Palliative care - Teaching Clinic Flashcards
Functional assessment metrics
Basic and instrumental Activities of daily living
- Basic: Dressing, Ambulation, Bathing, Eating, Transferring, Toileting
- Instrumental: Food prep, housekeeping, laundry, grocery shopping, using phone, managing medication, managing finances, using transport
ECOG performance status:
- ECOG <= 2: Asymptomatic, rarely a/w sudden death
- ECOG >= 3: Start of physical deterioration esp weight loss
- Higher ECOG = shorter median survival rate
Additional questions
Their ability to walk a half mile; stoop, kneel, or crouch; climb a flight of stairs; and do heavy housework, such as washing floors
Illness trajectories types
ECOG performance status trajectory with cancer progression
Predictors of life-expectancy of a cancer patient
- Median survival rate: guide only, survival range is vast
- Time to tumor growth (TTG)
- tumor size ratio (TSR)
- tumor growth rate (kG)
WHO definition of palliative care
Palliative care is:
- Active care of patients
- Whose disease is not responsive to curative treatment
- Control of pain, psychological, social, spiritual problems
- Acheivement of best possible QOL for patient and their family
- Applied early in the course of the illness with anti-cancer treatment
Cancer pain
- Prevelance
- Components of total pain
Prevalence
- 30-45% moderate to severe pain at diagnosis
- 65-90% pain at advanced disease
Total pain:
- Physical: cancer symptoms, treatment S/E, insomnia, chronic fatigue, cachexia, delirium
- Social: worry about family and friends, loss of job/ title/ income, Loss of social position, Feeling of abandonment and isolation
- Spiritual: point of life? purpose? God?
- Psychological: Anger at therapeutic failure and delays in diagnosis, disfigurement, fear of pain and death, helplessness
Cancer pain
Physical assessment
WHO pain ladder
- Define tiers
- Standard drugs in each tier
- Analgesic use recommendations
If pain occurs, there should be prompt oral administration of drugs in the following order:
1. non-opioids: Paracetamol 500-1000mg QID, NSAID conventional doses
2. then mild opioids: Tramadol 50-100mg QID; dihydrocodeine (e.g. DF118) 30mg Q4-6hrs
3. then strong opioids, until the patient is free of pain: Morphine (oral) 5mg Q4H PO, No ceiling dose
Recommendations:
- Oral route
- GIven on fixed dose schedule, not on as-need basis
- Dosage titrated against particular pain
- Adjuvant drugs should be used for specific pain etiologies
- Give laxatives (Senokot 2 tab nocte PO and/or lactulose 10ml TDS PO) for long-term opioid use
- Prescribe antiemetics to control nausea during the first week of opioid use: metoclopramide 10mg TDS or haloperidol 1.5mg - 3mg daily
List weak and strong opioids
Weak opioid
* Codeine
* Tramadol
* DF118 (Dihydrocodeine), oxycontin
Strong opioid
* Morphine
* Oxycodone
* Fentanyl
* Methadone
Tramadol
- Dose
- PK
- S/E
- D/D interactions
Dose: 50-100mg TDS-QID PO
* For elderly max dose <300mg/day
* For patients with mild renal impairment: <200mg/day
Half life: 6 hours. Prolonged in liver failure
Kidney excretion of metabolite
Side effects:
* Nausea/vomiting, dizziness, sweatiness, dry mouth
* Constipation, convulsion (rare)
Drug interactions
* Tricyclic antidepressants (TCAs)
* Serotonin selective receptor inhibitors (SSRI)
* Monoamine oxidase inhibitors (MAOIs)
Morphine
- Starting dose
- PRN dose
- Adjunct drugs
Starting dose: use short-acting morphine syrup first
* Morphine 5mg QID + 10 mg Nocte/zolpidem (or 5mg Q4H PO)
Consider 2.5mg Q4H in elderly patients or patients with marginal renal function
Always prescribe prn dose of morphine: 50-100% of regular dose, e.g.
