38649847 abc-of-palliative-care-2nd-ed

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38649847 abc-of-palliative-care-2nd-ed

  1. 1. ABC OFPALLIATIVE CARE SECOND EDITION Edited by Marie Fallon and Geoffrey Hanks Foreword by Derek Doyle
  2. 2. ABC OF PALLIATIVE CARE Second Edition
  3. 3. ABC OF PALLIATIVE CARE Second Edition Edited by MARIE FALLON St Columba’s Hospice Chair of Palliative Medicine, University of Edinburgh, Edinburgh and GEOFFREY HANKS Professor of Palliative Medicine, University of Bristol, Bristol Blackwell Publishing
  4. 4. © 1998 BMJ Books© 2006 by Blackwell Publishing LtdBMJ Books is an imprint of the BMJ Publishing Group Limited, used under licenceBlackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USABlackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UKBlackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, AustraliaThe right of the Authors to be identified as the Authors of this Work has been asserted in accordancewith the Copyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording orotherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the priorpermission of the publisher.First published 1998Second edition 20061 2006Library of Congress Cataloging-in-Publication DataABC of palliative care/edited by Marie Fallon and Geoffrey Hanks. — 2nd ed. p. ; cm. “BMJ Books.” Includes bibliographical references and index. ISBN-13: 978-1-4051-3079-0 (alk.paper) ISBN-10: 1-4051-3079-2 (alk.paper) 1. Palliative treatment. 2. Terminal care. I. Fallon, Marie. II. Hanks, Geoffrey W. C. [DNLM: 1. Palliative Care—methods. 2. Palliative Care—psychology. 3. Terminal Care.WB 310 A134 2006] R726.8.A23 2006 616 .029—dc22 2006009883ISBN-13: 978 1 4051 3079 0ISBN-10: 1 4051 3079 2A catalogue record for this title is available from the British LibraryCover image is courtesy of John Cole/Science Photo LibrarySet in 9/11 pt by Newgen Imaging Systems (P) Ltd, Chennai, IndiaPrinted and bound in Singapore by COS Printers Pte LtdCommissioning Editor: Eleanor LinesDevelopment Editors: Sally Carter, Nick MorganSenior Technical Editor: Barbara SquireEditorial Assistants: Francesca Naish, Victoria PittmanProduction Controller: Debbie WyerFor further information on Blackwell Publishing, visit our website:http://www.blackwellpublishing.comThe publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy,and which has been manufactured from pulp processed using acid-free and elementary chlorine-freepractices. Furthermore, the publisher ensures that the text paper and cover board used have metacceptable environmental accreditation standards.Blackwell Publishing makes no representation, express or implied, that the drug dosages in this bookare correct. Readers must therefore always check that any product mentioned in this publication is usedin accordance with the prescribing information prepared by the manufacturers. The author and thepublishers do not accept responsibility or legal liability for any errors in the text or for the misuse ormisapplication of material in this book.
  5. 5. Contents Contributors vi Foreword viii 1 The principles of palliative care 1 Balfour Mount, Geoffrey Hanks, Lorna McGoldrick 2 The principles of control of cancer pain 4 Marie Fallon, Geoffrey Hanks, Nathan Cherny 3 Difficult pain 8 Lesley Colvin, Karen Forbes, Marie Fallon 4 Breathlessness, cough, and other respiratory problems 13 Carol Davis, Gillian Percy 5 Oral health in patients with advanced disease 17 Jeremy Bagg, Andrew Davies 6 Anorexia, cachexia, nutrition, and fatigue 21 Kenneth Fearon, Matthew Barber 7 Nausea and vomiting 25 Kathryn Mannix 8 Constipation, diarrhoea, and intestinal obstruction 29 Nigel Sykes, Carla Ripamonti, Eduardo Bruera, Debra Gordon 9 Depression, anxiety, and confusion 36 Mari Lloyd-Williams10 Emergencies 40 Stephen Falk, Colette Reid11 The last 48 hours 44 James Adam12 Palliative care for children 48 Ann Goldman13 Communication 52 David Jeffrey14 The carers 56 Julia Addington-Hall, Amanda Ramirez15 Chronic non-malignant disease 59 Marie Fallon, Joanna Chambers, Francis Dunn, Raymond Voltz, Gian Borasio, Rob George, Roger Woodruff16 Community palliative care 68 Keri Thomas17 Bereavement 74 Marilyn Relf18 Complementary therapies 78 Michelle Kohn, Jane Maher Index 83 v
  6. 6. ContributorsJames Adam Karen ForbesConsultant in Palliative Medicine, Hunter’s Hill Marie Curie Macmillan Professorial Teaching Fellow in Palliative Medicine,Centre, Glasgow Department of Palliative Medicine, Bristol Haematology and Oncology Centre, BristolJulia Addington-HallProfessor of End-of-Life Care, University of Southampton Rob George Consultant in Palliative Medicine, Meadow House Hospice,Jeremy Bagg MiddlesexProfessor of Clinical Microbiology, Glasgow Dental Hospitaland School, Glasgow Ann Goldman CLIC Consultant in Palliative Care, Great Ormond Street Hospital for Children, LondonMatthew BarberConsultant Surgeon, Edinburgh Cancer Centre, Edinburgh Debra Gordon Clinical Nurse Specialist in Palliative Medicine, WesternGian Borasio General Hospital, EdinburghInterdisciplinary Palliative Care Unit, Department ofNeurology, Munich, Germany Geoffrey Hanks Professor of Palliative Medicine, University of Bristol, BristolEduardo BrueraProfessor of Oncology, UT MD Anderson Cancer Center, David JeffreyHouston, Texas, USA Consultant in Palliative Medicine, Borders General Hospital, ScotlandJoanna ChambersConsultant in Oncology and Palliative Medicine, Southmead Michelle KohnHospital, Bristol Complementary Therapy Adviser, LondonNathan Cherny Mari Lloyd-WilliamsDirector of Cancer Pain and Palliative Medicine, Share Zedek Professor, Academic Palliative and Supportive Care Studies Group,Medical Center, Jerusalem, Israel Division of Primary Care, University of Liverpool, LiverpoolLesley Colvin Lorna McGoldrickConsultant Anaesthetist, Department of Clinical Neurosciences, Clinical Nurse Specialist, Palliative Care, Western GeneralWestern General Hospital, Edinburgh Hospital, EdinburghAndrew Davies Jane MaherConsultant in Palliative Medicine, Royal Marsden Hospital, Consultant Oncologist, Mount Vernon Cancer Centre,London Middlesex Kathryn MannixCarol Davis Consultant in Palliative Medicine, Marie Curie Centre,Consultant in Palliative Medicine, Moorgreen Hospital, Newcastle-upon-TyneSouthampton Balfour MountFrancis Dunn Professor of Palliative Medicine, Department of Oncology,Consultant Cardiologist, Stobhill Hospital, Glasgow McGill University, Montreal, Quebec, CanadaStephen Falk Gillian PercyConsultant in Clinical Oncology, Bristol Haematology and Clinical Specialist Physiotherapist, Moorgreen Hospital,Oncology Centre, Bristol SouthamptonMarie Fallon Amanda RamirezSt Columba’s Hospice Chair of Palliative Medicine, University Professor of Liaison Psychiatry, Institute of Psychiatry,of Edinburgh, Edinburgh King’s College, LondonKenneth Fearon Colette ReidProfessor of Surgical Oncology, University of Edinburgh, Research Fellow in Palliative Medicine, Bristol HaematologyEdinburgh and Oncology Centre, Bristolvi
  7. 7. ContributorsMarilyn Relf Keri ThomasHead of Education, Churchill Hospital, Oxford Macmillan GP facilitator, ShrewsburyCarla Ripamonti Raymond VoltzPalliative Care Physician, National Cancer Institute of Milan, Consultant Neurologist, Institute for ClinicalMilan, Italy Neuroimmunology, Munich, GermanyNigel Sykes Roger WoodruffMedical Director, St Christopher’s Hospice, Sydenham, Director of Palliative Care, Austin and Repatriation Centre,London Heidelberg, Victoria, Australia vii
