PERAWATAN

PALIATIF

DIVISI ONKOLOGI GINEKOLOGI

FK USU

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PALLIATIVE CARE IN GYNECOLOGY ONCOLOGY

• Challenges and Opportinities

• Chemotherapy induced nausea, vomiting, diarrhea
• Pain
• Nutrition
• Psycho-oncology
• When should treatment stop
• Quality of life
• Euthanasia
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 CHALLANGES AND
OPPORTINITIES

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CHALLENGES AND OPPORTINITIES

• Palliative care (WHO) 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
assesment and treatment of pain and other problems,
physical, psychosocial and spriritual.

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• Simply put: aims to relieve suffering and improve
the quality of living and dying

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KEY FACTS
• Palliative care improves the quality of life of patients
and their families who are facing problems associated
with life-threatening illness, whether physical,
phsychosocial or spiritual
• Each year, an estimated 40 million people are in need
palliative care, 78% of them people who live in low-
and middle –income countries
• Worldwide, only 14% of people who need palliative
care currently receive it
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KEY FACTS (CONT)
• Overly restrictive regulations for morphin and other essential
controlled palliative medicines deny access to adequate pain
relief and palliative care
• Lack of training and awareness of palliative care among health
professionals is a major barrier to improving access
• The global need for palliative care will continue to grow as a
results of the rising burden of noncommunicable diseases and
ageing population
• Early palliative care reduces unnecesssary hospital admisisions
and the use of health services
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TEAM APPROACH
• Involvement of specialist in multiple disciplines
• Approach: multi – inter – or trans disciplinary
• Team : spiritual counselor, physician, social worker,
physical therapist, bereavement counselor,
pharmacist, psychologist, nursing services,
volunteer, family, community and patient
• Assessment - intervention – evaluation: carried out
jointly
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ASSESSMENT OF THE PHYSICAL DOMAIN
• Common symptoms:
• Pain, nausea, vomiting, constipation, dyspnoe, joundice,
cyanosis
• Symptoms related disease progression
• Symptoms related drugs side effect

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MASLOW’S HIERARCHY OF NEED

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ASSESSMENT OF THE EMOTIONAL DOMAIN

• Diagnosis of serious illness:

• Deeply effect patient and family wellbeing
• Each person reacts in different way
• Based on: psychoemotional, social, cultural
• Can experience:
• Anxiety, depression, fear, sadness, worry

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ASSESSMENT OF THE SOCIAL DOMAIN
• Human is need each other
• Live in cummunity
• Disease effect one person, illness effect family
• Isolated patient: lower acceptance
(disease/treatment)
• Evaluated practical and logistic issues:
• Daily activity, meal, health insurance and financial

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ASSESSMENT OF THE SPIRITUAL DOMAIN
• Spiritual pain:
• Meaning, hope, forgiveness, relatedness
• The member team: active listening with open
ended question
• Religion

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DIFFERENT SETTING IN PALLIATIVE CARE
• No specific model
• Has to adapt:
• Social and cultural needs
• Rules and regulation of different facilities
• Community resources
• Logistic: transportation, infrastructure
• Availability of opiods and other essential medicine

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GENERAL SETTING PALLIATIVE CARE
• Inpatient Palliative Care Consults Services
• Acute or long term care
• Ambulatory Outpatient Clinics
• Home Care
• Hospice Care

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PALLIATIVE CARE AND
GYNECOLOGY ONCOLOGY

• Women’s life expectancy increased

• Put them at risk for developing cancer
• Late first pregnant : cancer in pregnancy

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 CHEMOTHERAPY INDUCED
NAUSEA, VOMITING,
DIARRHEA

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PREDICTIVE FACTOR
• Most feared toxicities in chemotherapy
• Influenced by:
• Patient characteristic (younger)
• Emetogenicity of agent
• Anti emetic drugs administered
• Increased :
• Alcohol comsumption
• Hystory morning sickness
• Previous exposure to chemotherapy
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CHEMOTHERAPY CLASIFIED BY EMETIC RISK
• High risk
• Caused > 90%
• Cisplatin > 50 mg/m², cyclophosphamide > 1500 mg/m²
• Moderate risk
• Caused 31 – 90%
• Carbo, cisplatin < 50 mg, cyclo < 1500 mg
• Low risk
• Caused 10 – 30%
• Taxane, Gemcitabine
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CINV CLASSIFICATION
• Acute ( 0 – 24 hours)
• Delayed ( 24 – 120 hours)
• Anticipatory : learned response for poorly
controlled CINV
• Triggered by tastes, odors, sights, thoughts, anxiety
• Breakthrough and refractory: despite with
appropriate antiemetic therapy