* Morphine 5mg PO Q4H prn
* Morphine 2.5mg subcutaneous Q4H prn
Always prescribe laxative with opioid: Senokot 2 tab nocte PO, Lactulose 10ml BD-TDS PO
Antiemetics during the first week of opioid initiation: metoclopramide 10mg TDS, haloperidol 1mg - 2mg daily
Titration of morphine
Factors that warrant titration
Typical dose levels
Increase or decrease morphine dose based on
* Patient’s pain score (do not aim for 0 score)
* The need of prn analgesics (as needed)
* Increase the regular dose every 2-3 days/ if severe pain
* Side effects profile: any signs of opioid toxicity, renal function, hydration status
* Consider decrease dose if tumor responded well to treatment (chemo/targeted therapy / radiation therapy) or toxicity significant
* Change to long-acting opioid (MST continuous tablet) if needed
Dose levels commonly used: e.g. 5mg Q4H ↔ 7.5mg ↔ 10mg ↔
15mg ↔ 20mg ↔ 30mg
Morphine titration
Define satisfactory pain control
Titration ratio for oral morphine syrup to SC/ IV/ MST tablet
Satisfactory pain control level
* Pain score 0-3
* Need of prn morphine for breakthrough pain 0-2 times per day
* Patient can sleep well
* Patient’s subjective judgment
Conversion of oral to SC Morphine = 2:1
Conversion of oral to IV Morphine = 3:1
Conversion of morphine syrup to MST = 1:1
Onset time for oral morphine: 30min
Onset time for SC morphine: 15min
Morphine and renal impairment
- Caution
- Dosage
- C/I
- Active metabolite of morphine: morphine-6-glucuronide (M6G)
- Accumulation of M6G occurs in patients with renal insufficiency
- Patient with creatinine clearance / glomerular filtration rate <50ml/min should be initiated with morphine at 50% dosing with high caution. Specialist consultation is recommended
- Use of morphine in patient with CrCl/GFR <10ml/min should be avoided
S/E of opioids
Early (72 hours)/ mild:
- Nausea / Vomiting, treat with prophylactic antiemetics
- Sedation/ drowsiness: transient, self-resolving 2-4 days
- Constipation: treate with laxative prophylaxis, increase dose or combo laxatives (not bulking agent)
- Pruritis: treat with anti-histamine
- Xerostomia: pilocarpine 2%, mouth care
- Urinary retention: resolve in a week
Severe:
- Opioid induced neurotoxicity: hyperalgesia, allodynia, agitation, delirium, hallucinations
- Myoclonus: early sign of neurotoxicity
- Respiratory suppression, decreased consciousness
Patients at high risk of opioid s/e
Signs of OD
Management of adverse effects
High risk: elderly, frail patient, marginal renal function, poor oral intake
OD:
- Pinpoint pupils, LOC, Shallow/ slow respiration, pale skin, cyanosis, snoring/ stretor (tongue obstruction)
Management:
- Withhold 1-2 doses
- Opioid rotation
- Consult pain specialist
- diluted naloxone bolus IV injection - 0.04mg/ml
Fentanyl
- Route of administration
- Advantage
- Disadvantage
- Conversion with morphine
Route: Patch/ SC infusion
Advantage: Less constipating, less sedative, can be used in renal failure patients
Disadvantage: slow onset, very difficult to titrate
Conversion to morphine:
* 25mcg/hr = 4.2mg = 60-90mg oral morphine
Methadone
- Starting dose
- Advantage
- Disadvantage
Starting dose: as low as possible
Long t1/2: 30 hours, given Q12H, takes 1 week to reach static state
Advantage: Spare high dose morphine/ morphine washing effect; lower nephrotoxocity, better at neuropathic pain
Disadvantage: High dose (>40mg/day) causes fatal arrhythmia, difficult to titrate
Palliative RT for pain control
- Indications
- Advantage
- Disadvantage
Indications:
- Uncomplicated bony met.
- Mediastinal obstruction, cough, hemoptysis
- Bleeding control in GIT, GUT, H&N, breast CA
- Control CNS symptoms in cerebral/ leptomeningeal met.
