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Terapi Paliatif

pada Keganasan
dr Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit Dalam


Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara

Traditional Health Care Model


Curative

The primary goal is cure


The object of analysis is
the disease process
Symptoms are treated
primarily as clues to
diagnosis
Primary value is placed
on measurable data

Tends to devalue
information that is
subjective,
immeasurable, or
unverifiable
Therapy is medically
indicated if it eradicates
or slows the progression
of disease

Symptoms at the End of Life:


Pain
Trouble breathing
Nausea and vomiting
Sleeplessness
Confusion
Depression
Loss of appetite
Constipation
Bedsores
Incontinence

Cancer
Other
84%
47%
51%
51%
33%
38%
71%
47%
28%
37%

67%
49%
27%
36%
38%
36%
38%
32%
14%
33%

Seale and Cartwright, 1994

PALLIATIVE CARE:
World Health Organization Definition
Palliative care is 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.
4

Palliative Care

Google Images

Comprehensive care for


patients whose diseases are
not responsive to curative
treatment
Care is provided by an
interdisciplinary team of
physicians, nurses, social
workers, chaplains and other
health care professionals
Palliative Care Teams
practice in hospitals, nursing
homes and in the outpatient
setting.

History of Palliative Care


Dame Cecily Saunders was the founder of St
Christophers Hospice which opened in London in 1967

Connecticut Hospice- first Modern Hospice in USA in


1974
Medicare Hospice Benefit introduced in 1983

General Principles

Patient and family as unit of care


Attention to whole person
Interdisciplinary team approach
Education and support of patient and family
Extends across illnesses and settings
Bereavement Support

National Consensus Project for Quality Palliative Care, 2004

Components of Palliative Care

Effective symptom control


Effective communication
Rehabilitation maximising independence
Continuity of care
Coordination of services
Terminal care
Support in bereavement

Domains of Palliative Care

Structure and Processes of Care


Physical Aspects of Care
Psychological and Psychiatric Aspects of Care
Social Aspects of Care
Spiritual, Religious and Existential Aspects of Care
Cultural Aspects of Care
Care of the Imminently Dying Patient
Ethical and Legal Aspects of Care

Clinical Practice Guidelines for Quality Palliative Care, 2004

Structure and Processes of Care

Comprehensive, interdisciplinary plan of care based on


expressed values and goals of patient and family

Teams have relationships with one or more community


hospice programs

The physical environment in which care is provided meets


the needs of the patient and family to the extent possible

Patients and families have access to palliative care staff 24


hours a day, seven days a week

Physical Aspects of Care

Pain, other symptoms, and side-effects are managed based upon the
best available evidence
Breathlessness
Insomnia
Anxiety
Depression
Constipation

Anorexia
Fatigue/weakness
Nausea
Confusion

The outcome of symptom management is the safe and timely


reduction of the symptom to a level that is acceptable to the patient

Concept of Total Pain

Physical pain
Anger
Depression
Anxiety
All affect patients perception of pain.
Needs thorough assessment
90% can be controlled with self-administered oral
drugs

Depression

Loss of social position


Loss of job prestige, income
Loss of role in family
Insomnia and chronic fatigue
Helplessness
Disfigurement

Anxiety

Fear of hospital, nursing home


Fear of pain
Worry about family and finances
Fear of death
Spiritual unrest
Uncertainty in future

Anger

Delays in diagnosis
Unavailable physicians
Uncommunicative physicians
Failure of therapy
Friends who dont visit
Bureaucratic bungling

Treatment options

Analgesic drugs
Adjuvant drugs
Surgery
Radiotherapy
Chemotherapy
Spiritual and emotional support (total pain)

Analgesic drugs
Mainstay of managing cancer pain
Choice based on severity of pain, not stage
of disease
Standard doses, regular intervals, stepwise
fashion
Non-opiodweak opioidstrong opiod
+-adjuvant at any level (WHO analgesic
ladder)

Non-opioid drugs
Paracetamol
1g 4 hourly
NSAIDS
Ibuprofen 400mg 4 hourly
Aspirin 600mg 4 hourly
NB daily maximum doses

Weak opioids
Codeine
60mg 4 hourly
Dihydrocodeine
30-80mg tds max 240mg daily
Dextropropoxyphene
65mg four hourly
Tramadol 50-100mg 6 hourly
Prescribing more than the maximum daily dose will
increase s/e without producing further analgesia

Combinations
Convenient
Care with dosing
Some combinations e.g co-codamol contain
subtherapeutic doses of weak opioid
Co-proxamol only contains 325mg
paracetamol
Get dosing right before moving on to strong
opioids

Strong Opioids

Morphine
Hydromorphone
Fentanyl
Diamorphine
Buprenorphine

Bone pain

Paracetamol
Morphine
NSAIDS
Radiotherapy
Bisphosphonates

Neuropathic pain
Features which suggest neuropathic pain

Burning
Shooting/stabbing
Tingling/pins and needles
Allodynia
Dysaesthesia
Dermatomal distribution

Neuropathic pain

Antidepressant

Anticonvulsant

Dexamethasone 12mg daily

Antiarrhythmics

Sodium Valproate 200mg bd (or Gabapentin or Carbamazepine)