  8. 8. ForewordIt is almost impossible for a health care professional to avoid being called upon to care for people getting frailer as life ebbs away, tocare for them at their dying and to have to help and support their loved ones afterwards. Who can be insensitive to their pain, theirbreathlessness, their weakness and their fears? Who can forget how helpless they have felt at these times, how lost for words, howunskilled and unprepared. Doctors and nurses, whether generalist or specialist, can no more avoid these professional and personalchallenges than they can deny or avoid death itself. Palliative care – “the care of patients with active, progressive, advanced disease where the prognosis is short and the focus of care is the qualityof life” – is a basic human right, not a luxury for the few. Its principles are not peculiar to the care of the dying but are the integralfeatures of all good clinical care – freedom from pain and the alleviation so far as is possible, of all physical, psychosocial and spiritualsuffering; the preservation of dignity; the utmost respect for honesty in all our dealings with these patients and their relatives. The emergence in 1987 of palliative care as a medical sub-specialty (mentioned in the Preface to the first edition of this book)has brought about improvements in care, research, professional education and training, and in the understanding by the public andthe politicians of what needs to be done and what can be done for those at the loneliest time on their life journey. It has also had adownside. Many have come to suspect that providing palliative care requires unique people to do justice to this demanding work,unique skills to do it well, and more time than today’s doctors and nurses ever have. So easy is it to phone a palliative care specialistwhether working in a hospital, a specialist unit or in the community, and get advice or an admission that some are leaving thepalliative care of their patients to them. In fact only about 10% of terminally ill patients have problems so rare or so complex thatspecialist expertise is needed. All the others can be cared for by non-specialists if they learn the principles of palliative care, if theydevelop the right attitude to it, if they are willing to share themselves as well as their therapeutic skills… and if they study this book.One thing is undeniable – no-one is born with a built-in ability to provide excellent care. It has to be learnt from a book such as this,and hopefully from watching others with more experience, but that is a luxury some never have. In situations where too often the knee-jerk response can be “there is no more we can do”, the reader will find that there is alwaysa means of helping and of caring. It may be pharmacological or psychological, nursing or physiotherapy, occupational therapy, musicor art therapy, or complementary medicine. Often it may be no more, no less than enabling patients to open their hearts in thatatmosphere of safety created by the doctor or nurse who has learned to be honest, and is humble enough to listen and to learn. The reader will be surprised at how richly rewarding palliative care can be; how surprisingly often terminally ill patients speak ofthe sense of safety they feel when suffering has been relieved and they know everyone is being honest with them and the loved onesthey will leave behind. This can happen anywhere – in a hospital, in a hospice, in a nursing home or in someone’s home. This excellent book produced by editors and contributors with international reputations deserves to be read by every doctor andnurse who will ever offer palliative care – and that means most of us! Derek Doyle Retired consultant in palliative medicine Vice President, National Council for Palliative Care Founding Member and Adviser, International Association for Hospice and Palliative Careviii
  9. 9. 1 The principles of palliative careBalfour Mount, Geoffrey Hanks, Lorna McGoldrickComponents of palliative care Palliative care is the approach that improves the quality of life of patients and their families facing the problemsPalliative care is recognised by individualised, holistic models of associated with life threatening illness, through thecare, delivered carefully, sensitively, ethically, and prevention and relief of suffering by means of earlytherapeutically by using skilled communication with attention identification and impeccable assessment and treatmentto detail, meticulous assessment, and advancing knowledge. of pain and other problems, physical, psychosocial, and Wherever palliative care is used, its core ingredient is the spiritual (World Health Organization, 2005)quality of presence that the caregiver brings to the patient, away of caring that enables discernment of the ongoing needs ofthe patient and family as they evolve and emphasises beingalongside them. The focus is on all that is still possible in thistime of multiple losses, the patient’s and family’s quest formeaning, and sustaining their experience of connectedness asthey adapt to the challenges of the moment. The term “palliative care” implies a personalised form ofhealth care. It extends the healthcare professional’s mandatebeyond the biomedical model to the wider horizon necessary ifone is to attend to suffering as well as the biology of disease,caring as well as curing, quality of life as well as quantity of life. HealingThe patient and family or significant others are taken together asthe unit of care in assessment of needs related to illness. The aim Experience Quality of life Experience of suffering and of wholenessof palliative care is to support optimal quality of life and to foster anguish and integrityhealing—that is, a shift in response towards an experience ofintegrity and wholeness on the continuum of the quality of life. WoundingBeyond the physical The quality of life continuumMeticulous attention to the alleviation of symptoms is thefoundation of care of the whole person. Important psychosocialand spiritual concerns may be eclipsed by the presence ofuncontrolled pain, nausea, constipation, and the other symptomsof advanced disease. Optimal treatment demands carefulassessment of the multiple contributory factors to each symptom.If increasing doses of opioid are prescribed in response to painthat is escalating due to unrecognised existential anguish, theresult will be persistent pain, opioid toxicity, and ongoing distressfor the patient, family, and caregivers. If we are body, mind, andspirit, those domains are inseparable and interdependent.Thoughtful assessment of each complaint should be consideredin the context of the patient’s total suffering; therefore Palliative care: selected philosophical perspectives andthoughtful assessment is mandatory. assumptions G Nothing matters more than the bowels (Cecily Saunders)Not just symptom control G Humanise, personalise, de-institutionaliseControl of symptoms in palliative care commonly involves the G Clinical care grounded in qualitative and quantitative inquiryconcurrent use of six to eight or more medications. The goal is G Experience of illness viewed as a narrative: relational,consistently to prevent rather than treat symptoms. Effective meaningful, filled with potential G Assist progressive understanding of reality at a rate acceptable tomanagement depends on frequent adjustment to consistently the patientsustain the minimal effective doses of medication and an G “Reality” as illusion; subjectivity of experience; acknowledgmentemphasis on skilled nursing care as well as the use of the of mysterycomplementary skills of an interdisciplinary team experienced G Quiet efficiency, not hustle and bustlein end of life care. G Focus on quality of living in the present moment, not death Laboratory investigations—and even such non-invasive G Accompaniment: empathic presence to the other in the momentroutines as monitoring blood pressure, pulse, and G Team: led by the patient; egalitarian rather than hierarchical G Environment: centred on the patient, welcoming, peacefultemperature—are undertaken only if doing so may lead to G Uniqueness, limitations, defences of the patient/familyinterventions that will enhance the quality of life. G Healing of psyche: an innate potential Palliative care is founded on a philosophy that promotes G Potential for adaptation, integration, reconciliation,sensitivity to cultural, religious, sexual, and other defining transcendenceperspectives from the patient’s point of view; the intent to meet G Importance of compassion, celebration, community, paradox,patients where they are rather than where the caregivers feel humour G With unresolved symptoms, “Review! Review! Review!” (Robertthey should be; sensitivity to the determinants of coping, Twycross)particularly concerning major existential challenges for the 1
