Clinical Oncology SC019: Palliative And Hospice Care: Adding Life To Years Flashcards
Palliative care
WHO: - Approach that improves QoL of patients and their families facing the problem associated with ***life-threatening illness, through ***prevention + ***relief of suffering by means of ***early identification + impeccable assessment + treatment of pain and other problems —> ***Physical —> ***Psychosocial —> ***Spiritual
Palliative care:
- Affirms life and regards dying as a ***normal practice
- Neither hastens nor postpones death
- Provides ***relief from pain and other distressing symptoms
- Integrates the **psychological and **spiritual aspects of care
- Offers ***holistic care
- Offers a support system to help patients live as active as possible until a death
- Offers a support system to help the ***families of patients cope during the patient’s illnesses and in their own bereavement
Essential components of Palliative care
- Control of symptoms
- Effective communication
- Rehabilitation
- Continuity of care
- Terminal care
- Support in bereavement
- Education (Patients + Family)
- Research
Palliative care vs End-of-life care
Palliative Care: - At ***any point of a chronic disease - Can still seek for ***curative treatment (e.g. Palliative chemo / target therapy for metastatic CA lung) - Goal: —> Provide comfort, QoL —> Support to patients and families
End of life care/ Hospice care:
- ***Part of palliative care
- A specific type of care at the **last stage of life (usually **<6 months)
- Provides comfort ***without a curative intent
- ***No curative options available / patient has chosen not to pursue curative or aggressive treatment
Who needs palliative care
- Cancer patients (good condition until disease progress —> condition drops rapidly)
- Chronic organ failure (multiple exacerbations / recovery before death)
- Heart failure
- Respiratory disease
- Liver disease
- Renal disease - Frailty related illness (start with poor initial condition, gradual deterioration)
- Advanced dementia
- Parkinson’s disease
Who should provide palliative care
- Primary palliative care clinicians
- Provide basic management of physical + psychological symptoms
- Discuss **goals of care with the patient
- Discuss **end-of-life care / ***DNACPR - Secondary + Tertiary palliative care
- Physical / Psychological symptom **assessment + management
- **Complicated, refractory symptoms/ distress
- **Conflict resolution
- **Futility issues
- Work alongside the patient’s primary clinician
Multidisciplinary team
- Physicians
- Nurses (Palliative, Home care nurses)
- Therapists (OT, PT)
- Social workers
- Pharmacists
- Home health aides
- Spiritual counselors
- Volunteers
When should palliative care be provided?
Conventional model:
Anti-cancer treatment
—> Not work
—> ***Abrupt change to Palliative / Hospice care
Problems:
- Persistent, unattended symptoms + ***distress in the phase of active treatment
- Patients and families: ***less time for preparation of deterioration
- Patients and families may refuse the “abrupt” referral to palliative care service —> feel abandoned
Current model:
- **Early integration of palliative care into oncology practice
- Anti-cancer treatment + Palliative care (ongoing at the same time, add more palliative care component as anti-cancer treatment less effective / condition deteriorate)
Advantages:
- Maintain / Improve ***QoL
- Reduce depression + anxiety
- Reduce ***invasiveness of end-of-life care
- Reduce symptom ***intensity (e.g. less pain)
- Does ***NOT compromise anti-cancer intensity
- Reduce ***over-treatment at end-of-life period (50% reduction of IV chemo exposure within 60 days of death)
- Better understanding of treatment nature but less anxiety and depression
- Improve ***overall survival
Benefits of Palliative care
- Improves communication between patients, caregivers, healthcare providers
- Addresses needs of caregivers as they cope with + care for a loved one with a serious illness
- Improves patients and family satisfaction with care
- Improves QoL while reducing costs
- Enables patients to remain comfortable by preventing + relieving pain / suffering
- Allows patients to maintain connections to family and friends
- Foster vitality and independence in patients
Importance to Society:
- Higher patient’s satisfaction, Less admission —> Lower health care cost
4 Main aspects in Palliative care
Focus on Disease ***as well as QoL
QoL:
- Physical
- Psychological
- Social
- Spiritual
Means:
- Identification
- symptoms
- functional status
- needs - Assessment
- performance status
- physical, psychological, social, spiritual - Treatment
- management
—> constantly re-assess / monitor —> treatment again
—> **ONLY proceed with investigations / assessments that would **change the management plan (e.g. End stag CA lung: checking CEA / PET scan)
- Physical
