Clinical Aspects of Palliative Care

Symptom management

Alan Barnard
Liz Gwyther
Family Medicine and Palliative Care
University of Cape Town

1
 Acknowlegements
 HPCA Clinical Guidelines
 Palliative Care colleagues
 Patients

2
 Objectives
 Refresh the principles of palliative care
 Discuss HPCA approach to symptom
management
 Specific symptoms
– Pain
– Nausea and vomiting
– Dyspnoea
– Confusion or Cognitive impairment

3
 WHO definitions of palliative care
 What are the similarities and differences
between adult and paediatric palliative care?

4
 WHO Definition of Palliative Care
http://www.who.int/cancer/palliative/definition/en/

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.
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 Palliative care:
 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

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 Offers a support system to help patients live
as actively as possible until death
 Offers a support system to help the family
cope during the patient’s illness and in their
own bereavement
 Uses a team approach to address the needs
of patients and their families, including
bereavement counseling, if indicated

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 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 chemotherapy, radiation
therapy, or antiretroviral therapy and
includes those investigations needed to
better understand and manage
distressing clinical complications
8
 WHO definition of Paediatric
Palliative Care
Who definition appropriate for children and their
families (including chronic disorders):
 Palliative care for children is the active total care
of the child’s body, mind and spirit, and also
involves giving support to the family.
 It begins when illness is diagnosed, and continues
regardless of whether a child receives treatment
directed at the disease.
 Health providers must evaluate and alleviate a
child’s physical, psychological and social distress.

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 Effective palliative care requires a broad
multidisciplinary approach that includes the family
and makes use of available community resources;
it can be successfully implemented even if
resources are limited.
 It can be provided in tertiary care facilities, in
community health centres, and even in children’s
homes. (the child’s own home, community home
or institution)

10
 Similarities and differences in the definitions
of adult & paediatric palliative care
 Similarities  Differences
 Holistic care  Not normal for a child (or
young adult) to die
 Interdisciplinary team  Place of care – palliative
 Involves the family care can also be provided
 Palliative care in any setting for adult
patients
appropriate from the
 Chronic illness – palliative
diagnosis of life-
care is applicable for
threatening illness chronic illness adults and
children

11
 Ethical principles
 BEAUCHAMP AND CHILDRESS (USA)
 autonomy
 beneficence 
 non-maleficence
 justice

12
 Beneficence
 Provide benefit to patient
 In end-of-life care, balance risk vs benefit
 Empowerment combines autonomy &
beneficence
 Rigorous and effective professional
education
 Effective medical & palliative care research

13
 Non-maleficence
 First do no harm
 Treatment can only be justified if there is
benefit to the patient
 Consider principles of beneficence & non-
maleficence together
 ‘Risk-benefit’

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Beneficence and Non-maleficence

Treatment is justified only if there is benefit to the patient

Balance benefit/risk of treatment
Withholding or withdrawing treatment may be a sound
medical decision ( reached in discussion with patient,
family & carers)
Continuity of care
Non-abandonment, there is always an appropriate treatment
plan
Referral to hospice or palliative care service if symptom
control is not achieved within time frame specified in
individual care plan.

15
 Autonomy
(deliberated self-rule)

 Informed consent
 Participation in decision-making
 Confidentiality and privacy
 Refusal of treatment
 Based on good communication, assessment of
patient’s understanding
 Empowerment combines autonomy & beneficence

16
 Justice
 Distributive justice
– distribution of scarce resources
 Rights based justice
– equal access to health care
– right to palliative care
– right to pain and symptom control
– right to competent, trained clinician
 Legal justice
– in accordance with the laws of the state

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General approach to symptom
management
1.Appropriate assessment to identify cause and
severity of symptoms
2.Explanation to patient and family at all stages
3.Correct reversible factors
4.Consider disease-specific palliative therapy
5.Institute non-pharmacological interventions

HPCA Clinical Guidelines, 2006

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General approach to symptom
management
6. Prescribe appropriate first-line treatment
7. Consider adjuvant/second-line treatment
8. Review assessment and management
9. Involvement of interdisciplinary team
10. Referral to appropriate service (hospice)
/more experienced clinician (palliative care
physician)

HPCA Clinical Guidelines, 2006

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 Symptom management
 Pain
 Nausea and vomiting
 Dyspnoea
 Confusion