  10. 10. ABC of palliative carepatient, family, and caregivers (death; isolation; freedom—the Initial hospice programmes:absence of external structure; meaning); attention to the predominantly oncology and selected neurodegenerative diseasesmeaning of the illness for the patient, family, and caregivers; and Life prolonging therapy Palliative careattention to the need for relating to people in an empathic way. Palliative care relevance, current view:Application all end stage diseases and clinical settings Life prolonging therapyThe early successes of hospice care in alleviating the suffering of Palliative carepatients with cancer and those with motor neurone disease andsome other neurodegenerative diseases at the end of life has led Changes in allocation of resources with the development of palliative carenow to broad agreement concerning the relevance of palliativecare across the spectrum of disease and healthcare settings. Palliative careCare delivery G Affirms life and regards dying as a normal practice G Neither hastens nor postpones deathConsiderations in the provision of palliative care include a G Provides relief from pain and other distressing symptomsseamless continuity of care appropriate to the needs of the G Integrates the psychological and spiritual aspects of carepatient and the family, with options that include home care; G Offers a support system to help patients live as actively as possiblechronic inpatient care; acute, specialised inpatient (tertiary) until death G Offers a support system to help the families of patients copecare; consultation services available for those still receiving during the patient’s illnesses and in their own bereavementtreatment to modify the disease; day care with resources formultidisciplinary assessment; bereavement support for those atrisk of a complicated grief reaction. Essential components of palliative careSpecialist role G Control of symptoms G Effective communicationGeneral palliative care is practiced widely in specialties other G Rehabilitationthan palliative care. Multiprofessional teams who work full time G Continuity of carein palliative care, and are trained beyond the basic level, deliver G Terminal carespecialist palliative care. They aim to care for those patients and G Support in bereavementcarers who have complex physical, psychosocial, or spiritual G Education G Researchneeds that are difficult to manage. Their role is primarily aboutadvice, support, and education when they work alongside otherspecialties. Hospices and hospice wards have more directmanagement of patients and carers in an inpatient setting. Rolemodelling, service development in line with local, national, andWHO guidelines, education, and research are furthercomponents of the role.Multidisciplinary teamsCaring for patients and carers at a difficult time is synonymouswith palliative care. Each patient and carer will require aunique and individualised approach to incorporate all theirbiopsychosocial and spiritual needs. There cannot be auniversal optimum model for the delivery of care; adaptabilityand flexibility is paramount, and this is an increasing challengein today’s healthcare systems. A single profession, like a single model of care, can only failto meet the holistic fluctuating needs of patients and carers.The knowledge and skill of many professions—medical,nursing, pharmacy, social work, physiotherapy, occupationaltherapy, and chaplaincy—held together by endlesscommunication and teamwork is vital.Future challenges Dame Cecily Saunders, founder of St Christopher’s Hospice (reproduced with permission)New and evolving challenges in palliative care are emerging aspatients live longer with improved palliative tumoricidaltreatments. Symptoms that are difficult to control and arechronically debilitating test the resilience and resources ofweary patients, carers, and providers of health care. Educationand robust multiprofessional support are necessary to equipthose working in palliative care with the sustainable resilience2
  11. 11. The principles of palliative caredemanded by an unwavering quality of presence that continuesto effectively focus on quality of life and care and attend tosuffering of patients with longer and more difficultexperiences. Without research, advances in the science of control ofsymptoms and quality of care will stagnate and palliative care Further readingwill cease to meet the future needs of patients with advanced G Cassell EJ. The nature of suffering and the goals of medicine. 2nd ed.life threatening illnesses and their carers. Though there are New York: Oxford University Press, 2004. G Doyle D, Hanks GW, Cherny N, Calman K, eds. The Oxford textbooknumerous epidemiological surveys outlining problems, few of palliative medicine. 3rd ed. Oxford: Oxford University Press,researchers do good quality interventional studies or try to 2004.extend knowledge through collaboration with basic science. G Halpern J. From detached concern to empathy: humanizing medicalMore collaborative research involving basic science and other practice. New York: Oxford University Press, 2001.appropriate specialties is needed urgently. G Kearney M. A place of healing: working with suffering in living and The late Dame Cecily Saunders and her vision of combining dying. Oxford: Oxford University Press, 2000. G Saunders C, Sykes N. The management of terminal disease. 3rd ed.optimum care, observation, and appropriate research London: Edward Arnold, 1993.established the essential ingredients of modern palliative care; G Yalom ID. Existential psychotherapy. New York: Basic Books, 1980.this should remain our basis for the future. 3
  12. 12. 2 The principles of control of cancer painMarie Fallon, Geoffrey Hanks, Nathan ChernyPain is a complex phenomenon which is the subjectiveendpoint of a variety of physical and non-physical factors. For Physical pain Integrated pain and • Other symptoms mood pathwaysmost patients, physical pain is only one of several symptoms of • Adverse effects of treatmentcancer. Relief of pain should therefore be seen as part of acomprehensive pattern of care encompassing the physical, Depression Angerpsychological, social, and spiritual aspects of suffering. Physical • Loss of social position • Bureaucratic bungling • Loss of job prestige • Delays in diagnosisaspects of pain cannot be treated in isolation from other and income • Unavailable physiciansaspects, nor can patients’ anxieties be effectively addressed • Loss of role in family Total pain • Uncommunicativewhen patients are suffering physically. The various components • Insomnia and chronic physicians fatigue • Failure of therapymust be addressed simultaneously. • Sense of helplessness • Friends who do not Our understanding of the basic mechanisms of pain has • Disfigurement visitimproved considerably over the past few years. Thisunderstanding has included a greater appreciation of the Anxiety • Fear of hospital or nursing homerelationship between the physical injury, pain pathways, and • Fear of painour emotional processing of this information; these factors are • Worry about family and finances • Fear of deathinterlinked in the nervous system, rather than working in • Spiritual unrest, uncertainty about futureparallel. We now understand from basic science more of themechanisms of total pain than ever before. It is clear that Factors affecting patient’s perceptions of pain (adapted from Twycross RG,anxiety, fear, and sleeplessness feed into the limbic system and Lack SA, Therapeutics in terminal disease, London: Pitman, 1984)cortex. In turn, the brain talks back to the spinal cordmodifying pain input at spinal levels. This then feeds back tothe brain and a loop is established. Analgesic drugs commonly recommended for Mood disturbance is common in patients with uncontrolled cancer paincancer pain and may need specific management, however,sometimes it will improve dramatically with effective resolution Mild pain G Aspirin 600 mg four times a dayof pain. Hence the first principle of managing cancer pain is an G Paracetamol 1 g four times a dayadequate and full assessment of the cause of the pain, bearing Moderate painin mind that most patients have more than one pain. With G Codeine 60 mg (plus non-opioid drug) four timeseffective assessment and a systematic approach to the choice of a dayanalgesics using the WHO’s three step analgesic ladder, over Severe pain80% of cancer pain can be controlled with the use of G Morphine 5–10 mg (starting dose) every fourinexpensive drugs that can be self administered by mouth at hoursregular intervals.The WHO analgesic ladder Non-drug treatments used in management of cancer painThe analgesic ladder remains the mainstay of our approach to G TENS (transcutaneous electrical nerve stimulation)analgesia, though this was never designed for use in isolation. G PhysiotherapySurgery, radiotherapy, and appropriate tumoricidal treatments G Acupuncturewill have an important role in some