Palliative care in small animal oncology Flashcards
Define palliative care
Relieving pain without dealing with the cause of the condition
“Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, and is applicable early in the course of the illness, in conjunction with other therapies that are intended to prolong life.”
Who is involved in palliative care?
Animal-centred therapy - Holistic approach
Owners
- Communication (prognosis, end-point)
- Home-care
When it comes to palliative care what is the primary concern of 90% of owners?
Quality of life
Why is quality of life a difficult term to define?
Vague term
Multiple definitions
Definition changes over time
Species specific (painful dog vs cat)
Individual specific
Subjective
Quality of life can be seen as an individuals satisfaction of which aspects of life?
Its physical and psychological health
- Physical domain
- Emotional domain
Its physical and social environment
- Social domain
Its ability to interact with that environment”
What are the domains of quality of life?
Physical domain
Emotional domain
Social domain
What are 4 key features linked to health related quality of life
Appetite
Pain
Mobility
Behaviour
When does palliative care start and end?
Starts - before cancer
Ends - upon death/euthanasia
What are the 2 main consequences of pain?
Decreased quality of life
Alter physiologic functions (cellular metabolism, immunity)
What are the main classifications of pain?
Adaptive vs maladaptive
Nociceptive vs neuropathic
Acute vs chronic
Which physical responses can be used to recognise pain in individuals?
- Response to palpation
- Self trauma (licking, scratching)
- Vocalization
Which measurable parameters can be used to recognise pain in individuals?
Appetite change
Increased respiration/heart rate
Appearance of the coat (failure to groom)
How can behaviour be used to recognise pain in individuals?
- Reduced activity (activity monitor)
- Posture, ambulation, gait (gait analysis)
- Attitude change (aggressiveness, dullness, shyness)
- Facial expression (head hung low, squinted eye, sad expression)
- Sleep disturbance
Which drugs are used in the initial management of pain?
NSAIDs, paracetamol
Which drugs are used in the second stage of managing of pain?
Codeine
Tramadol
Which drugs are used in the final stage of managing of pain?
Morphine, methadone, fentanyl
Describe the pros/cons of NSAIDs for pain management
Meloxicam, carprofen, robenacoxib
- Very good painkiller; possible anti-tumour effect (carcinoma)
- Contra-indicated with corticosteroids, GI/kidney issues
Describe the pros/cons of prostaglandin receptor antagonists for pain management
Grapiprant
- Safe and effective in dogs with OA
- Lack of data in cats
- Not with other NSAIDs or corticosteroids
Describe the pros/cons of paracetamol +/- codeine for pain management
Good painkiller
Not in cats!!!!
Liver function??
Can use with corticosteroids
Describe the pros/cons of tramadol for pain management
Opioidergic/monoaminergic drug
Main action: weak µ-agonist
Can cause dysphoria, sedation, nausea
Doubt on its efficacy in dogs …
Not palatable for cats
Describe the pros/cons of gabapentin for pain management
Mechanism of action unclear
Neuropathic pain
Can cause mild sedation and ataxia
Delayed onset of action, wean off slowly
In osteosarcomas what are the mechanisms of pain?
Tumour associated inflammation (due to neoplastic osteoblasts)
Bone destruction (due to osteoclasts)
Describe a multimodal approach to pain in osteosarcomas
NSAID – paracetamol – gabapentin/amantadine +/- tramadol +/- Liberela
Over-treatment of pain is better than too little
Describe how palliative radiation therapy could be used for osteosarcomas
- Aim for pain management: cell death of both neoplastic osteoblasts and resorbing osteoclasts
- Palliative setting: 1 – 4 treatments
- Minimal side effects
- Good efficacy: 75-95% of pain alleviation for 2-4 months
Describe the function of bisphosphonates in palliative pain management
Aim for pain management = Induction of osteoclasts apoptosis => limit bone resorption
- Can be used for multiple cancers with associated osteolysis
- IV or oral medication (IV preferred)
- Moderate efficacy: 50% in one small study
Describe some non-drug methods for symptomatic pain relief?
