Practical symptom management
for cancer and beyond
St Ann’s Hospice
• Dr Catriona Barrett-Ayres
• Speciality doctor Palliative Medicine
• Dr Alison Phippen
• Associate Specialist Palliative Medicine
Palliative Care
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What is it?
How is it relevant to you now?
How is it relevant to you in the future?
Practical applications for foundation jobs
Quiz
Questions
Palliative care (from Latin palliare, to cloak)
WHO Definition of Palliative Care
“..an approach that improves the quality of life
of patients and their families facing the
problem 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.”
Palliative care encompasses
• holistic care of patients with advanced progressive illness.
• Management of pain and other distressing symptoms through
early identification and thorough assessments to promote comfort
• psychological and emotional, social, spiritual support, care
coordination and advance care planning (multidisciplinary
approach)
• achievement of the best quality of life for patients and their
families.
• Affirms life and regard dying as a normal process
• Neither hastens or postpones death
• Offers a support system to help patients and families cope during
the patient’s illness and with their own bereavement
• Strives for excellent communication with patients and families
• Many aspects of palliative care are also applicable earlier in the
course of the illness.
How is palliative care provided?
• Hospital advisory service (Macmillan nurses
and specialist palliative care consultants)
• Community-GP/ Macmillan nurses/ District
nurses/ continuing health care
• Nursing homes
• Hospice inpatient
• Outpatient services
• Day care
• Carer support through outpatients (NCCC)
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Symptom control
Pain
Nausea and vomiting
Dry mouth
Breathlessness
Bowel obstruction
Lymphoedema/ ascites
Psychological support
Bleeding
Difficult wounds
secretions
What is pain?
• .ƒ“an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage”
• “ƒpain is a category of complex experiences,
not a single sensation produced by a single
stimulus.”
• ƒ“pain is what the experiencing person says it
is, existing whenever (s)he says it does.”
PAIN
• Assess what it is! Reverse anything reversible.
• What is the aetiology? Does it need urgent
investigation?
• Is it new and therefore needs further
investigation? Is it escalating?
• What is the severity?
• Visceral?
• Neuropathic?
• Bone pain?
• Incident pain?
PAIN in cancer patients
• Pain associated with cancer often increases with progression
of the disease.
• 1/3 with cancer report pain, rising to 3/4 in the advanced
stages of cancer.
• Attempts to control pain and hence improve functional ability
and quality of life have been overshadowed in the past by
attempts to cure the underlying disease.
• Several myths surrounding opiates make patients and Drs
wary
• Cancer pain has many dimensions including psychological,
physical, social and spiritual which must be addressed in order
to improve quality of life and functional ability
Where to look for help
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BNF or Palliative care formulary
Symptom control guidelines St. Ann’s Hospice
SIGN guidelines 2008
NICE guideline (in progress)
If in doubt seek help/ advice from senior staff,
Macmillan team
WHO pain ladder
Step 1
• Regular paracetamol
• NSAID (remember can worsen renal function,
bleeding risk)
Step 2
• Codeine
• Tramadol
cocodamol can reduce tablet burden
Remember side effectsconstipation/neuropsychiatric disturbance
Step 3
• Morphine
• Morphine type drugs may be used but this is
more specialist and you should seek advice
about these.
• Oxycodone
• Fentanyl
• bupenorphine
• hydromorphone
• Alfentanil
• Lozenges/ buccal/ intranasal/ subcutaneous
Adjuvants
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Amitriptyline
Gabapentin
Ketamine
Methadone
clonazepam
Benzodiazepines
Antidepressants
Amitriptyline
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Unlicenced for neuropathic pain
Dose range for pain is 10-75mg
TCA
NNT=3
Comes as liquid preparation
Dry mouth, presyncope can limit
Helpful in sleep disorders, depression
Gabapentin
• Anticonvulsant
• NNT=3
• eg 300mg TDS(can be increased gradually to
900mg tds)
• Capsules can be opened
• Dry mouth, movement disorder, tremor
ataxia, dry mouth, drowsiness can limit
• Reduce in renal failure
Pregabalin is (an expensive) pro-drug. It is
licenced for anxiety. It is indicated if other
agents have failed or not been tolerated
Opiates
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In use since 4th century
Brompton cocktail – 1920’s
Queen Victoria used laudanum
Patients often think they mean euthanasia
Opiate Problems
•Problems- addiction/ tolerence ( 1000 opiate related
deaths in England and Wales in 2004, 327,500
problem users in 2005)
•Respiratory depression/OD } think trainspotting!