20
 Pain management
Definition of pain
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage

Twycross ‘pain is what the patient says

hurts’ – believe the patient

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 Total Pain
Dame Cecily Saunders

Physical pain

Emotional Psycho-social
pain PAIN pain

Spiritual pain

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 Clinical assessment of pain
Consider cause and severity of pain
Accept patient’s description of the pain

Careful history of the pain

P - precipitating and relieving factors
Q - quality
R - radiation
S - site and severity
T - timing and treatment
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 Clinical assessment of pain
 Use a formal pain assessment tool, e.g.
Numerical Rating Scale, Verbal Descriptor
Scale or Visual Analogue Scale.
 Assess every pain.
 Elicit the meaning of the pain to the patient.
 Consider all dimensions of “total pain”.

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25
 Measurement of pain
 Visual analogue scale
No pain worst possible
pain
 Numerical rating scale
No pain 0 1 2 3 4 5 6 7 8 9 10 worst possible pain

 Faces scale for children

No pain worst
possible
pain

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 Clinical assessment of pain
 Examination
– Thorough clinical examination
 Appropriate investigations.
– X Ray and other imaging, blood tests,
– Bone scan to detect bony metastases, lumbar
puncture to diagnose cause of meningitis

27
 Management of pain
 Explanation to patient and family: discuss
treatment options, fears, anxieties regarding pain
management with opioids, adjustment of
activities to reduce painful episodes.
 Correct reversible factors
 Consider disease specific palliative treatment
 Eg single dose radiotherapy for bone
metastases, fluconazole for cryptococcal
meningitis, antiretroviral treatment for HIV
neuropathy

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 Management of pain
 Non-pharmacological methods
– Application of heat/cold
– massage
– meditation
– relaxation
– distraction
– music therapy.
– Offer psychological and spiritual support, addressing
the meaning of the pain to the patient.

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 Prescription for pain
First line analgesia: World Health
Organisation (WHO) Analgesic Guidelines.

General principles of pain management:

By mouth: use oral medications unless the patient is vomiting
or comatose.
By the clock: for persistent pain, analgesics should be given
regularly at a fixed dose on a fixed schedule.
By the ladder

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 Prescription for pain
 For the individual: individual requirements for
analgesics vary enormously; the dosage of
analgesic must be titrated against the particular
patient’s pain.
 Use of adjuvants: to enhance analgesic effect, e.g.
corticosteroids, anti-convulsants.
 Attention to detail:
– Take nothing for granted.
– Be precise in history taking.
– Give precise instructions, verbally and in writing.

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WHO 3-step analgesic ladder

Strong opioids
+/- non-opioid
Weak opioids +/- adjuvant
+/- non- Step 3
opioid
Non-opioid +/- adjuvant
+/- adjuvants Step 2

Step 1

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 Prescription for pain
 Step 1 (simple analgesics)
– Centrally acting agents
paracetamol
– Non steroidal anti-inflammatory agents
diclofenac, indomethacin, salicylic acid
 Step 2 (weak opioids)
codeine, tramadol

33
 Prescription for pain
 Step 3 (strong opioids)
 Morphine - mist morphine
- morphine tabs
- morphine sulphate inj
 Fentanyl (patches)
 Methadone, hydrocodone, oxycodone (not
yet available in SA)

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 Morphine
 Morphine is safe, reliable and easy to use
provided clinicians have been trained in its use
 Morphine is the most commonly used strong
opioid analgesic
 Morphine should not be withheld from patients
experiencing severe pain
 There is no upper limit to morphine dosage
 Dosage is indicated by the patient’s analgesic
requirements
 Toxic

Morphine safety
IV
Oral (titrated)
csci

Serum
levels
Therapeutic
range

Sub-therapeutic

Bioavailabilty graph Time

 Adjuvant analgesics
 Non-steroidal anti-inflammatory drugs
– Bone pain, soft tissue infiltration, hepatic
capsule pain
 Corticosteroids
– Increased ICP, soft tissue infiltration, nerve
compression
 Antidepressant medication } neuropathic
 Anticonvulsant medication } pain
 Bisphosphonates - bone pain
 Antispasmodics – hyoscine butyl bromide
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When do we start a step 3
analgesic? (morphine)

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 Prescription for pain
GUIDELINES ON COMMENCING MORPHINE
 When strong opioid needed use oral morphine
syrup
 review of the dose every four hours
 Starting dose:
 Morphine syrup 5-20mg/ml
 5 – 10mg 4-hourly
– 2.5 – 5mg 4-hourly elderly, cachexic, renal impairment

39
 Prescription for pain 4
 Increasing dose - increments of 30-50 percent of
dose
 There is no ceiling (maximum) dose of morphine.
 Morphine dose titrated to the patient’s pain control
requirement.