patients, as will non-drug G Relaxation therapytreatments. A combined approach can lead to optimumanalgesia with minimum side effects. Analgesic drugs do, however, remain key in managingcancer pain. The choice of drug should be based on theseverity of the pain, not the stage of disease. Drugs should be Freedom from cancer painadministered in standard doses at regular intervals in a stepwise 3 Opioid for moderate to severe pain epfashion. If a non-opioid or, in turn, an opioid for moderate ± Non-opioid St ± Adjuvantpain is not sufficient, an opioid for severe pain should be used. When a non-opioid drug is used with an opioid for Pain persisting or increasing 2 epmoderate pain, many patients find combination formulations Opioid for mild to moderate pain Stmore convenient to use. Care must be taken with the dose of ± Non-opioid ± Adjuvanteach drug in the formulation; some combinations of codeine 1or dihydrocodeine with aspirin or paracetamol (including co- Pain persisting or increasing ep Stcodamol and co-dydramol) contain subtherapeutic doses of the Non-opioidopioid. The decision to use an opioid for severe pain should be ± Adjuvantbased on severity of pain and not on prognosis. Pain WHO analgesic ladder (adapted from WHO’s Cancer pain relief and palliative care technical report series 804)4
  13. 13. The principles of control of cancer painAdjuvant analgesics Common adjuvant analgesics for cancer painAdjuvant analgesic drugs may be usefully added at any stage. Drugs IndicationsAn adjuvant analgesic is a drug whose primary indication is for Non-steroidal anti- Bone painsomething other than pain but that has an analgesic effect in inflammatory drugs Soft tissue infiltrationsome painful conditions. Examples are corticosteroids, non- Hepatomegalysteroidal anti-inflammatory drugs, tricyclic antidepressants, Corticosteroids Raised intracranial pressureanticonvulsants, and some antiarrhythmic drugs. Soft tissue infiltration Nerve compressionTricyclic antidepressants and anticonvulsants HepatomegalyTricyclic antidepressants are effective in relieving neuropathic Antidepressants Nerve compression or infiltrationpain. There are no significant differences in efficacy between Anticonvulsants Paraneoplastic neuropathiesthe different tricyclic antidepressants, though unfortunately, Antiarrhythmicsside effects often limit their use. While the evidence for Bisphosphonates Bone painvenlafaxine is less strong, its use can be justified, particularly inpatients with both neuropathic pain and low mood. There is alack of high level evidence of the efficacy of selective serotonin Fear, anxiety, sleep, Locationreuptake inhibitors (SSRIs) for treating neuropathic pain. punishment, and The anticonvulsants carbamazepine, phenytoin, sodium autonomic changes intensity Cortexvalproate, clonazepam, gabapentin, and pregabalin are Limbic system Attention Thalamuseffective in treating neuropathic pain. Benefit is independent VPLof the characteristics of the pain. Gabapentin and pregabalin Parabrachial PAGare licensed for treatment of neuropathic pain. There is no measurable difference in the analgesic benefit RVM Dorsal columns The brain canof the two drug classes (tricyclic antidepressants or + – talk back toanticonvulsants) in neuropathic pain or in the number of the spinal cordpatients needed to treat before a minor or major adverse effect Lamina Ioccurs. Gabapentin and pregabalin, however, can have fewer Spinal Peripheralside effects in many patients, though systematic examination of changes mechanismsthis is awaited in patients with cancer pain. and spinal inputs Patients with neuropathic pain should have a trial of a Lamina Vtricyclic antidepressant or venlafaxine or an anticonvulsant. Motor activation/autonomicThe choice of drug should be based on relative Integration of pain and emotion at higher centres. With permission fromcontraindications, possible drug interactions, and risk of side Professor A. Dickensoneffects for each patient. Antidepressants and anticonvulsantsmay occasionally be prescribed simultaneously, though it isgood clinical practice to introduce only one drug at a time.Opioid analgesics for severe pain The skilled use of morphine will confer benefit rather thanMorphine is the most commonly used opioid in this group. harm, but many patients express fears, which should beWhen possible, it should be given by mouth, the dose tailored discussedto each patient, and doses repeated at regular intervals so thatthe pain is prevented from returning. There is no arbitraryupper limit, but negative attitudes to using morphine still exist. Opioid alternatives to morphine Dose titration—A normal release formulation of morphine G Hydromorphone—Titration is usually with hydromorphone normal(either elixir or tablet), with a rapid onset and short duration of release capsules; when pain is controlled, patients may convert toaction, is preferred for dose titration. The simplest method is to controlled release preparation. As it is about seven times strongerprescribe a regular four hourly dose but allow extra doses of the than morphine, care is needed with patients with no previoussame size for “breakthrough pain” as often as necessary. After 24 exposure to opioidsor 48 hours, the daily requirements may be reassessed and the G Oxycodone—Can be up to 1.5 times stronger than morphine.regular dose adjusted as necessary. This process is continued Similar titration as morphine and hydromorphone G Methadone—see chapter 3, Difficult painuntil pain relief is satisfactory. By this method, the many factors G Fentanyl—Self adhesive patches provide transcutaneous deliverythat contribute to the variability in dose are taken into account. of strong opioid. The patch is changed once every 72 hours. It isThese include the severity of the pain, the type of pain, the used with normal release morphine for breakthrough pain. It isaffective component of pain, and variation in pharmacokinetic suitable only for patients whose pain is stable because of the timeparameters. The regular four hourly dose may range from required to titrate the dose upwards. It takes up to 24–48 hours5–10 mg to 250 mg (or the equivalent in controlled release before peak plasma concentrations are achieved G Buprenorphine—Transdermal, as above, and may have advantagestablets). The dose is titrated against effect, though few patients in patients with renal dysfunctionneed high doses—with most requiring 200 mg a day. G Diamorphine, limited availability, is a semisynthetic derivative and Maintenance dose—Patients with advancing disease and a prodrug of morphine. Use of oral diamorphine is an inefficientincreasing pain may require continual adjustment of dose. For way of delivering morphine to the body, but, for parenteralmany patients, however, there is a period of stability during administration, its greater solubility confers an advantage overwhich the dose required remains unchanged or needs only morphinesmall adjustments, and this may last for weeks or months or G Pethidine is a short acting opioid and not appropriate for the management of chronic painsometimes longer. Once pain is relieved, maintenance will be 5
  14. 14. ABC of palliative carewith a controlled release preparation of morphine. Controlledrelease morphine is available as a once daily preparation thatremains effective for 24 hours or a twice daily preparation witheffects that last 12 hours.Alternative routes of administrationThe rectal bioavailability of morphine is similar to its oralbioavailability, and it is available in suppository form. The rectalroute may be appropriate for patients unable to take drugs bymouth, and the same dose as that taken orally should be givenevery four hours. For many patients, however, it may be more convenient to Portable syringe driver for automatic drug infusionconvert directly to a subcutaneous infusion of opioid via aninfusion device such as a portable, pocket sized, syringe driver.This simple technique allows continuous infusion of opioidanalgesics in patients unable to take drugs by mouth. Therelative potency of opioids is increased when they are givenparenterally: the oral dose of morphine should be halved to getthe equianalgesic dose of subcutaneous morphine and halvedor divided by three for subcutaneous diamorphine, dependingon the clinical situation. Rarely, patients may require intravenous administration,which can be appropriate for those with an indwelling