Principles of Palliative Care
Dr. Tony O’Brien
Marymount Hospice &
Cork University Hospital
Wednesday March 9th, 2010
Medicine is about people
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Every body has a story to tell.
Allow people to tell their own
unique story, in their own way
and in their own time.
No two people ever share the
same illness.
Definition
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Disease – describes a specific pathology
affecting an organ, tissue or system in the
body
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Illness – describes the subjective experience
of the disease in the unique context of an
individual’s life – past, present and
anticipated future
Birth
Death
PAST
FUTURE
Birth
Death
PAST
Palliative Care
.. is an approach that improves the quality of life of
patients and their families facing the problems
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
W.H.O. 2002
Palliative Care
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Provides relief from pain and other distressing
symptoms
Affirms life, and regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates the psychological and spiritual aspects of
patient care
Offers a support system to help the family cope during
the patient’s illness and in their own bereavement
W.H.O. 2002
Palliative Care
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Uses a team approach to address the needs of patients
and their families, including bereavement counselling if
indicated
Will enhance quality of life, and may also positively
influence the course of illness;
Is applicable early in the course of illness, in conjunction
with other therapies that are intended to prolong life,
such as radiotherapy or chemotherapy, and includes
those investigations needed to better understand and
manage distressing clinical complications.
W.H.O. 2002
My world
Hospice
Living
Dying
Living
Dying
Dame Cicely Saunders
1918 - 2005
‘There is nothing
more to be done’
Disease Modifying
Treatments
Time
End
Of
Life
Care
Disease modifying
Symptomatic
Time
Palliative Care /
Bereavement
Pain
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Pain is an unpleasant sensory and
EMOTIONAL experience……
Pain is always subjective
Pain is what the patient says hurts
Pain is what the patient says it is
Pain Types
Nociceptive
Somatic
Visceral
Mixed
Neuropathic
Peripheral
Central
Nociceptive Pain
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Stimulation of peripheral sensory receptors
Neural pathways intact and functioning
Somatic pain: well localised
Visceral pain: less well localised; may be referred to
cutaneous sites
Neuropathic Pain
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Occurs as a result of aberrant somatosensory
processing in the nervous system
Central, peripheral or both
Diagnosis is based on history
Pain in an area with abnormal neurology
findings is typically neuropathic
Breakthrough Cancer Pain
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Transient exacerbation of pain that occurs
either spontaneously, or in relation to a
specific predictable or unpredictable trigger,
despite relatively stable and adequately
controlled background pain.
Davies, A et al. APM Guidelines,2009
Measurement
Visual Analogue Scale
No Pain
Worst Pain
Numerical Rating Score
0
1
2
3
4
5
6
7
8
9
Verbal Descriptor Scale
None
Mild
Moderate
Severe
Excruciating
10
Assessment
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Site
Radiation
Duration
Progression
Severity
Frequency
Significance
Effect on mood
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Quality
Precipitating Factors
Aggravating Factors
Relieving Factors
Effect on activity
Effect on sleep
Treatment History
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Medication(s)
Route
Dose
Compliance
Duration
Concerns re meds.
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Benefits
Adverse effects
Non-drug Rx
Non-medical Rx
Patient’s views
Relative’s views
Palliative Interventions
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Surgery
Radiology
Chemotherapy / Systemic therapy
Radiotherapy
Anaesthesia
Psychiatric / psychological
Surgery
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Excision e.g. Breast carcinoma
Debulking e.g. Brain metastasis
Debridement e.g. Fungating tumour
Diverting (Stoma) e.g. Bowel obstruction
Stabilisation e.g. Prophylactic pinning of bone
metastasis
Interventional Radiology
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Gastrointestinal stents
Biliary stents
Renal stents
Paracentesis
Pleural drain
Gastrostomy tube
Vascular stents / Filters
Systemic therapy
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Pain & symptom relief
Functional Improvement
? Life Prolonging
? Life enhancing - Balance
Radiation Therapy
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Metastatic bone disease
SVC obstruction
Spinal Cord compression
Brain metastases
Bleeding
Ulcerating / fungating tumours
Tumour shrinkage
Anaesthesia
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Nerve blocks
Plexus blocks
Epidural medication
Intrathecal medication
Pain Distress
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Severity (Visual Analogue Scale / Verbal
rating score)
Previous pain experience
Mood (Pain tolerance threshold)
SIGNIFICANCE
Pain Control - Essentials
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Believe, do not doubt!