Functional assessment: **Palliative performance scale
1. Ambulation
2. Activity + Evidence of disease
3. Self-care
4. Intake
5. Conscious level
—> **<70% —> worry if patient can still continue on anti-cancer treatment
Identification of S/S:
1. Pain
2. Chest symptoms: dyspnea, cough, haemoptysis
3. GI symptoms: vomiting, colic
4. Pelvic symptoms: fistula, discharge /
bleeding (PV / PR)
5. CNS symptoms: focal (e.g. seizures) / delirium
6. MSK: local wound management, bedsore
7. Systemic: insomnia, cachexia, fatigue
8. Treatment-associated SE
—> by ***History taking: OPQRSTUV (understanding, value (i.e. what’s his goal), significance of pain to him e.g. cannot walk)
Assessment of pain:
- Site
- Pain rating scale
Treatment:
- Pharmacological
- Analgesic - Non-pharmacological
- Heat
- Cold application
- Massage therapy
- Physical therapy
- Transcutaneous electrical nerve stimulation
- Spinal cord stimulation
- Aromatherapy
- Guided imagery
- Laughter
- Music
- Biofeedback
- Self-hypnosis
- Acupuncture
- CBT
Reassessment: 1. Treatment SE - Opioid —> N+V —> Constipation —> Drowsiness —> Delirium —> Xerostomia —> Sweating
- TCA
—> Anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention, dizziness, tachycardia, memory impairment)
—> Cardiac (arrhythmias, QT prolongation)
—> Sedation
—> Weight gain
- Gabapentin / Pregabalin —> Dizziness (usually in morning ∵ given nocte) —> Drowsiness —> Peripheral edema —> Dry mouth
- Treatment efficacy
- Pain score: compare with last assessment (2-3 days after escalation of dose)
- Functional: improvement in general condition - Any change in pattern
- breakthrough pain
- change of site of pain
WHO recommendations on Analgesic use
- By mouth
- oral administration of medication is an **effective, **convenient, **inexpensive method of medicating patients
- should be used wherever possible
- medicines are easy to **titrate - By the clock
- for **persistent pain
- additional doses as needed
- aim: **prevent (rather than react to pain)
- allow ***continuous pain relief by maintaining a constant level of drug in body —> prevent pain from recurring - By ladder
- non-opioid —> weak opioid —> strong opioid
- validated + effective method of ensuring therapy for pain
- administered according to severity of pain + drug suitability - On individual basis
- ***individualise pain management
- different patients will require different dosages / intervention to achieve good pain relief
WHO pain ladder
- Non-opioid (+/- Adjuvant)
- Paracetamol
- NSAID (generally avoided ∵ cause gastritis, renal impairment esp. long-term treatment)
—> other options: Celebrex (Celecoxib), Arcoxia (Etoricoxib)) - Weak opioid + Non-opioid (+/- Adjuvant)
- Codeine
- Dihydrocodeine
- Tramadol - Strong opioid + Non-opioid (+/- Adjuvant)
- Morphine
- Methadone
- Fentanyl
- Hydromorphone
- Oxycodone
—> Start with low dose morphine elixir: 2.5-5mg Q2-4 hourly
—> titrate against pain reported on the 1-10 scale
—> after 2-3 days add the total daily dose, divide it in two and administer as long-acting morphine sulphate tablets Q12 hourly
Adjuvant treatment:
- Somatic pain
- NSAIDs
- Bisphosphonates (for metastatic bone pain)
- RT (for metastatic bone pain) - Neuropathic pain
- Anticonvulsant: Gabapentin, Pregabalin
- Antidepressant: Nortriptyline (TCA, significant sedation), Venlafaxine (SNRI), Duloxetine (SNRI), SSRI - Visceral pain
- Corticosteroids (Dexamethasone) (useful for hepatic capsular pain)
(Other uses of Dexamethasone:
- Cerebral edema
- Brain metastasis
- Spinal cord compression
- SVCO
- Anti-emetic
- Appetite stimulant
- Adrenal insufficiency)
- Psychological
- Anxiety (6-39%)
- Depression (~25%)
- Coping skills / Adjustment disorder
- Mood / Affection
- Suicidal ideation / Hasten death
Anxiety / Depression
Identification:
- present with somatic symptoms e.g. dyspnea, ***insomnia, tremor, palpitations
- irritability, depressed mood, lack of hope, feeling of worthlessness
Assessment:
1. Screening tool
- **Hospital and Depression scale (HADS)
- **Brief Edinburgh Depression scale (BEDS)
—> assess pre-morbid personality + previous psychiatry history
—> medications used
—> any use of stimulated drugs, excessive alcohol / withdrawal of the drugs
—> review of family + social history
Treatment:
1. Pharmacological
- BDZ
—> Diazepam PO (more sedative effect)
—> Lorazepam PO/SL (more anxiolytic effect)
—> Midazolam SC/IV (emergency sedation / end-of-life)
- Antidepressants
—> SSRI (Sertraline, TCA)
—> SNRI
- Non-pharmacological
- CBT
- Relaxation techniques
- Various complementary therapies (e.g. massage, acupuncture)
- Social
- Financial support
- Family dynamics
- Community care plan
- old age home
- hospice care
- day care centre - Home care plan
- home care
- clean + tidy
- safety at home (OT to help in putting equipment)
- wheelchair
- home catering service - Volunteer service