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PATHOPHYSIOLOGY CIVN
• Initiated by stimulation vagal receptor in mocosa
intestine
• Chemo agent stimulated endocrine cells located in
mucosa small bowel
• Released local mediator such as: 5-
hydroxytryptamine (5-HT), substance-P,
cholecystokinin
• Afferent stimulus to hindbrain
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TREATMENT
• Pharmaceutical
• Selective 5-hydroxytriptmine 3 (5-HT3) receptor
antagonis : ondansetron, palonosetron,
• Substance P/Neurokinin 1 (NK1) receptor antagonis:
aprepitant
• Dopamine antagonist: metoclopramide
• Cannabinoids : tetrahydrocannabinol (THC)
• Non pharmaceutical
• Acupressure / Acupuncture
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DIARRHEA
• Occur from variety of etiologies
• Caused morbidity and mortality
• Abdominal radiation increased risk
• Treatment:
• Pharmaceutical: opioid loperamide, atropin,
somatostatin analog (octreotide acetate)
• Non pharmaceutical: bowel rest, hydration, electrolyte
replacement
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 PAIN

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COMMON SYMPTOM WHEN CURE IS NOT
POSSIBLE
• Vaginal bleeding or discharge
• Pelvic or back pain
• Urinary or bowel fistula
• Lower extremity oedema
• Deep venous thrombosis
• Dyspnea (anemia or lung metastase)
• Uremia
• Bowel obstruction
• Anorexia
• Liver metastase / failure
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PRINCIPLE OF PAIN MANAGEMENT
• Bilieve the patient
• Assess medical, psychological, spiritual, functional
factor contributing to patient pain report & distress
• Titrate analgesic, use opioids if pain severe
• When possible: long acting opioids
• If on opioid: must be on bowel regimen

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 NUTRITION

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CAUSES OF CANCER RELATED MALNUTRITIOIN
• Reduced food intake due to chemotherapy or radiation
• Deterioration in taste, smeel and apetite
• Altered food preferences/food avoidance/food aversion
• Dysphagia, odynophagia, partial or total GI obstruction
• Early satiety, nausea and vomiting
• Soreness, xerostomia, sticky saliva, painful throat
• Radiotherapy/chemotherapu induced mucositis
• Acute or chronic radiation enteritis
• Depression, anxiety, pain
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CONSEQUENCES OF CANCER RELATED
MALNUTRITION
• Reduced muscle function
• Reduced performance status
• Lower general health, lower social function, lower
outlook/happiness
• Tendency to depression, anxiety, insomnia
• High prescription and consultation rate
• Increased complication (surgery or chemotherapy)
• Increased chemotherapy induced toxicity
• Shorter overall survival
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 PSYCHO-ONCOLOGY

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PRINCIPLE
• Cancer is a devastating disease
• Its diagnostic is traumatic event
• Anxiety, depression and confused feeling
• The psychological impact depend:
• Medical parameter
• Patient coping abilities and emotional
• Financial support
• Gynecologic cancer:
• Femininity
• Sexuality
• Marital and family stability
• Childbearing

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PATIENT RESPONSES
• Patient must mobilize all their emotion, behavioral,
cognitive
• To find appropriate adaptive response
• This process called: coping
• Achieved by fighting, adopting or avoidance
• Abnormal response: need psychological support

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• The psycho-oncology offers a systematic approach
with questionaires and specific methodologies, but
the oncological gynecologist being in the first line of
the patient’s care, should be attentive to identify
psychological problem and find solution

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 WHEN SHOULD
TREATMENT STOP

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QUESTION: WHEN STOP?
• Involve:
• patient expectation
• physician knowledge and attitude
• scientific avidence
• How treatment affect the quality of life
• Aggressive care has no improvement in survival

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 QUALITY OF LIFE

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DEFINITION
• QoL in cancer patients is the difference, or the gap, that exist, at a
particular point in time, between the hopes and expectations of
the individual and the individual’s present experiences. (Calman,
Glasgow University)
• Good QoL is present when the individual’s hopes are reached and
satisfied by experience
• QoL is dynamic event, that change over time
• To improve QoL: narrowing the gap between hope and expectation
• It is a subjective event, is up to the patient not to the theurapeutic
team
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MULTIPLICITY OF FACTORS INFLUENCE QOL
• Mental and emotional state
• Physical or fucntional ability
• Frequency and severity of side effect
• Global life satisfaction
• Social status
• Sexuality
• Spiritual or religious well being
• Financial well being
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 EUTHANASIA

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MEDICAL DECISION CONCERNING THE END OF
LIFE (MDEL)
• Non treatment decision
• Alleviation of pain and/or other symptoms with
high dosages of opioids (APS)
• Euthanasia and physician assisted suicide (EAS)

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EUTHANASIA AND PHYSICIAN ASSISTED
SUICIDE (EAS)
• Part of terminal care in a few countries
• Legality, ethics and tehnique
• Effect on the bereaved family and friend

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