centralline, particularly children.Which opioid for cancer pain?Comparative trials of opioids in cancer pain are extremelydifficult to perform and do not always answer our questionsbecause of the complexity of the populations studied. A tensionexists between the need to have good quality randomised Rationale for alternative opioidscontrolled trials to provide evidence for pharmacotherapy of G Basic pharmacology of the drug and particular propertiescancer pain and the appropriateness and complexities of such relating to renal, hepatic, and cognitive impairmenttrials in patients with advanced cancer. G Progress in basic science, which has illuminated the genetic differences between individuals in response to opioids No strong evidence supports the superiority of one opioidover another. However, the balance between analgesia and sideeffects varies among opioids because of factors such aspharmacokinetic profiles, routes of administration, and geneticvariability in opioid responses. The transdermal route, which can be used with fentanyl ortransdermal buprenorphine, can be useful in patients withswallowing difficulties. Oxycodone or hydromorphone mayprovide an alternative to morphine if hallucinations ordisturbed sleep are troublesome. Any opioid can accumulate in patients with renaldysfunction. It is clear we do not fully understand the variousmetabolites from different opioids. Care should always be takenand in such patients opioid doses should generally be lower Common adverse effects of opioidsthan normal, with increased intervals between doses, or even G Sedation—Some sedation is common at the start of treatment,administered on an “as required” basis. It is usually acceptable but in most patients it resolves within a few daysto consider use of drugs such as fentanyl, alfentanil, G Nausea and vomiting—Nausea is common in patients taking oralhydromorphone, and buprenorphine. morphine, vomiting rather less so. These are initial side effects and usually resolve over a few days, but they can easily be controlled—metoclopramide (10 mg every eight hours) orTolerance, addiction, and physical haloperidol (1.5 mg at night or twice daily) is effective for most patientsdependence G Constipation develops in almost all patients and should be treated prophylactically with laxativesTolerance to opioids is rarely seen in the clinical practice of G Dry mouth is often the most troublesome adverse effect formanaging cancer pain. Requirements for increasing doses of patients. Patients should be advised on simple measures tomorphine can usually be explained by progressive disease combat this, such as frequent sips of iced drinks, saliva replacements, or saliva stimulantsrather than pharmacological tolerance. Psychological dependence or addiction is not a problem,except in some patients with pre-existing addiction. Ifalternative methods of pain control are used (such as nerve6
  15. 15. The principles of control of cancer painblocks) it is usually possible to reduce the dose of the analgesicor even withdraw it without adverse psychological effects.Physical dependence can occur, and this physiological responsecan manifest itself as a flu-like illness in some patients if anopioid is discontinued suddenly. This can be managed easily bya more gradual withdrawal of the opioid. Factors that affect the ability to tolerate opioidsOpioid toxicity G The degree of responsiveness of the pain to opioid analgesiaThere is wide variation, both between individuals and within G Previous exposure to opioidsindividuals over time, in the dose of opioid that can be G Rate of titration of the dosetolerated. Though toxicity can be frightening and life G Concomitant medicationthreatening, it is usually reversible if it is diagnosed early. G Concomitant disease Opioid toxicity may present as subtle agitation, seeing G Genetic factors G Biochemical factors such as renal functionshadows at the periphery of the visual field, vivid dreams, visualand auditory hallucinations, confusion, and myoclonic jerks.Agitated confusion may be misinterpreted as uncontrolled painand further opioids given. A vicious cycle then follows, in whichthe patient is given sedation and may become dehydrated,resulting in the accumulation of opioid metabolites and furthertoxicity. Management includes reducing the dose of opioid,ensuring adequate hydration, and treating the agitation withhaloperidol (1.5–3 mg orally or subcutaneously, repeatedhourly as needed). If toxicity is severe and opioid analgesia isstill needed, then a switch in opioid usually leads to a fasterrecovery. If a different opioid is required, a lower dose than theequianalgesic dose should usually be prescribed. Before the more sophisticated use of opioids, opioid toxicitywas often mislabelled as “terminal agitation.”Opioid responsivenessSome pains do not respond well to opioids. Although no paincan be assessed as unresponsive to opioids before a carefultherapeutic trial of the drug, some pains are more commonlyunresponsive. These include bone pain related to movement Further readingand some cases of neuropathic pain. Adjuvant drugs, G Doyle D, Hanks G, Cherny NI, Calman K. Oxford textbook ofradiotherapy, and anaesthetic block techniques may be helpful palliative medicine. Oxford: Oxford University Press, 2003.in such cases. Radiotherapy provides effective relief of pain G Sykes N, Fallon M. Cancer pain. Arnold: 2002. G WHO Expert Committee. Cancer pain relief and palliative care.from bone metastases in about half of cases—a single fraction is World Health Organ Tech Rep Ser 1990;804:1–75.often sufficient, thus avoiding frequent hospital visits. Problemswith difficult pain will be addressed in the next chapter. 7
  16. 16. 3 Difficult painLesley Colvin, Karen Forbes, Marie FallonPain occurs in up to 70% of patients with advanced cancer, andin about 65% of patients dying from non-malignant disease. Formost of these patients (about 80%) pain can be controlled byusing a simple, stepwise approach and a limited number of oralanalgesics as set out in the WHO’s analgesic ladder (chapter 2).About 10% of patients will require more complex, sometimesinvasive, management to control their pain, leaving another10% with cancer pain that is difficult to control. This group of patients with “difficult pain” present complexmanagement problems. Their pain often falls into one of threecategories: it responds poorly to opioids, it is episodic andbreaks through despite background opioid analgesia, oropioids are irrelevant in its management.Opioid irrelevant painPain is not just a physical experience. Patients with pain that Computed tomography scan showing advanced pelvic disease from colorectal tumour resulting in severe paindoes not respond to escalating doses of opioids should bereassessed and other contributors to their pain explored. “Totalpain” is best treated by exploring the underlying issues, ratherthan using opioids. The term “total pain” is used to describe thefinal sensation of pain perceived by a patient, acknowledgingthat this perception can be exaggerated by factors other than a Patients may be overwhelmed by their situation and thephysically noxious stimulus—for example, psychosocial distress. central nervous system can express this as physical pain, though social, psychological, or spiritual factors may be major componentsPain that responds poorly to opioidsThe European Association for Palliative Care (EAPC) guidelineson the use of morphine and alternative opioids in cancer painconfirm oral morphine as the opioid of choice for moderate tosevere pain. Dose titration with normal release morphine every About 10% of patients will have pain that responds poorly tofour hours, with the same dose for breakthrough pain as opioids and is uncontrolled even with a dose of morphine sufficient to give them intolerable side effectsrequired, is suggested. The patient’s 24 hour morphinerequirement can then be reassessed daily and their regular doseadjusted accordingly. Measures to treat such patients includeexploring psychosocial issues, managing the side effects,reducing the dose of opioid, switching to an alternative opioid,or changing the route of administration. The use of adjuvantdrugs or co-analgesics may be appropriate, depending on thecause of the pain. Many such patients will have neuropathic pain.Neuropathic painNociceptive pain results from real or potential tissue damage.Neuropathic pain is caused by damage to the peripheral orcentral nervous system. A simple definition is “pain in an area ofabnormal sensation.” Pain may be described as aching, burning,shooting, or stabbing and may be associated with abnormalsensation; normal touch is perceived as painful (allodynia). Itmay be caused by tumour invasion or compression but also bysurgery, radiotherapy, and chemotherapy. Many patients haveneuropathic pain that responds to opioids, and so initialmanagement should include a trial of opioids. Patients whoremain in pain will require additional measures. The early addition of adjuvant analgesics, such as a tricyclicantidepressant or an anticonvulsant, should be considered. Thenumber needed to treat is 3 for both categories. There is noevidence for a specific adjuvant for specific descriptors of Classical changes associated with a brachial plexopathy due to a rightneuropathic pain. Pancoast tumour: oedema, trophic changes, muscle wasting8
