Palliative medicine and symptom control

Chapter 10 Palliative medicine and symptom control

Introduction and general aspects

Palliative care is the active total care of patients who have advanced, progressive life-shortening disease. It is now recognized that palliative care should be based on needs not diagnosis: it is needed in many non-malignant diseases as well as in cancer (Box 10.1).

The goal of palliative care is to achieve the best possible quality of life for patients and their carers by managing not only physical symptoms, but also psychological, social and spiritual problems. When life-prolonging treatments are no longer improving or maintaining quality of life, death is accepted as a normal process. The aim is to enable the patient to be cared for and to die in the place of their choice, with excellent symptom control and an opportunity to say goodbye and bring closure.

Importance of early assessment

Early assessment of needs, with SPC referral if required, is crucial to obtaining the best outcome for rehabilitation and for maintaining or improving quality of life for both patient and carer. Palliative care is most effective when it is given as soon as possible after diagnosis and is given alongside disease-specific therapy, such as radio/chemotherapy for cancer or cardiac medication for heart failure. Early referral links palliative care with quality of life improvements; positive associations increase the likelihood that patients and families continue to use palliative care services when they need them. Furthermore, in malignant disease, there is good evidence that integrating palliative care and anti-tumour treatment soon after diagnosis reduces long-term distress and increases survival in selected cases.

If palliative care is seen only as relevant for the end-of-life phase, patients who have non-malignant disease are denied expert help for complex symptoms. Timely management of physical and psychosocial issues earlier in the course of disease prevents intractable problems later (Box 10.2).

Symptom control

This section outlines the medical aspects of symptom control. Good palliative care integrates these with appropriate non-pharmacological approaches, including anxiety management and rehabilitation (see p. 489).


Pain is a feared symptom in cancer and at least two-thirds of people with cancer suffer significant pain. Pain has a number of causes, and not all pains respond equally well to opioid analgesics (Fig. 10.1). The pain is either related directly to the tumour (e.g. pressure on a nerve) or indirectly, for example due to weight loss or pressure sores. It may result from a co-morbidity such as arthritis. Emotional and spiritual distress may be expressed as physical pain (termed ‘opioid irrelevant pain’) or will exacerbate physical pain.

The term ‘total pain’ encompasses a variety of influences that contribute to pain:

Strong opioid drugs

Dose titration and route

Morphine is the drug of choice and, in most circumstances, should be given regularly by mouth. The dose should be tailored to the individual’s needs by allowing ‘as required’ doses; morphine does not have a ‘ceiling’ effect. If a patient has needed further doses in addition to the regular daily dose, then the amount in the additional doses can be added to the following day’s regular dose until the daily requirement becomes stable; a process called ‘titration’. When the stable daily dose requirement has been established, the morphine can be changed to a sustained-release preparation. For example:





The starting dose of morphine is usually 5–10 mg every 4 hours, depending on patient size, renal function and whether they are already taking a weak opioid.

If there is significant renal dysfunction, morphine should be used in low doses and should not be given in continuous dose regimens (e.g. by subcutaneous infusions) because of the risk of metabolite accumulation (it is renally excreted). In renal impairment, an alternative opioid (e.g. fentanyl) can be given transdermally, e.g. 72-hour self-adhesive patches.

If a patient is unable to take oral medication due to weakness, swallowing difficulties or nausea and vomiting, the opioid should be given parenterally. For cancer patients who are likely to need continuous analgesia, continuous subcutaneous infusion is the preferred route.

Both doctors and patients may have erroneous beliefs (e.g. fear of addiction), which mean that adequate doses of opioids are not prescribed or taken; however, addiction is very rare with the risk of iatrogenic addiction being <0.01%.

Gastrointestinal symptoms

Anorexia, weight loss, malaise and weakness

These result from the cancer-cachexia syndrome of advanced disease and carry a poor prognosis. Although attention to nutrition is necessary, the syndrome is mediated through chronic stimulation of the acute phase response, and tumour-secreted substances (e.g. lipid mobilizing factor and proteolysis inducing factor). Thus, calorie-protein support alone gives limited benefit: parenteral feeding has been shown to make no difference to patient survival or quality of life.

There is a small and evolving evidence base for specific therapies such as eicosapentaenoic acid (EPA) fish oil, cyclo-oxygenase (COX) inhibition with an NSAID and antioxidant treatment, but currently, unless the patient is fit enough for, and responds to, anti-tumour therapy, management is supportive. Some patients benefit from a trial of a food supplement that contains EPA and antioxidants. Megestrol may help appetite, but weight gain is usually fluid or fat. It is also thrombogenic and is of little benefit.

Until recently, corticosteroids were recommended and they are still commonly used as an appetite stimulant; however, the weight gained is usually fluid and muscle catabolism is accelerated. Also, any benefit in appetite stimulation tends to be short-lived. Thus, their use should be limited to short term only.

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Mar 31, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Palliative medicine and symptom control

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