Palliative care in small animal oncology

Question 1

What is palliative care?

Answer 1

« 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.”

Question 2

What are primary concerns for vets + owners?

Answer 2

• 90% of owners will trade quantity for quality of life

Question 3

What does quality of life include?

Answer 3

• Physical domain
• Emotional domain
• Social domain
• Role / function

** Subjective **

Question 4

What are 4 features of health-related quality of life?

Answer 4

• Appetite
• Pain
• Mobility
• Behaviour

Question 5

What are consequences of pain?

Answer 5

• Decreased QoL
• Alter physiologic functions

Question 6

How can you assess pain?

Answer 6

• Physical responses
• Measurable parameters
• Activity, gait and posture
• Attitude and expression

Question 6

Whats the best approach for pain?

Answer 6

• Multimodal approach
• NSAIDs
• Opioids

Question 7

What are good/bad about NSAIDs / paracetamol?

Answer 7

• NSAIDs (meloxicam, carprofen, robenacoxib…)
• Very good painkiller; possible anti-tumour effect (carcinoma)
• ! Contra-indicated with corticosteroids, GI/kidney issues
• Prostaglandin receptor antagonists (Grapiprant)
• Safe and effective in dogs with OA
• ! Not with other NSAIDs or corticosteroids
• Paracetamol (+/- codeine)
• Good painkiller
• Not in cats!!!!
• Liver function??
• Can use with corticosteroids

Question 8

Whats good / bad about tramadol?

Answer 8

• Opioidergic/monoaminergic drug
• Main action: weak µ-agonist
• Can cause dysphoria, sedation, nausea
• Doesn’t work in dogs
• works well in cats but Not palatable

Question 9

What are other adjuvants that you could use?

Answer 9

• Gabapentin
• Mechanism of action unclear
• Neuropathic pain
• Can cause mild sedation and ataxia
• Delayed onset of action, wean off slowly
• Amantadine
• Minimal evidence of action, delayed onset of action
• Minimal side effects (lethargy, dizziness)
• NMDA antagonist
• Oral buprenorphine
• Tricyclic antidepressant (amitriptyline, clomipramine, fluoxetine)
• NGF monoclonal antibody

Question 10

What is the mechanism of pain with osteosarcoma?

Answer 10

• Tumour associated inflammation (due to neoplastic osteoblasts)
• Bone destruction (due to osteoclasts)

Question 11

What can be done to manage pain with osteosarcoma?

Answer 11

• Multimodal analgesia
• Radiation therapy - kill neoplastic osteoblast/clasts
• Bisphosphonates - osteoclast apoptosis
• Amputation

Question 12

What is pain management depending on symptom?

Answer 12

• Amputation
• Surgical excision of ulcerated / painful mass
• Stenting - urethra / trachea
• Cystotomy tubes - urethral obstruction - not long term

Question 13

What is the difference between anorexia + cachexia? Causes?

Answer 13

• Cachexia = inflammatory process - destroy muscle + fat (Extensive lipolysis/proteolysis, insulin resistance)
• Anorexia = doesn’t eat + doesn’t have fat (oral/abdominal pain w neoplasia / use of chemotherapy)

Question 14

What should nutritional management be for neoplastic animals?

Answer 14

• Well-balanced diet - consider comorbidities (CKD / Diabetes mellitus) + Supplements - omega 3
• Monitor body weight

Question 15

What are adverse effects of steroids?

Answer 15

• Weak analgesia effect
• Preclude use of NSAIDS
• Muscle wastage and other adverse effects
• No effects on carcinoma and sarcoma
• Can prevent diagnosis
• Can create resistance

Question 16

What are benefits of steroids?

Answer 16

• Can stimulate appetite
• Useful for round cell tumour (lymphoma, myeloma, MCT)
• Reduce inflammation (brain tumour, radiation therapy side effects)

Question 17

What can be used for alternative medicine?

Answer 17

• Acupuncture - neuromodulation (pain control)
• Herbs / mushrooms - limited evidence
• Cannabinoids - analgesia

Question 18

When + why would you euthanise?

Answer 18

• Primary purpose is to relieve suffering
• Decision based on many factors =
• 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

Question 19

How would you perform the act of euthanasia?

Answer 19

1) Make sure YOU have enough time
2) Discuss “administrative aspects” BEFORE
- Owner’s presence or not
- Cremation, costs
- Sign consent form
3) Talk the owner through the procedure
- Warn the owner of reaction, urination/defecation
4) Check the catheter
- Pentobarbital stings if it extravasates
5) Consider sedating animal before
6) Give YOURSELF some time afterwards