  17. 17. Difficult pain In addition, there is no evidence for combining adjuvants.In clinical practice, an adjuvant is chosen for an individualpatient after all symptoms and potential side effects areconsidered. Doses should be titrated to balance analgesia withadverse effects. If titration has reached a limit and pain hasonly partially responded then a second adjuvant may be addedin some cases. This usually means a reduction in the dose ofthe first. A common example of combining adjuvants isgabapentin, which at maximum tolerated dose can sometimesbe reduced to allow the addition of amitriptyline.Adjuvant analgesics*Drug Dose Indications Side effectsNSAIDs—for example, 50 mg oral every 8 hours (slow Bone metastases, soft tissue Gastric irritation and bleeding, fluiddiclofenac or COX 2 NSAID release 75 mg every 12 hours); infiltration, liver pain, retention, headache; caution in renal(evidence of GI side effects) 100 mg per rectum once a day inflammatory pain impairmentSteroids—for example, 8–16 mg a day; use in morning; Raised intracranial pressure, Gastric irritation if used together withdexamethasone titrate down to lowest dose that nerve compression, soft NSAID, fluid retention, confusion, controls pain tissue infiltration, Cushingoid appearance, candidiasis, liver pain hyperglycaemiaGabapentin 100–300 mg nightly (starting dose) Nerve pain of any cause Mild sedation, tremor, confusion (titrate to 600 mg every 8 hours; higher dose may be needed)Amitriptyline (evidence for 25 mg nightly (starting dose) Nerve pain of any cause Sedation, dizziness, confusion, dryall tricyclics) 10 mg nightly (in elderly mouth, constipation, urinary retention; patients) avoid in patients with cardiac diseaseCarbamazepine (evidence 100–200 mg nightly Nerve pain of any cause Vertigo, sedation, constipation, rashfor all anticonvulsants) (starting dose)*Drugs with a primary indication other than pain, but analgesic when used as above.Non-pharmacological techniquesThere are several non-pharmacological techniques for themanagement of neuropathic pain.Psychological techniquesPsychological techniques, such as cognitive behaviouraltherapies, include simple relaxation, hypnosis, and biofeedback.These methods focus on overt behaviour and underlyingcognitions and train the patient in coping strategies andbehavioural techniques. Though this is clearly of more use inchronic non-malignant pain rather than in patients with cancerpain, simple relaxation techniques should not be forgotten.Stimulation therapiesAcupuncture has been used successfully in eastern medicine forcenturies. There does seem to be a scientific basis foracupuncture, with release of endogenous analgesics within thespinal cord. Acupuncture is particularly useful for myofascialpain, which is a common secondary phenomenon in manycancer pain syndromes. Transcutaneous electrical nerve stimulation (TENS) may have asimilar mechanism of action to acupuncture. There is evidenceto support its use in both acute and chronic pain. Herbal medicine and homoeopathy are widely used for pain, butoften with little evidence for efficacy. Regulations on safety forthese treatments are limited compared with those for TENS for control of neuropathic pain that responds poorly to opioidsconventional drugs, and doctors should be wary ofunrecognised side effects that may result.Episodic painIn 2002 an EAPC working group suggested the term episodicpain to describe “any acute transient pain that is severe and hasan intensity that flares over baseline.” Episodic pain thusencompasses breakthrough pain and incident pain. 9
  18. 18. ABC of palliative careBreakthrough pain includes pain returning before the nextdose of opioid is due or acute exacerbations of pain occurringon the background of pain usually controlled by an opioidregimen. Incident pain is usually defined as that occurring dueto a voluntary action, such as movement or passing urine orstool. Pain due to bony metastases exacerbated by movement orweight bearing can be particularly problematic.Incident painPatients with bony metastases in the spine, pelvis, or femoramay have pain that escalates on movement, walking, standing,or even sitting. Opioid analgesics along with non-steroidal anti-inflammatory drugs are the mainstay of treatment, with the aimof making the patient comfortable at rest. Increasing the opioiddose further is often unhelpful as a dose sufficient to makemovement possible is too sedating when the resting patient’sopioid requirement is decreased. Rescue or breakthrough dosesof normal release opioid are usually used in anticipation of Radiographs showing lystic lesions in femur (left) and internal stabilisationmovement, along with non-drug measures such as radiotherapy, of bone (right)possible surgery, and appropriate aids and appliances. Bisphosphonates are interesting drugs established in theprevention of skeletal events due to metastases in most solidtumours. In some patients, analgesia can be achieved acutely,and trial evidence is emerging for good analgesia in pain dueto bone metastases.Interventional techniquesBefore interventional techniques are considered, it is importantto exclude untreated depression, general anxiety, and distress(though untreated pain may also lead to any or all of these). Chapter 2 discusses the role of trying a different opioid.The fundamental limiting factor in most patients withuncontrolled difficult pain is the inability to give higher dosesbecause of side effects. It is worthwhile remembering all thestrategies to “open the therapeutic window,” including using adifferent drug. Methadone deserves a special mention in this context. Ithas unusual properties, which we do not fully understand. It Computed tomogram of enlarged liver due to metastatic spread of cancerhas a different receptor binding profile from the pure (reproduced with permission from Times Mirror International Publishing)agonists and can be remarkably potent at small doses. It is not unusual to achieve markedly superior analgesia anda better side-effect profile with a switch to methadone. Inaddition, difficult elements of a pain—such as neuropathic orincident pain, or both—may become easier to control. Methadone equianalgesic conversion—seek specialist Starting or switching to methadone can be complicated in advicesome patients, and specialist advice should usually be sought. NB: the ratio depends on the dose of previous opioid G If morphine 30–90 mg (oral) use ratio of 4:1 (for instance, morphine 30 mg is approximately equivalent to 7 mg ofInvasive analgesic techniques methadone) G If morphine 90–300 mg (oral) use ratio of 8:1 (for instance,Despite appropriate use of analgesia and non-drug therapies, morphine 300 mg (oral) is approximately equivalent to 35 mgchemotherapy, and radiotherapy by multidisciplinary teams, a methadone (oral)) G If morphine 300 mg (oral) use ratio of 12:1 (for instance,considerable number of patients will still have uncontrolled morphine 400 mg (oral) is approximately equivalent to 35 mgpain or unacceptable side effects, or both. methadone (oral)) Such patients should be considered for some form of invasive G If previous morphine dose is much higher than 300 mg, the doseanalgesic technique as part of their overall management. This ratio will be higher than 12:1may range from a simple nerve block to more invasivetechniques such as regional or neurodestructive blocks. The choice of technique is influenced by:G Patient’s expectations—Adequate assessment of pain is the first step in management. Involvement of patients and relatives is important and aids decisions about treatmentG Prognosis and required duration of analgesia—Although often difficult to predict, prognosis will affect how appropriate any10