Detailed assessment of EACH pain
Understand common pain types
Understand treatment modalities
Total pain concept
Total Pain
Physical
Emotional
Pain
Social
Spiritual
W.H.O. Analgesic Ladder
Strong
Opioids
Weak
Opioids
Non-Opioids
+/Adjuvants
+/Adjuvants
Adjuvant Drugs
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Non-steroidal anti-inflammatory drugs
Corticosteroids
Anti-convulsants
Anti-depressants
Anti-spasmodics
Anxiolytics
Local anaesthetic agents
NMDA receptor antagonists
Strong Opioids
Fentanyl
Oxycodone
Hydromorphone
MORPHINE
Diamorphine
Methadone
Buprenorphine
Analgesic drugs
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Drug & Dose
Route & Dose interval
Breakthrough pain
Titration
Side-effect prophylaxis
Sequential trial / Opioid Switch
Adjuvant drugs
Levy MH. NEJM, 1996. 335:10
Dose – limiting toxicity
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Central nervous system*
Gastrointestinal system*
Endocrine system
Immune system
Others
* hypercalcaemia
Opioid induced CNS toxicity
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Sleepiness, drowsiness
Confusion
Visual hallucinations
Myoclonus
Pruritus
Distorted sound of voice
Constipation
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Not just related to bowel frequency
Opioid induced bowel dysfunction
Primary feature of dose limiting toxicity
Patients may select pain over bowel
complications
Tolerance does NOT develop
Constipation associated features
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Anorexia
Nausea / vomiting
Reflux
Pain / cramps
Distension
Diarrhoea
Borborygmi
Obstruction
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Perforation
Peritonitis
Incomplete evacuation
Haemorrhoids
Fissures
Confusion
Urinary retention
Opioid induced bowel dysfunction
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Mediated by mu opioid receptors
Reduced and in-coordinated gut motility
Decreased secretions (including pancreatic
and biliary juice)
Increased sphincter tone
Resulting in OIBD
OIBD / Mechanism Based
Therapy
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OIBD mediated by action of opioid on GUT
mu receptors
Selective blockade of peripheral receptors
Maintain centrally mediated analgesia
Avoid risk of opioid withdrawal
Total Pain
Physical
Emotional
Pain
Social
Spiritual
Uncontrolled pain
‘the greatest reason for uncontrolled pain is
the failure by doctors and nurses to
appreciate fully that pain is NOT just a
physical sensation….
… there is ALWAYS more to analgesia than
analgesics!’
Dr. Robert Twycross
Spiritual Pain
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Failure to find any meaning
The ‘why’ question?
Anger, resentment, confusion, bewilderment
Infrequently recognised by patients, families
or health care professionals
May aggravate physical symptoms
Case study
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37 year old married lady
Previously healthy
February 2011: Fatigue, back pain, nausea
Investigated:
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Carcinoma gastro-oesophageal junction
Carcinomatosis peritonei
Obstructive uropathy / bilateral stents
Duodenal obstruction
Biliary obstruction / mass at head of pancreas
Rapidly progressive disease
Family tree
7
Spiritual anguish
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I don’t ask ‘why me’? I used to but not now.
I just have to fight this, get better
I can’t give up. I have too much to live for.
I feel angry all the time. I can’t sleep
What did he ever do to deserve this. He’s
only 7, he never harmed anyone.
Why is he being punished?
I just hope the chemotherapy can get rid of it
Birth
Death
PAST
Expressions of Spiritual Pain
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She never smoked and only took a drink at
Christmas
It doesn’t make any sense
What did she ever do to deserve this?
What’s the point of all this?
She never harmed anybody
It’s just not fair
Responding to Spiritual Pain
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Not about providing answers or solutions
Avoid pious platitudes
Staying with the questions
Staying with the pain
Staying with the uncertainty
Staying with the person
Being there!!!
Pain
SUFFERING