- Amputation: not metastasis cases
- Surgical excision of ulcerated / painful mass
- Stenting: Urethra, Trachea - Minimally invasive but technically challenging
- Cystotomy tubes: Urethral obstruction (TCC)
Why is nutritional management an important part of palliative care?
- Anorexia is a common occurrence: Due to cancer, Due to its treatment
- Weight loss is a common negative prognostic factor in dogs and cats with cancer
- Appetite is a critical element of dogs and cats QOL by owner: key for end of life
For what reasons would owners want to change their pets food in nutritional palliative management?
- Loss of appetite
- Internet, blogs, social media
- Distrust to conventional diet, scepticism on ingredients
- Belief that a low-carbohydrate diet will help
Define anorexia
Decreased fat and then muscle due to not eating
Why does cancer cause anorexia?
- Oral/abdominal pain with neoplasia
- Use of chemotherapy (olfactory alteration?, taste alteration?, GI side effects)
- Cytokine release (IL-6, IL-1) – “anorexigen”
Define cachexia
Decreased lean body mass +/- fat
Why does cancer cause cachexia?
Cytokine release (IL-1β, TGFβ, IL-6)
Extensive lipolysis, proteolysis
Insulin resistance (pre-diabetic state) – high glucose
More common in cats than dogs
Which diets are suitable for cancer patients?
- The ”low glucose” diet is not recommended
Well-balanced diet: - Commercial diet
- Home-made diet – need for veterinary nutritionist
- Avoid raw food: generally poorly balanced, risk of bacterial contamination
Take into consideration comorbidities e.g. - Chronic kidney disease (low protein diet)
- Diabetes mellitus (slow release carbohydrates)
How can a diet be monitored?
Follow body weight regularly
Assess body condition score
Assess muscle condition score
What can you do if a patient stops eating?
- Feeding techniques
- Change diet (more appetent) – TO BE DONE SLOWLY
- Change consistency
- Small frequent meals
- Warm up (cats especially) - Medications
- Manage vomiting/nausea: maropitant, ondansetron
- Mirtazapine: tricyclic anti-depressant
- Cyproheptadine
- Ghrelin analogue - Assisted feeding techniques
- Oesophagostomy tubes
- PEG tubes
What is a common misconception of steroid use in palliative care?
“steroid is the best palliative cancer treatment”
What are the advantages of using steroids as a part of palliative care?
- Can stimulate appetite
- Useful for round cell tumour (lymphoma, myeloma, MCT)
- Reduce inflammation (brain tumour, radiation therapy side effects)
What are the disadvantages of using steroids as a part of palliative care?
- Weak analgesia effect
- Preclude use of NSAIDS
- Muscle wastage and other adverse effects
- No effects on carcinoma and sarcoma
- Can prevent diagnosis of round cell tumours
- Can create resistance (lymphoma)
What do you need to consider when managing owners expectations of palliative care?
- Relationship-centred care (partnership over paternalism)
- Consider the owner’s needs, objectives, beliefs, routine, ability to give tablets …
- Express empathy (caregiver burden)
- Adapt communication: To the owner’s knowledge, To the owner’s need of information
Name 3 alternative medicines of palliative care
Acupuncture
Herbs/mushroom
Cannabinoids
What is the primary purpose of euthanisia?
Relieve suffering
List some factors that may lead to an euthanasia decision?
- Extent and nature of the disease and injuries
- Other treatment options
- Prognosis
- Potential quality of life after treatment
- Availability and likelihood of success of treatment
- Animal’s age
- Other disease/health status
- Ability of the owner to pay for private treatment
What are some key points to consider when communicating with owners about euthanasia?
- Difficult topic to talk about
- Sometimes, owner will wait for you to mention euthanasia
- Some owners will decline euthanasia even if appropriate time
- Prepare the owners before: Define endpoints, Express empathy, Emphasize on quality of life
- Has to be a joint decision: Better acceptance, Limit guilt
When performing euthanasia what steps must be considered/carried out?
- Make sure YOU have enough time
- Discuss “administrative aspects” BEFORE: Owner’s presence or not, Cremation, costs, Sign consent form
- Talk the owner through the procedure: warn the owner of reaction, urination/defecation
- Check the catheter
- Consider sedating animal before
- Give YOURSELF some time afterwards