  19. 19. Difficult pain particular intervention may be. Further planned oncological Examples of invasive analgesic techniques treatment may require short term use of interventions for pain control Peripheral CentralG Pathology—The site and extent of disease will affect the Peripheral nerve block Non-destructive response to analgesics and direct which interventions have a G Intercostal G Epidural G Femoral G Intrathecal high chance of improving pain control. Plexus or nerve root G Sciatic involvement is common, as is incident painG Personnel—Early involvement of pain specialists in a Major nerve block Neurosurgical/destructive G Brachial plexus G Rhizotomy multidisciplinary setting is important for planning analgesic G Psoas G Cordotomy strategies. This can help to minimise the length of stay in G Paravertebral sensory nerve root G Intrathecal phenol hospital and reduce problems with severe uncontrolled pain. ablation Local availability of expertise and adequate training of staff G Coeliac plexus and relatives must be considered when technique is selected. A basic rule is that the technique with the least likelihoodof severe side effects should be chosen by using simpletechniques before progression to more complex strategies. In general, neurodestructive techniques should be reservedfor when other measures have failed or when life span isobviously limited. Vertebra Spinal cordSpinal routes of drug deliveryWith improvements in catheter and pump technology, use ofspinal lines is becoming more common in pain control. If thetechnique is carried out by appropriately trained personnel,complication rates are low, allowing flexible, long termanalgesia that can be used in an outpatient setting. Catheterscan be inserted either into the epidural space or into thesubarachnoid (intrathecal) space, where the cerebrospinal fluidis found. The line may be tunnelled subcutaneously to reduce Kidneyrisks of infection and movement of the catheter. The choice of Inferior vena cavatechnique depends on several factors. AortaDrugsAs the patients who need this technique tend to have complex Coeliac plexus nerve blockpain problems, multimodal analgesia has the best results. Acombination of low dose local anaesthetic, opioid, andclonidine is effective for most patients. Midazolam can beuseful as an additional agent, particularly if there are problemswith opioid tolerance. If ketamine is used then it should bepreservative-free to reduce problems with neurotoxicity. Theinitial conversion of opioid dose from oral or systemic opioid isvariable and depends on the opioid used and comorbidity ofthe individual patient. Long acting opioids should be stoppedbefore the line is inserted and the patient converted to shortacting agents. An approximate dose calculation fromsubcutaneous diamorphine is: Factors affecting choice of regional technique Epidural IntrathecalG Epidural: 1/10 of systemic dose ProceduralG Intrathecal: 1/10 of epidural dose G Simple procedure—local G Sedation or general anaesthesiaThus, if a patient was on 100 mg of subcutaneous diamorphine a anaesthetic with or without usually required sedation G Deep fixation at time ofday, the equivalent epidural dose would be 10 mg and the G Fixation can be difficult insertionequivalent intrathecal dose would be 1 mg per 24 hours. G Catheters not designed for G Silastic catheter designed for The initial solution used for epidural infusion is normally: long term use long term use G Drug spread may be limited, G Drug spreads within CSF, unlessG 9 ml 0.5% bupivacaine especially if there is tumour obstruction to flow; lipidG 75–150 g clonidine in the epidural space, or solubility determines degreeG Diamorphine according to individual patient. scarring related to of spread radiotherapy G Safety—catheter can only This gives a total volume of 10 ml infused over 24 hours. G Safety—catheter migration to migrate OUT of intrathecal Should there be a major problem with pump malfunction, intrathecal space delivering spaceand the whole syringe were accidentally given at once, this should potential overdosenot give a major life threatening overdose. Education and Prognosistraining of staff is important to minimise potential complications. Short term use: Longer term use: G Limited prognosis G Several different options—for G Other definitive treatment example, external or fullyThe future planned—for example, implantable radiotherapyAgents not currently widely available in the UK that may be G Trial for intrathecal linehelpful in managing patients with cancer pain include: 11
  20. 20. ABC of palliative careG Lidocaine patches—These are currently available in the US but Potential complications of spinal line not in the UK. They have a good side effect profile and studies have shown efficacy in neuropathic pain. We have also Complication Sign/symptom Action used them in our centre for bone pain, particularly vertebral CSF leak Severe headache Lie flat, encourage metastases, with some success. (postural) fluid intake (iv ifG Pregabalin—This agent is a 3-alkylated analogue of GABA ( - necessary); blood amino butyric acid), with a similar pharmacological profile to patch gabapentin, acting via the 2/ subunit on voltage gated Infection Local signs, pyrexia Avoid—aseptic technique for any calcium channels in the central nervous system. However, it dressing changes, has greater potency than gabapentin. Randomised controlled line changes etc; trials to date have shown efficacy against some forms of antibiotics neuropathic pain and an improved sleep pattern. Side effects Cord compression— Signs of cord Rare, may need seem similar to those seen with gabapentin. Titration of dose may be secondary to compression— surgical treatment is easier than with gabapentin. tumour, haematoma, sensory level,G N-methyl-d-aspartate (NMDA) subtype selective agents—Currently abscess weakness, may be available agents are non-selective. There is evidence from pain animal models that particular subtypes of the NMDA Catheter block or Acute increase in Replace catheter receptor may have potential for analgesia with reduced side fracture pain, may be leakage of infusion fluid effects and opioid sparing effects. These include agents Catheter Leakage of infusion Wrap in sterile saline acting at the glycine-B modulatory site or the NR2B subunit. disconnection fluid from soaked swabG Calcitonin gene-related peptide (CGRP) antagonists—CGRP is disconnection site immediately found in sensory neurones. Non-peptide analogues with a Replace syringe, line, favourable pharmacokinetic profile may have potential as and distal filter analgesics. Complications related to drugs Complication Sign/symptom Action Opioid withdrawal Agitation, insomnia, Increase opioid dose etc either via catheter or short acting oral doseFurther reading Opioid toxicity Hallucinations, Decrease dose, stopG Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, Mc Quay HJ, sedation, twitching, opioids by other et al. Morphine and alternative opioids in cancer pain: the EAPC respiratory routes, use naloxone recommendations. Br J Cancer 2001;84:587–93. depression if clinically importantG Mercadante S, Radbruch L, Caraceni A, Cherny N, Kaasa S, respiratory Nauck F, et al. Steering Committee of the European Association depression for Palliative Care (EAPC) Research Network. Episodic Acute opioid Requiring rapid Add midazolam to (breakthrough) pain: consensus conference of an expert tolerance dose escalation infusion mixture, working group of the European Association for Palliative Care. despite stable situation switch to different Cancer 2002;94:832–9. with tumour opioidG Portenoy R, Forbes K, Lussier D, Hanks GW. Difficult pain problems: an integrated approach. In: Doyle D, Hanks GW, Pruritus— Itching—often nasal Naloxone (low dose), Cherny N, Calman K, eds. Oxford textbook of palliative medicine. 3rd uncommon with change or stop ed. Oxford: Oxford University Press, 2003:438–58. long term use opioidG World Health Organization. Cancer pain relief. Geneva: WHO, Urinary retention— Unable to pass urine Catheterise 1996. more common inG Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of men World Health Organization Guidelines for cancer pain relief: a Excess motor block Leg weakness Decrease local 10-year prospective study. Pain 1995;63:65–76. anaesthetic dose12