Steroids

Amitriptyline 50mg nocte

Mexiletine 50-300mg tds (or flecainide or lignocaine)

Anaesthetics

Ketamine
Nerve blocks and spinal anaesthesia

Neuropathic pain
Complementary therapies

TENS
Acupuncture
Hypnosis
Aromatherapy
Counselling
Social support

Common mistakes in cancer pain


management

Forgetting there is more than one pain


Reluctance to prescribe morphine
Failure to use non-drug treatments
Failure to educate patient about treatment
Reducing interval instead of increasing
dose

Palliative Care Patient Support


Services
Three categories of support:
1. Pain management is vital for comfort and to
reduce patients distress. Health care
professionals and families can collaborate to
identify the sources of pain and relieve them
with drugs and other forms of therapy.

Palliative Care Patient Support


Services
2. Symptom management involves treating
symptoms other than pain such as nausea,
weakness, bowel and bladder problems, mental
confusion, fatigue, and difficulty breathing

Palliative Care Patient Support


Services
3. Emotional and spiritual support is important
for both the patient and family in dealing with the
emotional demands of critical illness.

1.ILLNESS
1.ILLNESS
MANAGEMENT
MANAGEMENT

8.8.LOSS,
LOSS,
BEREAVEMENT
BEREAVEMENT
7.7.CARE
CARE
AT
ATTHE
THEEND
ENDOF
OF
LIFE
LIFE/ /
DEATH
DEATH
MANEGEMENT
MANEGEMENT

2.2.PHYSICAL
PHYSICAL

PATIENT
PATIENT&
&
FAMILY
FAMILY

6.6.PRACTICAL
PRACTICAL

3.3.
PSYCHOLOGICAL
PSYCHOLOGICAL

4.4.SOCIAL
SOCIAL

5.SPIRITUAL
5.SPIRITUAL

1. ILLNESS MANAGEMENT
1. ILLNESS MANAGEMENT
Primary diagnosis, prognosis, tests
Primary diagnosis, prognosis, tests
Secondary
diagnosis (for example,
Secondary diagnosis (for example,
dementia, psychiatric diagnosis, use of
dementia,
psychiatric diagnosis, use of
drugs,
trauma)
drugs, trauma)
Co-morbid
(delirium, attacks, organs
Co-morbid (delirium, attacks, organs
failure)
failure) episodes (collateral effects,
Adverse
Adverse episodes (collateral effects,
toxicity)
toxicity)
8. LOSS, BEREAVEMENT
8. LOSS, BEREAVEMENT
Loss
Loss
Pain
(for example, chronic acute,
Pain (for example, chronic acute,
anticipatory)
anticipatory) planning
Bereavement
Bereavement planning
Mourning
Mourning
7. CARE AT THE END OF LIFE/DEATH
7. CARE AT THE END OF LIFE/DEATH
MANAGEMENT
MANAGEMENT
End
of life (businesses ending,
End of life (businesses ending,
relationships
closing, to say goodbye)
relationships
closing,
to say
goodbye)
Delivery of gifts
(objects,
money,
Delivery of gifts (objects, money,
organs, thoughts)
organs, thoughts)
Creation
of legacy

Creation
legacy
Preparationoffor
the awaited death
Preparation for the awaited death
Anticipation
changes in agony
Anticipation changes in agony
Rituals
Rituals
Certification
Certification
Care
of agony

Care
of agony
Funerals
Funerals

2. PHYSICAL
2. PHYSICAL
Pain
& other symptoms
Pain & other symptoms
Conscience
level, cognition
Conscience level, cognition
Function,
safety, materials:
Function, safety, materials:
Motor
(mobility, shallowness,
Motor (mobility, shallowness,
excretion)
excretion)
Senses
(hearing, sight, smell, taste,
Senses (hearing, sight, smell, taste,
touch)
touch)
Physiologic
(breathing, circulation)

Physiologic
(breathing, circulation)
Sexual
Sexual
Fluids,
nutrition, wounds

Fluids,
nutrition,
wounds
Habits (alcohol,
smoking)
Habits (alcohol, smoking)
PATIENT & FAMILY
PATIENT & FAMILY
Characteristics
Characteristics
Demographic
(age, sex, race,
Demographic
(age, sex, race,
contact
information)
contact
information)
Culture (ethnic, language, nurture)
Culture (ethnic,
language,
nurture)
Personal
values, beliefs,
practices,
Personal values, beliefs, practices,
strengths
strengths status, education,
Development
Development status, education,
alphabetization
alphabetization
Disabilities
Disabilities

6. PRACTICAL
6. PRACTICAL
Everyday
activities (personal care,
Everyday activities (personal care,
home
work)
home work) pets
Dependents,
Dependents, pets
Access
to telephone, transport
Access to telephone, transport
Care
Care

3. PSYCHOLOGICAL
3. PSYCHOLOGICAL
Personality,
strengths, behavior,
Personality, strengths, behavior,
motivation
motivation anxiety
Depression,
Depression, anxiety
Emotions
(anger, distress, hope,
Emotions (anger, distress, hope,
loneliness)
loneliness)
Fears
(abandonment, burdens, death)

