1. Palliative Care:Case Presentation Steven Hermon Feb 2011

2. Objectives • Look at difficult case of controlling pain in a cancer patient • Analgesic options for the patient • Highlight importance of psychosocial issues and how it can impact on the patient and family

3. Introduction - Background • JM – 48 years old • Dx – Transitional Cell Carcinoma of left renal pelvis July 2009 following haematuria – biopsy confirmed locally advanced TCC - inoperable • Had treatment • Aug/Sept 2009 - 3 Cycles of Gemcitabine/Cisplatin • Jan 2010 – palliative R/T 30Gy in 11 fractions • March 2010 – Second line chemo – 6 Cycles Carboplatin/Paclitaxel • No reduction in tumour size • Decided no further treatment possible and for palliation

4. Background continued • Recent MRI 14/1/11showed • Extension of tumour into para-aortic area invading lateral borders of L1 and L2 vertebral bodies but no evidence of nerve root compression • Haemangioma present in T10 vertebral body • This was leading to pain which was proving very difficult to control • Main pain is in lower back around site of tumour and through to front of his abdomen

5. Reason for admission 11/2/2011 • Main issue pain control • Week leading to admission not been able to take oral medication • Needing many additional PRN injections to help control pain • Switched to syringe driver due to additional PRN meds. • Lots of strain on community team – esp DNs and GP as unable to get on top of JM’s pain and finding distressing • Felt had got to last resort of Phenobarbitone infusion

6. Medication • Amitriptyline 100mg ON • Diclofenac 50mg TDS • Paracetamol 1g QDS • Pregabalin 150mg BD • Oxycodone 1500mg/24o • Midazolam 60mg/24o • Levomepromazine 50mg/24o • Oxycodone dose equivalent to what dose of Oral morphine?

7. Additional requirements • Had been having Ketoralac 30mg s/c which had eased pain and seemed to be working best for him • 200mg oxynorm prn with minimal to no relief • Midazolam 5-10mg prn

8. Management issues • What are possible options for analgesia? • What dose is required? • Patient wishes? • Best options for community team? • Family concerns? • Psychosocial aspects of care?

9. Patient wishes & Family Concerns • Patient initially adamant wanted to return home • Managed to convince him best way to avoid further admissions is to stay and try to get on top of pain as need to monitor as planning on switching main analgesic • Admission was during night and JM felt pressurised to come in • Partner very concerned as unable to get pain controlled • Difficult seeing JM in discomfort • Fatigue issues with JM’s partner as she is his main carer with no additional carers involved and JM deteriorating

10. Psychosocial issues • Finances • JM – lots of worries regarding finances as has his own business which feels he has lost control of • Currently no benefits being received • Recent letter from HMRC about how he had underpaid tax on previous 2 years and he had not responded to the letter and this was a big worry for JM • All of the above can exacerbate pain symptoms if causing him to be upset or distressed which it obviously was

11. Analgesic options? • Was decided to change from oxycodone to diamorphine due to sheer volume of oxycodone required due to the dose which led to needing 3 CSCI to be set up on admission • Switching to diamorphine meant we were able to reduce the number of syringe drivers from 3 to 1 as diamorphine is more soluble so we are able to mix with other meds more easily • Dose of diamorphine – 1500mg/24o with 200-250mg s/c prn • Midazolam 60mg/240 - agitation • Levomepromazine 50mg/240 – antiemetic • Ketorolac 90mg/24o added meaning a second driver – potent NSAID generally used short term – Lansoprazole 30mg PO cover

12. Analgesia continued • Good response to diamorphine intially – pain relatively well controlled with only 1-2 prn doses required over 24o • Developed further breakthrough pain but relieved with extra s/c diamorphine – Diamorphine increased to 2000mg/24o • JM drowsy so Levomepromazine reduced to 25mg/24o • Small dose of Ketamine 10mg prn s/c as first line for breakthrough pain

13. Community issues on discharge • Pain management if patient self discharges before analgesia stabilised • Contingency plans need to be in place • Agreed plan both community team and patient are happy with

14. Questions?

15. Summary • Pain management is very difficult but very important as directly affects patient and family but also community team • Largest dose Consultant has had to use in his 20 years experience • Balance of pain control and side effects