Palliative care

Definition

The active, total care of patients at a time when their disease is no longer responsive to curative treatment and when control of pain (or other symptoms) and of psychological, social and spiritual problems are paramount

Principles of palliative care

Affirms life and regards dying as normal
Neither hastens nor postpones death
Perceives the patient and family as a unit
Creates a caring, comforting environment
Coordinates care
Provides relief from distressing symptoms
Maintains the independence of the patient for as long as possible
Provides information
Endeavours to reduce fear and anxiety
Promotes an atmosphere where an open and honest exchange of views can take place
Helps the patient to come to terms with impeding death
Endeavours to alleviate isolation
Offers a support system to family to help them cope with illness and bereavement

Analgesia

Pain is the commonest and most feared symptom associated with cancer
Chronic pain can be controlled in more than 80% of patients
WHO analgesia guidelines form the most common template for pain control
Consists of a three-stepped ladder

With increasing pain increasing strength of analgesia is required
On each step of the ladder the maximum dose and frequency should be used
Drugs should be prescribed on a regular basis not 'as required'
Co-analgesic agents often have a synergistic effect
May increase efficacy of a particular analgesic agent

Morphine

Most commonly used strong analgesic in palliative care
Should initially be prescribed as an immediate release preparation (e.g. oramorph)
Can be given as 5-10 mg every four hours
Dose can be increased every 24 hours until pain is adequately controlled
Once pain controlled total daily dose can be calculated
Immediate release can then be substituted for delayed release preparations
Most commonly used are MST given twice daily or MXL given once daily
Immediate release preparations can still be given for breakthrough pain
No ceiling exists for the maximum permissible dose of morphine
Laxative should be prescribed to prevent constipation
Patients may also require antiemetic
Complications include itch, hallucinations, dry mouth
Respiratory depression is rarely a problem
Physical dependence may occur
Psychological dependence and addiction are not a problem in the palliative care setting
If oral route unavailable consider subcutaneous diamorphine or fentanyl patches

Co-analgesia

Co-analgesics have little intrinsic analgesic activity
Have additive effects to analgesic agents
NSAIDs useful in bone pain
Anticonvulsants and antidepressants useful in neuropathic pain
Steroids increase well being
Benzodiazepines reduce muscle spasm

Other symptoms

Bone pain

Often well controlled with single fraction of radiotherapy
NSAID may have useful co-analgesic effect
Biphosphonates reduce osteoclastic activity and reduce bone pain

Neuropathic pain

Often resistant to treatment
Anticonvulsants and antidepressants may have useful effect
Neurolytic blocks may be considered if fails to respond to pharmacological agents

Liver capsule pain

NSAID often have excellent additive effect in this situation
Steroids can reduce swelling, inflammation and pain
Dexamethasone is usually the drug of choice

Dyspnoea

Not always due to underlying malignancy
Consider treatment of any underlying infection, cardiac failure etc.
Causes of breathlessness related to malignancy include:
- Pleural effusion
- Lymphangitis carcinomatosis
- Intrapulmonary metastases
- Constricting chest wall disease
Aspiration of a pleural effusion often produces symptomatic improvement
Pleurodesis with talc or bleomycin only effective drained to dryness
A pleuro-peritoneal shunt may produce symptomatic improvement
Steroids produce symptomatic improvement in those with lymphangitis and intrapulmonary metastases
The respiratory depressant effect of morphine will also reduce dyspnoea

Nausea and vomiting

Nausea and vomiting is usually multifactorial in origin
Causes include:
- Hypercalcaemia
- Liver metastases
- Constipation
- Drug side effects
- Intestinal obstruction
Metaclopramide, domperidone and cyclizine useful if gastric stasis or intestinal obstruction
5-HT₃ blockers (e.g. ondansetron) useful for chemotherapy induce nausea
Haloperidol useful in morphine-induced nausea
Can be administered as a continuous subcutaneous infusion

Constipation

Treatment should be continuous and anticipatory
Often a side effect of opiate analgesia
Can be worsened by inactivity, dehydration and hypercalcaemia
Opiate-induced constipation best treated with compound preparations
Contain both a stool softener and stimulant (e.g. co-danthrusate)

Bibliography

Davis C L, Wee B L. Recent advances in palliative care. In: Johnson C D, Taylor I eds. Recent advances in surgery 20. Churchill Livingstone, Edinburgh 1997; 161-176.

Hanks G W, de Conno F, Hanna M et al. Morphine in cancer pain: modes of administration. Br Med J 1996; 312: 823-826.

Hardy J R. Medical management of bowel obstruction. Br J Surg 2000; 87: 1281-1283.

Twycross R. Corticosteroids in advanced cancer. Br Med J 1992; 305: 969-970.

Ventafridda V, Tamburini M, Caraceni A, de Conno F, Naldi F. A validation study of the WHO method for cancer pain relief. Cancer 1987; 59: 850-856.