Palliative Care

1. Palliative Care Dr Philip Lee Palliative Medicine Staff Specialist WSAHS Acting Director Palliative Care WSAHS

2. Palliative Care Definitions

3. To cure, occasionally To relieve, often To comfort, always Anonymous (16th Century) Death should simply become a discreet but dignified exit of a peaceful person from a helpful society … without pain or suffering and ultimately without fear. Philippe Ariès, 1977 The Hour of Our Death

4. Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patient’s illness, including bereavement care.Roger Woodruff Palliative Medicine 2nd Edition

5. Palliative Care Caring for a person with an active, progressive, far advanced disease with little or no prospect of cure and for whom the primary treatment goal is quality of life

6. PALLIATIVE CARE - WHEN? PALLIATIVE CARE BEREAVE-MENT ACTIVETREATMENT DEATH DIAGNOSIS ACTIVETREATMENT BEREAVE-MENT DEATH PALLIATIVE CARE

7. PALLIATIVE CARE - WHERE? • Palliative Care is a Network • Services are provided by Teams • Services are available in: • Community, home and aged care facilities • Acute hospitals • Private Hospitals • Specific inpatient units eg St Joseph’s, Mt Druitt, Neringah, Greenwich, Braeside Hospitals

8. PALLIATIVE CARE - COMMUNITY • GP “case manager” • Generalist Community Nurse - GCN • Clinical Nurse Specialist - CNS • Clinical Nurse Consultant - CNC • Palliative Care Medical Officer • Community Palliative Care Specialist

9. WHAT DOES PALLIATIVE CARE OFFER? • Pain control • Other symptom control • Terminal care • Family support • Bereavement support

10. Cancer pain • 30-50% of cancer patients undergoing active treatment • 70-90% of cancer patients with advanced disease • Prospective studies indicate that as many as 90% of patients could attain adequate pain relief with simple drug therapies.

11. The Context Symptoms of debility Non-cancer pathology Side effects of therapy Cancer Loss of social position Bureaucratic bungling SOMATIC SOURCE Loss of job prestige and income Friends not visiting TOTAL PAIN Loss of role in family Delays in diagnosis DEPRESSION ANGER Chronic fatigue and insomnia Unavailable doctors Sense of helplessness Irritability ANXIETY Disfigurement Therapeutic failure Fear of pain Fear of hospital or nursing home Family finances Worry about family Loss of choices Fear of death Uncertainty about future Spiritual (existential) unrest

12. WHO analgesic ladder PainPain persists Pain persists or increases or increases 3. Strong opioid ± non-opioid ± adjuvant 2. Weak opioid ± non-opioid ± adjuvant 1. Non-opioid ± adjuvant

13. Guidelines for opioid use • Preferably oral • Continuous rather than PRN • Commence with immediate release • Once stable convert to slow release + immediate for breakthrough pain relief • If more than 2 episodes of breakthrough pain increase regular dose • Laxatives

14. Analgesic Classes • Aspirin • Paracetamol • NSAIDS • Opioids

15. Weak opioids Codeine Dextropropoxyphene Strong opioids Oxycodone Morphine Methadone Fentanyl Hydromorphone Pethidine Tramadol Opioids

16. Opioid receptors All opioids produce analgesia and other effects by mimicking the actions of endogenous opioid compounds (endorphins) at multiple subtypes of the three major opioid receptors in the brain stem, spinal cord and peripheral tissues.

17. Opioid actions The perception of pain is altered both by a direct effect on the spinal cord, modulating peripheral nociceptive input, and by activation of the descending inhibitory systems from the brain stem and basal ganglia.

18. Patients’ concerns about narcotics • Addiction & withdrawal • Tolerance • Implications of taking morphine • Side effects

19. Side effects • Sedation • Hallucinations • Nausea & vomiting • Constipation • Urinary retention • Myoclonus • Respiratory depression • Pruritus

20. Cognitive impairment • Some sedation early in use of morphine • Tolerance develops • Prior sleep deprivation due to poor pain control • Other causes of cognitive impairment need to be excluded

21. Opioid Dose Duration of Action

22. Routes of administration of morphine • Oral • Subcutaneous • IVI • Epidural & intrathecal • Rectal • Topically

23. Morphine metabolism • Primarily metabolised in the liver • Metabolites excreted in urine • Morphine-3-glucuronide (M3G) • Morphine-6-glucuronide (M6G) • Caution in renal impairment • M6G potent morphine agonist • M3G no significant analgesic action • Liver disease not reported to alter pharmacokinetics

24. Pros “Gold Standard” Well understood Readily available Usually well tolerated No “ceiling” Cons Accumulates in renal failure Constipating Nausea Sedation Misconceptions Morphine

25. Morphine Preparations

26. Pros Various dose forms, immeadiate & slow release Neuropathic pain “New” OK in renal failure Cons No parenteral form Constipating Nausea Confusing names Oxycodone

27. Oxycodone & Tramadol

28. Pros Less constipation Less nausea Less psychotomimetic effects Convenient OK in renal failure Cons Reliant on good fat stores Inflexible dosing Difficult to titrate Expensive Breakthrough medications Fentanyl

29. Pros Less sedating Less constipating Less hallucinations Less nauseating OK in renal failure Cons Availability No slow release currently available Hydromorphone

30. Pros Neuropathic pain Cons Stigma Difficult dosing schedule Variable half-life Methadone

31. Fentanyl, Methadone & Hydromorphone

32. Pethidine • Repetitive dosing leads to accumulation of the toxic metabolite norpethidine • Norpethidine accumulation causes • CNS hyper-excitability & subtle mood changes • Tremors • Multifocal myoclonus • Seizures • Common with repeated large doses, eg 250 mg per day