•Withdrawal
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• Recent death in media- opiate naïve patient given
diamorphine high dose
• Side effects- confusion, nausea, constipation
• No set dose- metabolism and requirements differ
Communicate
• Explain possible side effects
• Arrange frequent review of the patient to
monitor progress and adjustments
• Titrate up according to need, increase if
ineffective, review if pain is sensitive
• Reduce if toxicity
• Write down/ look at prn doses
• Involve carer
Concurrent prescribing
• Regular laxatives eg senna
• Antiemetics for 1-2 weeks- eg metoclopramide
(avoid if bowel obstruction/colic)
• 30% started on opiates get nausea
How to start morphine
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Check opiates are appropriate-not in chronic pain.
Is pain opiate sensitive?
Are they at step 3 WHO ladder?
Would a neuropathic agent be better?
Opiate naïve? 2.5-5mg 4 hourly PRN oramorph . May need
to be offered 4 hourly regularly plus PRN if pain is still
problematic.
• Convert total in 24h to Modified Release equivalent twice
daily once dose established.
• Breakthrough instant release dose is 1/6 total
• Review every 48 hours and Increase according to extra
PRN’s used but only by 30-50% total dose. Caution with
rapid dose escalation
Initiating Opiates
• Already on step 2 weak opiates?
– Codeine in 24h/10 to convert to morphine (eg 60mg
qds=240mg/10= 24mg morphine= 10mg zomorph twice
daily)
– Tramadol in 24h/10 (eg 100mg qds= 400/10 = 40mg
morphine ie 20mg zomorph twice daily)
– Refer to symptom control guidelines/ conversion tables
• Elderly/ renal failure? 1.25mg 4-6 hourly PRN
oramorph.
• Reduce the dose if toxicity occurs (30-50%)
• Consider alternative opiate. Get advice.
Opiate toxicity
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Drowsiness
Pin point pupils
Twitching (myoclonus)
Hallucinations
Nausea
Slow cognition
Confusion
Respiratory depression- rr<8 omit, consider
naloxone, seek advice
Other things that may help
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Addressing total pain
Antidepressants for low mood/ anxiety
What does the pain mean?
Which route of administration do they need?
Interventional anaethsetic blocks
Bisphosphonates
Lignocaine plaster/ capsaisin cream
Local heat or cooling
Surgical intervention
Complementary therapy
Sore mouth
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Any triggers- recent chemoradiotherapy?
Is it dry?
Is the patient dehydrated?
Do their dentures fit?
Is it coated?
Are they immunocompromised? diabetes etc
Is there infection- viral, fungal or bacterial?
Look for thrush and treat if present
Dry mouth (xerostomia)
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Tongue is dry and fissured
Add gravy and sauces
Saliva replacements – tablets, spray or gel
Mints and sweets or gum(sugar free)
Melon, avoid citrus
Ice chips/ water/ frozen drinks (G&T!)
Pilocarpine drops
Do they have salivary reserve or not?
Do they have their own teeth?
Do they object to animal products?
Is it iatrogenic? O2 or drugs
Simple things can make a big
difference to comfort
Oral candida
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Treat with topical or systemic treatments
Is there a short prognosis?
Can they swallow?
Are they on any medications that could
interact with antifungals?
• Do their dentures need to be treated?
• In resistant cases consider a swab
Treatments
• Fluconazole 150mg stat dose
• Fluconazole 50mg once daily for 1 week
• Daktarin oral gel to mucous membranes and
angles of mouth
• Nystatin drops to tongue
• Milton solution for dentures
Rx stomatitis
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Good dental hygiene
Mouthwashes
Coating agents
Topical anaethetics
Systemic anagesia
IV fluids
Nutritional drinks
Coated Tongue
Gentle Brushing
Mouthwashes- chlorhexidine (dilute with water)
Pineapple Chunks