  21. 21. 4 Breathlessness, cough, and other respiratory problemsCarol Davis, Gillian PercyRespiratory problems are common in patients with advancedincurable disease. This article describes palliation in adults withmalignant disease, but the principles can be applied to manytypes of non-malignant disease. A detailed history, examination, and appropriateinvestigations are needed to establish the most likely cause of anysymptom. The degree of functional impairment should beassessed, as should the influence of factors that affect the severityof the symptom, including pre-existing diseases (for example,chronic obstructive pulmonary disease, COPD), exacerbatingfactors (for example, anaemia, ascites, or profound anxiety), andadditional factors (for example, pulmonary embolism, infection,or left ventricular failure). All influence management.BreathlessnessBreathlessness has non-physical as well as physical aspects and,like pain, can be defined by what a patient says it is. It is theunpleasant sensation of being unable to breathe easily. It is Radiograph of patient with malignant pericardial effusion and secondarycommon in the terminal stages of cancer: in one survey 70% of pleural effusion causing breathlessness1700 patients experienced breathlessness during their last sixweeks of life. It is a particularly distressing and frighteningsymptom, not only for patients but also for carers. Activity,levels of anxiety, speed of onset, and previous experience mayinfluence patients’ perception of breathlessness and its severity. While there is often an obvious cause (such as pleural General principles of managing breathlessnesseffusion or extrinsic bronchial compression), in some patients G Reassurance to patient, family, and non-professional andno cause is found despite thorough assessment. Little is known professional carersabout the effects of cachexia on respiratory muscle function; G Explanationhyperventilation may account for breathlessness in some cases. G Advice on techniques to conserve breathing, positioning G Stream of air such as fan or open windowManagement G Distraction and relaxation techniquesManagement of a breathless patient should be individualised, G Consider blood transfusion if patient is anaemicbut some general principles apply. Many members of an G Encourage adaptations in lifestyle and expectationsinterdisciplinary team can contribute. As well as nursing andmedical input, physiotherapy is often helpful, particularly foradvice on techniques for conserving breathing, positioning,control of panic, and relaxation methods. Occupationaltherapists can give essential advice on strategies and practicalaids for daily activities. There is good evidence to support Therapeutic options for specific situationsbreathlessness clinics led by nurses. In selected patients specific treatment, such as anticancer Pleural effusion G Pleural aspiration with or without pleurodesistherapy, can improve control of symptoms and quality of life. G Pleuroperitoneal shuntThe appropriateness of various strategies varies with time, but,for many patients, the disadvantages of travelling to a distant or Pericardial effusion G Aspiration, with or without percutaneous fenestrationregional centre may be justified when weighed againstsymptomatic relief gained from radiotherapy, laser therapy, or Lymphangitis G High dose corticosteroidsstenting of an endobronchial tumour. Pleurodesis should beconsidered early rather than after repeated pleural aspirations Endobronchial disease G High dose corticosteroidsas nearly all patients experience recurrence one month after G Laser therapysimple aspiration. G Cryotherapy G StentingOxygenOxygen is usually seen as a non-specific treatment forbreathlessness. Patients can become highly dependent onoxygen therapy; many see it as their lifeline. In patients withchronic lung and heart disease, however, there is goodevidence that oxygen therapy is beneficial only in specificsituations such as hypoxia or pulmonary hypertension. 13
  22. 22. ABC of palliative care It is not clear whether oxygen is better than air at relievingbreathlessness in patients with advanced cancer; furtherresearch is needed to identify which patients are most likely to Potential advantages and disadvantages of oxygen treatmentbenefit. Meanwhile, the pros and cons of oxygen therapy Advantages Disadvantagesshould be considered on an individual basis. Not all breathless G Reverse hypoxia G Claustrophobiapatients are hypoxaemic and, in any case, not all hypoxaemic G Sense of wellbeing G Discomfortpatients benefit from oxygen therapy. It seems sensible to G Patients, families, and G Drying effectprescribe a therapeutic trial of oxygen to patients with resting professionals feel they G Difficulties in communicationoxygen saturation concentrations 90%. At the least, some are doing something G Distancingform of objective assessment of the benefits, or not, of oxygen G Risk of patient/relatives smoking G Costin an individual patient should be performed; and oximetrymay be helpful. If relatively long term use is likely, an oxygenconcentrator rather than cylinders should be considered forpatients at home. The use of nasal speculae can avoid some ofthe inconvenience of a mask. The gas can be humidified, butthis is noisy. Few patients require continuous oxygen. For others, Breathlessnessexplanation and individualised coping strategies, including abedside or hand held fan, sometimes combined with non-specific drug measures, such as opioids or anxiolytics, are moreappropriate and often more successful. Fear of dying Panic Lack of understandingCoping with anxiety and panicThe vicious cycle in which anxiety aggravates breathlessness andbreathlessness, in turn, creates further anxiety is experienced tosome degree by most breathless patients, regardless of thecause. Some may experience a severe panic attack and become Increased anxietyconvinced that they are about to die. Such attacks are morecommon than is acknowledged. Patients should be advised of Cycle of increasing panic and breathlessnessmeasures that they can initiate to allow them to regain control.These have been summarised as “Stop, purse lips, drop(shoulders), and flop.” It is important to teach lay andprofessional carers how to cope; simple strategies such as gently Advice to patient about “panic attacks”massaging the breathless person’s back can be helpful. G Try to stay calm Research on the use of benzodiazepines in breathless G Purse your lipspatients with chronic non-malignant lung disease is equivocal G Relax shoulders, back, neck, and arms; let yourand, in patients with cancer, does not support their use in muscles breathe with you, not against you G Concentrate on breathing out slowly (if breathingunselected patients. If anxiety seems to be a major component in seems difficult)or trigger of breathlessness and cannot be relieved by non-pharmacological measures, then a therapeutic trial of a lowdose benzodiazepine either regularly or as required seemssensible. Concern about possible respiratory depression isusually unfounded, and any such concern should be weighedagainst the potential benefit of treatment.OpioidsThe relation between opioids and respiration is not simple; ifused inappropriately, opioids can induce respiratorydepression, which is determined by pathophysiology, previousexposure to opioids, rate and route of dose titration, andcoexisting pathology. However, low dose oral opioids canimprove breathlessness, sometimes dramatically, though theprecise mechanism of action is unknown. The dose of opioid can be titrated in the same way as whenit is used for pain control, but lower doses and smallerincrements should be used. In patients not previously exposedto opioids, as little as 2.5 mg of normal release morphine everyfour hours may be sufficient. If a patient is already receivingcontrolled release morphine, many convert to a normal releasepreparation and allow for a dose increment. For patientsunable to swallow, subcutaneous diamorphine can be used. The opium poppy, Papaver somniferum (photos.com)Concurrent laxatives should be prescribed.Nebulised drugsIf a trial of a nebulised drug is thought appropriate, thennebulised normal saline should be used in the first instance.14

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