Palliative medicine

chapter 39 Palliative medicine



INTRODUCTION AND OVERVIEW


In the mind of the general public, palliative care is commonly equated with terminal care, and many members of the medical community no doubt share this opinion. Traditionally, palliative care has predominantly provided service to cancer patients and their families. However, the role of palliative care is much richer and more varied than this. Palliative care principles can readily be applied to many incurable diseases as they become more severe, and can also be useful in the management of symptoms during the earlier stages of disease.


Palliative care, at its best, is provided by a team of individuals working towards common goals for a particular patient. The team may include doctors, nurses, allied healthcare staff, counsellors and family members. Symptom control, achievement of optimal quality of life and assistance with decision-making are all components of palliative care that can be provided by the general practitioner (GP). The critical role of the GP in the coordination of patient care is particularly pronounced for patients with advanced disease. Furthermore, a GP who has known a patient for much of their life is likely to have worthwhile insight into their values and wishes, and is well placed to assist them in negotiating difficult transitions.



GOALS OF CARE


It is often helpful to establish and focus upon the goals of care for a patient. These will be influenced by the nature and stage of the disease, the age of the patient, their general health and their life philosophy. As cancer progresses, the situation may become more complex and decisions may seem increasingly difficult. It is helpful at these times to return the focus to the goals of care and reflect on the outcome that we are trying to achieve. This will assist in more clearly identifying a pathway that is likely to accomplish these objectives. The GP should take an active role in reviewing the overall situation and incorporating a holistic understanding of their patient.


For example, a 55-year-old woman first confronted with a diagnosis of breast cancer is likely to elect to pursue chemotherapy if this is advised. She will consider the temporary side effects, reduction in quality of life and time taken to attend therapy to be worthwhile in view of the potential benefits. An 83-year-old woman with multiple other medical issues resulting in some frailty will often be more susceptible to adverse effects of routine chemotherapy for breast cancer. She may find the effort required to attend clinics, undergo invasive investigations or procedures and the time taken to recover from each cycle of chemotherapy to be an unacceptable trade-off for the potential benefits, which in all probability will be of a lesser magnitude.


Many important decisions may need to be made by a person confronted with a life-limiting illness. For an excellent and practical guideline on how to approach this, the reader is referred to Clayton & Hancock, ‘Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a terminal illness, and their caregivers’, published as a supplement in the Medical Journal of Australia.1



CARING FOR THE WHOLE PERSON


Nowhere is integrated and holistic care more important than when dealing with death and dying. Obviously the physical aspects of care need to be attended to, and dealing with various symptoms will be dealt with in detail in this chapter. Obvious also is the impact of emotional, social and spiritual/existential aspects involved in confronting end-of-life issues.


A deep-seated fear of dying, for example, or longstanding and unresolved guilt can have an enormous impact on how a patient deals with physical pain. It is not uncommon for deeper emotional and existential issues to influence and magnify such symptoms. If physical treatments only are administered (e.g. prescribing escalating doses of pain killers) but the underlying emotional and existential issues are not acknowledged or dealt with, then the problem of pain will likely be unsolvable, whereas if these deeper issues are dealt with well, the pain will often be far more manageable.


Most patients confronting life-threatening illnesses wish to speak to their medical team about spiritual and religious issues (see Ch 12, Spirituality). Whether the doctor provides such counselling or helps to link the patient with counsellors, pastoral care and allied healthcare professionals, one way or another this aspect of care needs to take place and not be ignored among the more obvious and apparently more pressing physical needs.


At all times one needs to also bear in mind that it is the whole family who will be experiencing the grief and anxiety associated with the illness—sometimes far more grief and anxiety that the patient, who may already have come to terms with their situation.



THE ROLE OF COMPLEMENTARY THERAPIES


The frequency of complementary therapy use by cancer patients may be as high as 83%2 (see Ch 24, Cancer). This includes herbal medicines, music therapy and physical therapies such as acupuncture, among others. Patients use these therapies to improve symptoms, in the hope of curing cancer or increasing survival, and as a response to pressure from family or friends.3 It is certainly reasonable to encourage the use of those therapies that are proving helpful to the patient without causing undue hardship or interfering with conventional treatment. Some incur a considerable cost with little or no benefit, and occasionally there may be a risk of the therapy interfering with conventional medical care or causing harm to the patient. For example, many herbs can interact with drugs such as warfarin. The GP has an important role in discussing the use of such therapies with the patient.



