Challenges in Palliative Care : P ain, Nausea, Constipation & Coordination

1. Challenges in Palliative Care:Pain, Nausea, Constipation & Coordination Family Medicine Academic Half-Day February 28, 2014

2. Objectives By the end of the session, you will be able to: • apply a rational approach to manage pain, nausea & constipation • identify & mobilize resources to support patients at home • utilize PPS & ESAS to facilitate assessment & communication by care providers

3. Moderate Mild Severe (Bruera, JPC 1991)

4. Victoria Hospice Society Stable Transitional End-of-Life

5. Mrs. Nadeau You are a family physician in Bancroft

6. Mrs. Nadeau • 76 years old • You have been her primary MD for years • Two months ago she reported abdominal bloating and pelvic discomfort • CT scan: complex left ovarian mass & widespread intra-abdominal and pelvic metastases • Serum CA125 elevated • consistent with ovarian cancer

7. Mrs. Nadeau • At her appointment with a gynecologic oncologist Mrs. Nadeau was emphatic that she wished no invasive diagnostic procedures or chemotherapy • “I just want to be home with my cats to live out my days as well as I can”

8. Mrs. Nadeau Social History: • widow, lives alone in apartment • 3 supportive children in the area Past Medical History: • hypertension; urgency incontinence Medications: • acetaminophen (325 mg) & codeine (30 mg) • hydrochlorothiazide 50 mg daily • oxybutinin SR 10 mg daily

9. Mrs. Nadeau Wednesday morning phone call from her home visit nurse: • PPS 60% • Constant, dull pelvic pain • acetaminophen (325 mg) & codeine (30 mg) 1 tab q4h regularly and 1 tab q4h prn pain • using 0-1 breakthrough doses per day • No BM x 4 days

10. Mrs. Nadeau: ESAS Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Worst Possible None

11. Mrs. Nadeau Problem: No BM x 4 days List potential causes or contributing factors

12. Mrs. Nadeau • You visit Mrs. Nadeau at home that evening • No evidence of obstruction • You determine that her problem is constipation Write orders for the home chart and related prescriptions

13. Constipation: Causes Organic • Diverticulitis, tumour, neurological, endocrine, recto-anal Functional • Insufficient fluids, low fibre diet, immobility, impaired defecation Drugs • Opioids, anticholinergics, diuretics, neuroleptics, antacids, anticonvulsants

14. Constipation Key decision points: • Obstruction? • Rectum full? • Feces hard? • Address behavioural factors, if possible • Create realistic expectations • Educate regarding latency period • Prevention vs. crisis intervention

15. Bulking Agents* Fiber, Bran, Psyllium Softeners* Docusate sodium Stimulants Sennosides, Bisacodyl Osmotics Lactulose PEG 3350 PEG with electrolytes* Increases fecal bulk & fluid retention Increases water penetration; softens stool Stimulates mucosal nerves to increase motility; reduces absorption of water Draws water into gut; promotes peristalsis; improves stool frequency and consistency Induces catharsis by strong electrolyte and osmotic effects Oral Laxatives *Not recommended

16. Lubricants Mineral oil enema Osmotics Glycerin suppository Stimulants Bisacodyl suppository Saline Phosphate enema (Fleet) Allows penetration of water into stool to soften stool Increases water in intestinal lumen Increases intestinal motility; stimulate nerve endings in colonic mucosa Increases intestinal water secretion; stimulates peristalsis Rectal Laxatives

17. Discussion Is your plan… • Logical & likely to be effective? • Comprehensive? • Addresses all important factors? • Practical? • Communicated clearly?

18. Mrs. Nadeau • Mrs. Nadeau’s bowels begin moving every 1-2 days • She does well for 3 weeks on: • Acetaminophen (325 mg) & codeine (30mg) 2 tabs QID • Senekot 4 tabs QHS • Lactulose 30 ml BID

19. Mrs. Nadeau Sunday afternoon you are on call: • Mrs. Nadeau’s daughter calls to report increased, steady, aching abdominal pain over past 3 days • You agree to see her at home

20. Mrs. Nadeau: ESAS Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Worst Possible None

21. Mrs. Nadeau • PPS 50% • Passing flatus • Eating little; drinking well; no nausea • You note: • Abdomen soft and moderately tender • Bowel sounds present • You recommend assessment in ER • Mrs. Nadeau wishes to avoid this

22. Mrs. Nadeau Problem: Pain = 6/10 Write new analgesic orders and prescriptions NOTE: Focus on analgesics only

23. Pain Assessment • Location (can be multiple sites) • Quality • Severity • Timing • Setting • Aggravating/alleviating factors • Associated manifestations 0 (no pain) to 10 (worst pain imaginable)

24. WHO Analgesic Ladder (WHO 1990)

25. Regular dosing Oral route Titrate to effect Individualize Opioids for Cancer Pain: Principles

26. Opioids for Cancer Pain • Equivalent doses: morphine 20 mg po q4h morphine 10 mg sc q4h codeine 200 mg po q4h hydromorphone 4 mg po q4h

27. Opioids for Cancer Pain Regular dose • use immediate-release agents q4h eg. morphine 5 mg po q4h • titrate every 24 hours by 25-100% • reassess pain and side effects Breakthrough dose • 5-10% of 24-hr regular dose • available po q2h or sc q1h prn eg. morphine 2.5 mg po q2h prn pain

28. Discussion Is your plan… Logical & likely to be effective? Comprehensive? Addresses all important factors? Practical? Communicated clearly?