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 Prescription for pain 4
 Anticipate side effects routinely
– Constipation Lactulose 15 – 30ml daily
– Nausea Haloperidol 1.5mg bd or
metoclopramide 10mg tds
– Confusion/Drowsiness - temporary side effect
and usually wears off after a few days.

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 Nausea and Vomiting
 Reflect on the last time you felt nauseous
– With vomiting?
– Dignity?
– Guilt?
– Did you feel sick?

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 Pathophysiology of nausea
  and vomiting
CHEMO-
ABDOMINAL RECEPTOR CORTEX
VISCERA TRIGGER ZONE

VOMITING
CENTRE

SALIVATORY CENTRE
VASOMOTOR CENTRE
RESPIRATORY CENTRE
CRANIAL NERVES

EFFECTOR
(TWYCROSS AND LACK)
ORGANS 43
 Receptor sites
Chemoreceptor Trigger Zone – D2, 5HT3

Vomiting Centre – H1, Achm, 5HT3

GIT - D2, 5HT3, 5HT4, H1, Achm

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 Causes of nausea and vomiting
 Mechanical
– gastric stasis, intestinal obstruction, excessive
coughing
 “Toxic”
– drugs, radiotherapy, infection, renal failure,
hypercalcaemia
 Central
– brain metastases and raised ICP
– From cortex – pain, anxiety, olfactory

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 Management

Non-drug measures
 Fresh air, avoid olfactory triggers
 Small portions, frequent feeds, avoid
precipitants eg food preparation
 Cold food instead of hot food
 Cool sparkling drinks
 Calm reassurance
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 Management
Correct reversible causes
 Cough
 Constipation
 Raised intra-cranial pressure
 Drugs (NSAIDS, antibiotics, cortico-steroids
etc)
 Hypercalcaemia

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 Management

Select anti-emetic drug

First-line
 Haloperidol – “toxic”
 Cyclizine – central
 Metoclopramide, domperidone – mechanical
Second-line/adjuvant
 Combine haloperidol with metoclopramide or
cyclizine
 Levomepromazine
 Hyoscine butyl bromide (high dose)
 Dexamethasone 48
 Dyspnoea
Definition

Dyspnoea is a subjective sensation of

difficulty in breathing, not necessarily related
to exertion, that compels an individual to
increase his ventilation or reduce his
activity.

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 Management of dyspnoea
 Assessment to identify cause and severity
of breathlessness
 Set goal of care
– Reduce sensation of dyspnoea within 6-8hrs
 Explanation to patient and family
especially discuss anxieties and fears,
limitations of activities
 Oxygen if hypoxic only, and beware
‘dependence’ NB cost of oxygen therapy
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 Management of dyspnoea
Reversible causes of breathlessness?
Cardiac failure
Infection(NB TB, PCP)
Anaemia
Pleural effusion
Arrythmia
Pulmonary embolus
Bronchospasm
Pneumothorax
Emergency: Superior Vena Cava obstruction –Give
high dose steroid before admission for urgent
oncology consultation

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 Management of dyspnoea

Consider disease specific palliative therapy

– Chemotherapy for carcinoma

– Radiotherapy for SVC obstruction
– Cotrimoxazole for PCP

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 Management of dyspnoea
Non-pharmacological interventions:
– Simple breathing exercises
– Relaxation training
– Adaptation of activities of daily living
– Positioning of patient
– Open window/use fan for flow of air across face
– Breathing retraining - physiotherapy

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 Management of dyspnoea
Medication
For anxiety and panic
lorazepam 1mg sublingually prn
diazepam 5mg po nocte
midazolam 10-30mg CSCI (continuous
subcutaneous infusion)
alprazolam 0.25mg tds po

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 Management of dyspnoea
To reduce the subjective sensation of
dyspnoea