Fears
burdens, death)
Control, (abandonment,
dignity, independence
Control, dignity, independence
Conflict,
guilt, stress, assuming answers

Conflict,
stress, assuming answers
Self-image,guilt,
self-esteem
Self-image, self-esteem
4. SOCIAL
4. SOCIAL
Values,
cultural, beliefs, practices

Values,
beliefs,
practices
Relations,cultural,
roles with
the family,
friends,
Relations, roles with the family, friends,
community
community
Isolation,
abandonment, reconciliation
Isolation, abandonment, reconciliation
Safe,
comforting environment
Safe, comforting environment
Privacy,
intimacy

Privacy,
Routines, intimacy
rituals, leisure, vocations
Routines, rituals, leisure, vocations
Financial
resources, expenses
Financial resources, expenses
Legal
(powers of attorney for
Legal (powers of attorney for
businesses,
health attention, advanced
businesses,
attention, advanced
directives, lasthealth
desire/testament
directives,
last
desire/testament
beneficiaries)
beneficiaries)
5.SPIRITUAL
5.SPIRITUALvalue
Significance,
Significance, value
Existential,
transcendental

Existential,
transcendental
Values, beliefs,
practices, affinities

Values,
beliefs,
Spiritual advisors,practices,
rituals affinities
Spiritual advisors, rituals
Symbols,
icons
Symbols, icons

Psychological and Psychiatric Aspects of Care

The interdisciplinary team includes professionals with


training and skills in the psychological consequences and
psychiatric co-morbidities of serious illness

Appropriate pharmacologic and non-pharmacologic


therapies are initiated for depression, anxiety, insomnia or
other symptoms

Bereavement support is available for up to 13 months

Cancer and Palliative Care


It is generally estimated that roughly 7.2 to 7.5 million
people worldwide die from cancer each year.
More than 70% of all cancer deaths occur in developing
countries, where resources available for prevention,
diagnosis and treatment of cancer are limited or
nonexistent.
More than 40% of all cancers can be prevented. Others
can be detected early, treated and cured. Even with latestage cancer, the suffering of patients can be relieved with
good palliative care.

Palliative Care and Cancer Care


Palliative care is given throughout a patients
experience with cancer.
Care can begin at diagnosis and continue
through treatment, follow-up care, and the end
of life.

Social Aspects of Care

Comprehensive interdisciplinary assessment


identifies the social needs for patients and their
families

Referrals to appropriate services are made that meet


identified social needs:
Access to care
Transportation
Rehabilitation
Medications
Counseling
Community resources
Equipment
Advocacy
Help in the home, school or work

Spiritual, Religious and Existential Aspects of Care

Professionals with expertise in assessing and responding to spiritual


and existential issues are included on the interdisciplinary team

Regular ongoing exploration of spiritual and existential concerns


occurs as appropriate

Contacts with spiritual/religious communities, groups, or individuals


as desired by the patient and/or family are facilitated

Religious or spiritual rituals as desired by the patient and/or family


are supported

Cultural Aspects of Care

The Palliative Care team assesses and attempts to meet


the culture-specific concerns of patients and their families

Communications are respectful of cultural preferences


regarding disclosure, truth-telling and decision-making

The program attempts to respect and accommodate the


range of language, dietary, and ritual practices of patients
and their families

Care of the patient who is imminently dying

Signs and symptoms of


impending death are
recognized and
communicated and
appropriate care is provided
to the patient and family
based on their preferences

End-of-life concerns, hopes,


fears and expectations are
addressed openly and
honestly in the context of
social and cultural customs

Ethical and Legal Aspects of Care

Care is consistent with the professional code of ethics


for all involved disciplines

The team aims to prevent, identify and resolve ethical


dilemmas related to specific interventions
withholding or withdrawing treatments
instituting DNR orders
use of sedation

Team members are knowledgeable about legal and


regulatory aspects of palliative care

NON-SPECIFIC INTERVENTIONS
FOR SUFFERING
1. Non-pharmacological
Talk about death and dying
Calm reassurance
Emotional and spiritual support
2. Pharmacological
Opioids, other analgesics and adjuvants (eg/
gabapentin)
Sedatives
Neuroleptics CPZ, methotrimeprazine
Possibly benzodiazepines
Corticosteroids reduce inflammation, edema
41

Palliative Care
Interdisciplinary Care
Aims to
relieve suffering
improve quality of life
Combined with ALL OTHER appropriate
medical treatment

Palliative Care Is Palliative Care Is NOT:

Excellent, evidence- Not giving up on


based medical
a patient
treatment

Vigorous care of
Not in place of
pain and symptoms
curative or lifethroughout illness
prolonging care

Care that patients


may want at the
same time as Rx to
cure or prolong life

Not always the


same as hospice

Palliative care is not about whether to treat or no


treat but about what is the best treatment

Palliative Care Improves Quality


Relieves pain and other symptoms

Supports re-evaluations of goals of care and d

decision-making

Improves quality of life, satisfaction for patien

their families

Helps patients complete life prolonging treatm