29. Mrs. Nadeau Three days later: Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Worst Possible None

30. Mrs. Nadeau • PPS 50% • When asked which is her most distressing symptom, Mrs. Nadeau replies: “The nausea. It comes in terrible, unpredictable waves. It haunts me even when it isn’t there!”

31. Mrs. Nadeau Problem: Nausea = 6/10 List potential causes or contributing factors Write orders for the home chart and related prescriptions

32. Nausea & Vomiting

33. Neurochemistry of Nausea & Vomiting Visceral - gastric irritation - obstruction - constipation - visceral distention • Vagus • Sympathetic afferents Chemical - drugs - biochemical upsets - toxins CTZ Vomiting Center Somatic & visceral efferents Vomiting Center CNS - psychological - CNS cancer - raised ICP Vestibular - motion / position - local tumour Vestibular nerve & nucleus

34. H-1 Visceral - gastric irritation - obstruction - constipation - visceral distention Histamine H-1 H-1 Vagus, sympathetic afferents Serotonin 5-HT3 5-HT3 5-HT3 5-HT3 Dopamine D-2 D-2 D-2 Muscarinic Cholinergic Chemical - drugs - biochemical upsets - toxins M-C M-C M-C CTZ Vomiting Center Somatic/visceral efferents CNS - psychological - CNS cancer - raised ICP Vestibular - motion / position - local tumour Vestibular n. and nucleus Neurochemistry of Nausea & Vomiting 5-HT4 5-HT2 5-HT4 5-HT2 Glare PA, Drugs(2008)68:18,2575-2590 Bentley A et al, Palliat Med(2001)15:247-253 Lichter I, J Pall Care(1993)1:42-50, 2:19-21 Mannix K, Clin Med 2006;6:144-7

35. Antiemetic drugs • Dopamine antagonists • Phenothiazines, haloperidol, prokinetics • Antihistamines • Dimenhydrinate • Anticholinergics • Scopolamine • 5-HT3 receptor antagonists • Ondansetron

36. N&V: Management Pearls • Identify the most likely cause • Treat this cause, if possible • Identify the pathway & neurotransmitters involved • Prescribe the most appropriate antiemetic • Choose the most appropriate route • Give medication regularly and titrate carefully • Review effects

37. Discussion Is your plan… Logical & likely to be effective? Comprehensive? Addresses all important factors? Practical? Communicated clearly?

38. Coordinating Community Care • Can Mrs. Nadeau’s care needs be met at home? • What challenges can you identify? • What would facilitate keeping her at home? • What is the role of the family physician? • How can you plan for symptom crises at home? • Why bother?

39. Mrs. Nadeau Mrs. Nadeau’s symptoms settle She does well for 2 weeks on: Sustained-release morphine 15 mg po q12h Morphine 5 mg po q2h prn for pain (using 2/day) Senokot 4 tabs QHS Lactulose 30 ml BID Domperidone 10 mg po QID Metoclopramide 10 mg po q2h prn nausea (using1/day)

40. It is Tuesday at 9 am – start of a busy office Mrs. Nadeau’s daughter calls to report: new cramping abdominal pain for 24 hours nausea with vomiting 4 times overnight no flatus for two days unable to eat or drink for 24 hours Mrs. Nadeau What do you do?

41. Mrs. Nadeau: ESAS Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Worst Possible None

42. Mrs. Nadeau PPS 10% Physical exam: Awake, drowsy, in bed Abdominal distension Tinkling bowel sounds Diagnosis: malignant bowel obstruction You recommend assessment in ER Family adamantly refuse

43. Mrs. Nadeau PPS 10% Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea morphine 15 mg po q12h morphine 5 mg po q2h prn senokot 4 tabs po QHS lactulose 30 ml po BID domperidone 10 mg QID metoclopramide 10 mg po prn None Write new orders & prescriptions

44. Summary and Wrap Up • Coordination & Communication • How could scenario have ended better? • Management of: • Constipation • Pain • Nausea and vomiting • Role of primary care team in palliative care

45. Palliative Care Resources Available at Cancer Care Ontario: http://www.cancercare.on.ca/toolbox/symptools/