeprazine— Possibly benzodiazepinesPossibly benzodiazepines

• Corticosteroids – reduce inflammation, edemaCorticosteroids – reduce inflammation, edema

Interdisciplinary Care

Aims to • relieve suffering• improve quality of life

Combined with ALL OTHER appropriate medical treatment

Palliative Care

Palliative Care Is Palliative Care Is NOT: Excellent, evidence-

based medical treatment

Vigorous care of pain and symptoms throughout illness

Care that patientsmay want at the same time as Rx to cure or prolong life

Not “giving up” on a patient

Not in place of curative or life-prolonging care

Not always the same as hospice

Palliative care is not about whether to treat or not to treat but about what is the best treatment

• Relieves pain and other symptoms

• Supports re-evaluations of goals of care and difficult decision-making

• Improves quality of life, satisfaction for patients and their families

• Helps patients complete life prolonging treatments

Palliative Care Improves Quality