PAIN


Pain is a complex experience involving specific neural pathways that convey nociceptive information to consciousness. Neuronal systems also exist that modify pain—for example, descending inhibitory pathways in the central nervous system. This chapter focuses mainly on cancer pain, but many of the principles can be applied to non-malignant pain in patients with advanced or near end-stage disease. Chronic pain, while sharing some features, requires important differences in approach and is not discussed here (see Ch 38, Pain management).


Pain is common is cancer and more so in advanced malignancy, with 70–90% of patients reporting pain.4 It is also common in the elderly (28–86% of nursing home residents5) and in those with other chronic disease (e.g. 40% of patients with Parkinson’s disease). As such, competent assessment and management of pain is a crucial skill for GPs.


The most effective approach to cancer pain requires consideration of the pathophysiology as well as the aetiology of the pain.



PATHOPHYSIOLOGY


Pathophysiology is important, as the different pain types respond differently to specific medications and thus can guide therapy.



• Somatic pain is caused by activation of peripheral nociceptors in response to inflammation or injury of surrounding tissues. Examples include bone metastases, arthritic pain and burn injury.

• Visceral pain occurs when nociceptors in thoracic or abdominal viscera are activated by infiltration, distension or compression of the organ. Liver metastases or bowel obstruction are examples.

• Neuropathic pain results from direct injury to the peripheral or central nervous system, such as peripheral neuropathy, spinal cord compression or cancer infiltration of a neural plexus.

It is common for cancer patients to have mixed somatic and neuropathic pain, for example when a rib metastasis causes bone pain and also has a neuropathic element by involving the intercostal nerve.


In addition, pain can also be classified on the basis of ‘timing’. Incident pain describes pain that occurs with movement; breakthrough pain refers to pain that ‘breaks through’ otherwise adequate levels of analgesia.



AETIOLOGY


In patients with cancer, pain may be:


• cancer-related—e.g. bone metastasis, infiltration of nerves or organs

• treatment-related—e.g. mucositis secondary to chemotherapy-induced neutropenia

• non-cancer-related—e.g. coexisting osteoarthritis.


HISTORY AND EXAMINATION


Careful history and examination can often assist in determining the likely pathophysiology and aetiology of a patient’s pain. The history will focus on the qualities, temporal features and other descriptive features of the pain. Details such as location, duration, onset, offset, relieving and exacerbating features should be elicited, along with a description of pain quality. It is clearly important to enquire about other symptoms such as nausea and vomiting, history of a recent fall, previous treatments and so on.



• Somatic pain descriptors include dull, constant, aching. Pain is usually well localised. This pain responds well to simple analgesics and to opioids.

• Visceral pain may have a gnawing, colicky or cramping character, feels deep and is less well localised. Be aware that visceral pain may be referred to other sites, e.g. shoulder tip pain from liver metastases, central abdominal pain from early appendicitis.

• Neuropathic pain may be described as burning, shooting or constricting, and often has a particularly unpleasant character. It can occur in paroxysms with or without a more constant component. Neuropathic pain may be felt in a dermatomal or peripheral nerve distribution. Features such as anaesthesia or allodynia strongly suggest an element of neuropathic pain.

The focus of the examination will be determined by the specifics of the pain and the patient’s previous history, but a general approach should include:


• overview of the patient—are they confused, markedly cachexic, dehydrated?

• a careful examination of the affected area, looking for tenderness, signs of deformity, infection, presence of a mass, loss of function and so on

• neurological examination to elicit any weakness or sensory abnormality, as it is possible that the patient will not have noticed these or recognised their importance.


INVESTIGATIONS


It is not possible to cover the scope of investigations that may be relevant. Some form of radiological imaging is generally useful to accurately determine the cause of the problem, but initiation of good analgesia should not be delayed while waiting for these results. In appropriate clinical circumstances, a variety of other investigations such as a full blood count, urine culture or calcium level will be indicated.



INTEGRATIVE MANAGEMENT



• Prevention—not realistic in the conventional sense, but severe, ongoing problems may potentially be minimised if pain is addressed promptly and effectively. For example, rapid initiation of therapy for shingles can reduce the incidence of postherpetic neuralgia.6

• Evaluation—in all cases, pain should be adequately evaluated. Some patients will choose not to pursue intervention but these are a minority, with relatively low levels of pain and greater general wellbeing.

• Self-help, lifestyle, home remedies—some strategies that patients are able to use in order to relieve pain include the use of heat or cold packs, resting the affected area (not always possible) and various relaxation strategies.