– mist morphine 2.5-5mg 4hrly (for opioid-naïve

patients)
– if patient is on regular opioid for pain control,
increase regular dose by 25-50% 4hrly
– Morphine rests homeostatic control pCO2 in
respiratory centre
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 Confusion

 Delirium
– acute
– reversible
– organic brain dysfunction
 Dementia
– chronic
– progressive
– global

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 Delirium and dementia may co-exist
 Elderly and ill patients have limited cerebral
reserve
 “Dementia” may be reversible in AIDS

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 Causes of dementia
Related to cancer or treatment
- malignant infiltration
- radiotherapy/chemotherapy
- infection
- paraneoplastic syndromes

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 Causes of dementia
Unrelated to cancer or treatment
- Alzheimer’s
- alcohol
- cerebrovascular disease
- hydrocephalus
- thyroid dysfunction
- vitamin deficiency

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 Causes of delirium
 DIMTOP
– Drugs
– Infection (local, systemic, HIV)
– Metabolic (glucose, calcium, urea, sodium)
– Trauma, Tumour
– Oxygen (supply, carriage or perfusion)
– Physical Psychiatric

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 Drugs and delirium
 Drugs: opioids, corticosteroids, anxiolytics,
antiemetics (metoclopramide), some
chemotherapeutic agents, antidepressants,
anticonvulsants, alcohol, antihistamines,
anticholinergics (hyoscine), NSAIDs
 Drug withdrawal: alcohol, nicotine,
benzodiazepines, barbiturates

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 Management of delirium
Explanation to patient and family
Reassure the patient and family members
Acknowledge their distress
Lucid periods
Say that…
– the patient is not ‘going mad’ but that there is a
physical cause for the delirium and confusion.
– It is not pain or suffering
– It does not necessarily mean imminent death
– Medication will be given to control confusion and
agitation

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 Treatment of delirium
Correct the reversible
Disease specific treament

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 Treatment of delirium
Non-pharmacological measures:
 Continue to treat the patient with courtesy and
respect
 Keep calm and avoid confrontation
 Facilitate orientation, do not change the position
of the patient’s bed, provide nightlight,
continually inform patient of time and place if
disorientated (use calendar, clock, photographs)
 Avoid over-stimulation (lots of visitors, light,
noise, alcohol)
 Provide constant reassuring presence (family
member or designated staff member)
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 Treatment of delirium
Non-pharmacological measures (cont):
Explain every procedure and event in detail
 Reinforce patient’s long-term memory
 DO NOT USE PHYSICAL RESTRAINTS
 Patient should be allowed to walk about
accompanied
 Repeat important and helpful information

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 Treatment of delirium
Routes of administration
Oral
Intramuscular
Subcutaneous

66
 Treatment of delirium
Agents to use
 Benzodiazepines
– Diazepam
– Lorazepam
– Midazolam
 Haloperidol
 Chlorpromazine
 Others
– Propofol
– Phenobarbitone

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 Pharmacological management
Indication Drug Dosage Route

Agitation Haloperidol 1.5-20mg PO, IV, s/c

/24hr

Aggression Midazolam 2.5-5mg IV, s/c

Violent behaviour Propofol 20-50mg IV

Phenobarb. 5-70mg/hr s/c or IM

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 Review Objectives
 Refresh the principles of palliative care
 An approach to symptom management
 Specific symptoms
– Pain
– Nausea and vomiting
– Dyspnoea
– Confusion or Cognitive impairment

69
 Important considerations in
palliative care
Missouri Baptist Medical Center
1.Proactive communication with patient and family members leads to improved
results.
2.Treat even the most minor complaint with a positive, sympathetic approach.
3.Understand the cause of a symptom, so that treatment best matches the
complaint.
4.Assess and reassess the symptom, adjust doses stepwise, or change palliative
drugs on a regularly scheduled basis.
5.Integrate symptom control into a continuous plan of treatment for palliation.
6.Treat symptoms with regular (not prn) doses of medications where feasible.
7.Use adjuncts to maximize symptomatic relief.
8.Depression and anxiety are common concomitant symptoms and should be
treated simultaneously for the best palliation.
9.Anticipate side effects of pain and other palliative therapies, and treat them
accordingly.
10.Keep your options of palliative treatment open as wide as possible. Consult
allied health professionals, other physicians and community resources.
11.Don't try to predict life expectancy.

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Thank you

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