Advantage:
- Non-invasive
- Tolerable
- Brief treatment (1 day to two weeks)
Disadvantage:
- 70% effective
- Ionizing radiation
Intraspinal opioid
Dose conversion
MoA
Indications
Intrathecal versus epidural opioid administration
Dose conversion: intrathecal to PO: 1mg to 300mg
Implanted programmable pump with different programming options
Less systemic side effects
Patient selection:
* intractable pain >5
* daily morphine consumption >200mg/day or intolerable side effects
* life expectancy >4-6 months
Malignant spinal cord compression
Determinants of treatment modality
Spinal Instability Neoplastic Score (SINS):
- SINS > 7 indicate instability and surgical treatment e.g. kyphoplasty/ vertobroplasty
Tokuhashi score: Criteria of predicted prognosis:
- Total score 0-8 : <6m
- Total score 9-11: 6-12m
- Total sore 12-15: >12m
Surgery indicated:
■ Limited levels of cord compression
■ Minimal neurological impairment
■ Spinal instability (leading to mechanical and functional pain)
■ Previous radiotherapy which has been administered at the level of metastatic spinal cord compression
Neurolytic blocks
- Locations of blocks
- MoA
Injection of alcohol or phenol to deaden the nerve causing pain
Celiac plexus block: Pancreatic CA, upper abdominal tumor
Ganglion impair block: Perineal pain
Superior hypogastric plexus block: Pelvic tumor
Breathlessness in palliative care patients
- ATS definition
- Prevalence
- Effects
Breathlessness: also termed Breathlessness, Dyspnea, Shortness of Breath, Chest tightness
ATS definition:
- subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity
- derives from interactions among multiple physiological, psychological, social, and environmental factors
- may induce secondary physiological and behavioral responses
Prevalence: Up to 70% patients with advanced cancer
Effect:
- On patient and family: disabling/ distressing, anxiety/ depression, anorexia, poor concentration, lower QoL, poorer prognosis
- Social: financial burden to healthcare, more adverse events in hospitals, need of sedation, more hospital admission
Pathophysiology of breathlessless in palliative care patients
Assessment of breathlessless in palliative care patients
Assess Total Pain: Physical, Spiritual, Psychological, social
Assess intensity of dyspnea: Physical:
- Visual analog scale (VAS), numerical rating scale (NRS): Score: 0-10
- Modified Medical Research Council (MRC) Dyspnea Scale
Psychological:
* Hospital Anxiety and Depression Scale (HADS)
* Brief Edinburgh Depression Scale (BEDS)
Social:
* Social support: carers
* Living environment
* Financial support
Spiritual Assessment: HOPE
* H: sources of hope, meaning, comfort, strength, peace, love,
connection
* O: Organised religion
* P: Personal spirituality and practices
* E: Effects on medical care and end of life care
Referral: Health care chaplain or person’s faith community leader
Pharmacological treatment options for breathlessness in palliative care patients
Pharmacological options:
Opioids:
- reduce baseline/ post-treatment dyspnea score
- Starting dose oral morphine 2-3mg Q4H; or 25% of 4 hourly breakthrough analgesic dose prn in immediate release tablets (MST)
BDZs: 3rd line, benefit unclear
* Lorazepam 0.5mg Q4-6hr SL
* Diazepam 2-5mg nocte, BD or prn po
* Midazolam 5-20mg Q24H IV/ SC in EOL
Oxygen therapy: benefit unclear
- NIV
- Can cause dependence, discomfort, dry air, restrict mobility, fires, high cost
Bronchodilators
Corticosteroids: Dexamethasone 4-8mg po om
Non-pharmacological treatment options for breathelessness in palliative care patients
- High strength of evidence:neuro-electrical muscle stimulation, chest wall vibration
- Moderate strength of evidence: Use of walking aids and breathing training
- Facial cooling with fan
- Positioning and pacing breathing (lean forward)
- Anxiety reduction training: relaxation, mindfulness, self-hypnosis…
- Education & Communication, lifestyle modifications
When to do pharmocological vs non-pharmacological treatments for breathlessness
Nausea and vomiting in cancer patients
- Causes
- Management
Causes:
* GI related: obstruction, gastric irritation
* Metabolic: hypercalcemia, uremia
* Drugs induced: opioid
* Treatment related: chemotherapy, radiotherapy
* CNS: brain / leptomeningeal metastases
Management:
* Treat reversible causes
Antiemetics:
* Prokinetics (metoclopramide)
* Central anti-dopaminergic drugs (haloperidol)
* Brain metastases: dexamethasone
* Chemo-induced 5HT3 antagonist (e.g. ondansetron), neurokinin-1 antagonist (aprepitant), antipsychotics (olanzapine)
Palliative care intervention
- Determinants of invasive intervention
Invasiveness of intervention should take account of the overall prognosis and the reversibility of underlying condition
e.g. Single hilar met causing CBD obstruction (by CA ampulla of vater) versus multiple liver met with mild bilateral intra-hepatic duct dilatation carries very different prognosis
Need careful assessment in every patient. No single straight forward answer
Advance directive
Function
Scope of discussions
Function: Plan on future end-of-life medical and personal care options for terminally ill patients, or make advance directive/ refusing life-sustaining treatment (e.g. CPR, continue with artificial nutrition/ hydration)
Involvement of patient, family and healthcare worker
Patient mentally incapable of making health care decisions.
Timing for advanced directive planning
- Significant decline in functional status and level of physical activity, or need to be institutionalized;
- Considerable discomfort in terms of physical and psychological
symptoms, and social anxiety; - Obvious commencement of the final stage of disease
- Futility of disease targeted treatments established and transition
from curative treatment to palliative care.
DNR/ DNAR/ DNACPR
- Definition
Do Not Resuscitate (DNR), Do Not Attempt Resuscitation (DNAR), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
- CPR is not to be initiated on the patient, based on prior deliberations between the patient/family and the healthcare team.
- Does not automatically imply whether the patient will
or will not be receiving other life-sustaining treatments.
Protocol for breaking bad news
Anorexia in terminal illness
Causes
Management
Causes: : pain, depression, dysphagia, nausea, cancer cachexia, oral pain, odour
Management:
* treat reversible causes
* maintain good oral hygiene
* frequent small meals
* Psychological support
* Acknowledge the worries of families
* Dietary supplement: no evidence to improve cachexia
Drugs: Appetite stimulants (cannot reverse cachexia)
- Cortiosteroid: dexamethasone 2-4mg daily, 1 week trial
- Progestogen
Alternative feeding:
- Parental nutrition
- Tube feeding
Malignant IO in terminal cancer
Causes
Treatment options
Most commonly associated with GI tract cancers and cancers causing peritoneal metastases
Most important diagnosis:
* Single-level obstruction with good performance status: consider bypass surgery / colostomy / stenting
* Multiple-level obstruction or patient with poor performance status: comfort care
Medical symptomatic treatment
* Anticolinergic / antisecretory: hyoscine infusion, ocetreotide
* Parental analgesics (IV or subcutaneous) morphine
NG tube decompression: only for high volume vomiting
Delirium in terminal cancer
Causes
Precipitation factors
Treatment
Causes:
1. Iatrogenic: opioid, anticholinergic, steroid, sedatives
2. Uncontrolled symptoms: pain, urinary retention
3. Infection / sepsis
4. Metabolic: hypercalcemia, hyponatremia, CO2 retention
5. CNS: brain metastases
6. Terminal end-of-life stage
Exacerbated by: change in environment, insomnia, fear, anxiety
Treatment:
* Identify all reversible causes
* Calm reassurance to patient and family
* Review drug chart! Withhold potentially related drugs
* Drug treatment after reviewing all reversible causes: Haloperidol, Chlorpromazine, Midazolam
End-of-life S/S
Impending death
* Profound weakness – usually the patient can’t get out of bed and has trouble moving around in bed
* Disinterest in food and fluid intake for days
* Trouble swallowing pills and medicines
* More drowsiness
* Confusion about time, place, or people
