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
Hardy J R. Medical
management of bowel obstruction. Br J Surg 2000;
87: 1281-1283.
Portenoy R K. Treatment of cancer pain. Lancet
2011: 377: 2236-2247.
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. |