Non-pharmacological



• Transcutaneous electrical nerve stimulation (TENS) machines are useful for some patients, often as part of a comprehensive pain management strategy.

• Complementary therapies have a role in pain management, in providing analgesia and in raising the pain threshold.
• Acupuncture is increasingly being used in pain management, including by GPs. Limited evidence is available regarding its use in advanced cancer, although various reviews of the literature conclude that benefit is likely.7,8

• Massage appears to be of some benefit in reducing pain and the anxiety associated with it. However, in some groups the benefit appears to be short-lived.9 A recent Cochrane review stated that overall there was insufficient evidence to draw firm conclusions about the benefit of massage.10 The addition of aromatherapy was not shown to provide any additional benefit.

• Music therapy is available through various avenues, including community palliative care services. It has been shown to reduce pain in cancer patients.2,11

• Other strategies employed by patients include hypnotherapy, meditation, relaxation and imagery. Trials are not consistent in demonstrating benefit.


Pharmacological


The choice of agent will depend on:


• pain severity

• likely aetiology of the pain

• presumed mechanism of pain (somatic, neuropathic etc)

• analgesics already tried

• patient preferences, fears and allergies.

Generally, analgesia for cancer pain should be given:


• orally

• around the clock rather than ‘as required’

• in adequate doses—using a combination of drugs may enable lower doses of each drug to be used, with fewer side effects.


Simple analgesics



• Paracetamol—the precise mechanism of action remains uncertain, although it may act on a cyclo-oxygenase enzyme (COX-3) only present in the brain. It can provide useful analgesia alone for mild pain or in combination with other agents for more severe pain. Newer preparations enable 8-hourly dosing to provide 24 hours of cover. Maximum doses should not be exceeded.

• NSAIDs—these have a particular role when the possibility of an inflammatory component to the pain exists, for example with bone metastases, cellulitis, thrombophlebitis. The side-effect profile should always be considered when using NSAIDs.

• Tramadol—this agent acts on multiple neurotransmitters, including weak affinity for the opioid receptor.


Opioids


Opioids are the mainstay of cancer pain management. They are particularly useful for somatic and visceral pain, as well as having an important role in neuropathic pain. The reader is referred to other textbooks for more in-depth advice on use of opioids in cancer pain. Some basic principles are listed here.



• In the elderly particularly, start low, go slow.

• Opioids should be used around the clock rather than ‘prn’. This has become much easier with the availability of slow-release preparations of morphine, oxycodone, fentanyl and so on.

• Injectable opioids have no advantage over oral where the patient is able to swallow and has a functioning gut.

• Provide ‘breakthrough’ medications to deal with exacerbations of pain. Ensure that these are rapid-acting rather than slow-acting. The breakthrough dose is approximately one-tenth of the total 24-hour baseline dose (see the example in Box 39.1; see Table 39.1 for conversions). The dose may need to be rounded to, for practical reasons.

• Calibrate the dose (see the example in Box 39.1).

• Avoid constipation. Most patients will experience constipation with opioids (although there is a lower frequency with fentanyl). Prescribe regular laxatives at the same time as the opioids are prescribed.

• Be mindful of other common side effects, such as nausea (∼30% initially) and drowsiness. Respiratory depression rarely, if ever, occurs without other signs of excessive dose, such as drowsiness.

• Patients must be warned that when opioids are commenced or increased, their ability to drive safely may be compromised. Once the dose is stable, patients can drive, provided they are not drowsy. They should be warned about additive effects of other sedative drugs, including alcohol, and advised not to drive if they use alcohol or other drugs.


BOX 39.1 Case study: opioid titration


Mr P is a 72-year-old man with pain due to metastatic colon cancer. In addition to simple analgesics he requires an opioid to adequately manage his pain. He is commenced on slow-release (SR) morphine 15 mg 12-hourly as baseline analgesia with immediate release (IR) morphine mixture 2.5–5 mg as needed for breakthrough pain (1/12 to 1/6 of 24-hour baseline dose). Aperients are prescribed prophylactically.


On review 3 days later he has consistently required 4–5 doses/24 hours of 2.5 mg morphine in order to control his pain, representing ~20 mg additional morphine. His baseline SR morphine is therefore increased to 25 mg 12-hourly with good effect. Thereafter he requires few additional doses.



TABLE 39.1 Opioid conversion to morphine equivalent

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Jun 3, 2017 | Posted by in GENERAL SURGERY | Comments Off on Palliative medicine

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