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Palliative care for family medicine trainees 2015


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Basic concepts of palliative care for family medicine trainees (Part 2)

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Palliative care for family medicine trainees 2015

  1. 1. Palliative Care for Family Medicine Trainees Dr Tan Chai Eng Dept of Family Medicine, UKMMC 21/9/2015
  2. 2. Objectives • Definition and concepts of palliative care • Pain control • Non-pain symptoms • Prognostication • Role of community-based palliative care providers
  3. 3. Definition of palliative care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (WHO, 2005) Centre of Medicare & Medicaid Services and National Quality Forum
  4. 4. Palliative care philosophy and delivery • 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 • 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 counselling, if indicated • 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 or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
  5. 5. • Coordinated by an interdisciplinary team • Communication of care needs between patients, family, palliative and non-palliative healthcare providers • Service given concurrently with or independent of curative or life- prolonging care • Supports patient and family hopes for peace and dignity: from illness to dying process and after death Palliative care philosophy and delivery Clinical practice guidelines for quality palliative care (3rd edition), 2013, National Consensus Project for Quality Palliative Care
  6. 6. End of life care data (UK Gold Standards Framework) • 1% of the population dies each year • 17% increase in deaths from 2012 • 40% of deaths in hospital could have occurred elsewhere (National Audit Office report example) • 60% people do not die where they choose • 75% deaths are from non-cancer conditions • 85% of deaths occur in people over 65 • £19,000 non cancer, £14,000 cancer - average cost/patient in final year of life • 2.5 million generalist workforce - 5,500 palliative care specialists.
  7. 7. Why “Palliative Care”? • Access to palliative care is a human right. • Great need, limited resources • Even healthcare professionals may have limited awareness or knowledge of palliative care!
  8. 8. Types of palliative care Palliative medicine General palliative care Palliative care approach All healthcare professionals! Additional training Specialised settings, hospice
  9. 9. How does it relate to family medicine? • From primary prevention to early diagnosis to terminal care • Comprehensive care • Continuity of care • Coordination of care • Multidisciplinary team • Provide care for intercurrent illnesses • Symptom management • Provide patients with the option of dying at home (patient- centeredness and autonomy)
  10. 10. Pain Control
  11. 11. Pain • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (Int Assoc Study of Pain) • Pain is what a patient says it is, existing when and where the patient says it does. (McCaferee & Bebee, 1968)
  12. 12. Concept of Total Pain (Cicely Saunders, 1978)
  13. 13. Pain assessment • Site • Nature of the pain • Severity of the pain • Duration / pattern of pain • Precipitating factors • Aggravating factors • Relieving factors • Associated symptoms • Physical signs ± Ix • To elicit the physical source of the pain • To determine the subsequent management
  14. 14. Pain severity • Numeric rating scale: 1-10 • Visual analog score • Wong-Baker Facial grimace scale • It is not necessarily using numbers!
  15. 15. WHO Analgesic Ladder No pain Mild pain Moderate pain Severe pain 0 1 4 7 10 Non-opioids: paracetamol, non-steroidal anti- inflammatory drugs Weak opioids e.g. codeine, tramadol ± Non-opioids: paracetamol, non-steroidal anti- inflammatory drugs Strong opioids e.g. morphine, fentanyl, oxycodone ± Non-opioids: paracetamol, non-steroidal anti- inflammatory drugs Adjuvants: non-analgesics that help to improve pain control when used together with analgesics Pain score
  16. 16. Use of opioids in palliative care • The skilled use of morphine will confer benefit rather than harm but many patients express fears, which should be discussed • Concerns of addiction • Concerns of side effects • Concerns of tolerance • Concerns of toxicity
  17. 17. Concerns of addiction • Addiction – maladaptive pattern of substance use with compulsive drug-seeking behaviour • Physical dependence - occurrence of a withdrawal after abrupt dose reduction or an administration of an agonist • Opioids used to manage cancer pain for patients with no prior history of substance abuse or addiction, is rarely associated with new onset of substance disorder Meera A. Pain and opioid dependence: Is it a matter of concern. Indian J Palliat Care [serial online] 2011 [cited 2015 Sep 20];17, Suppl S1:36-8. Available from:
  18. 18. Concerns of side effects Side effects Comments Drowsiness Usually transient. With continued doses, tolerance to this side effect develops quickly. Nausea and vomiting Usually transient. May last for about a week before tolerance develops. May be managed with oral metoclopramide or low dose haloperidol. Constipation Almost all patients will develop constipation for as long as they are on the opioids. Due to effect of opioids on gut motility. Osmotic laxatives alone are not beneficial. Usually require gut stimulants or combination of gut stimulants and osmotic laxatives. Respiratory depression Can occur if opioid-naïve patient started on high doses. With gradually titrated dosing, tolerance to this effect occurs rapidly and patients do not get respiratory depression.
  19. 19. Concerns of tolerance • Tolerance - a decrease in pharmacologic response following repeated or prolonged drug administration (Dumas, 2008). • Higher doses are required to maintain same level of pain control as time goes by. • There is NO ceiling dose for morphine in pain control for palliative care. However, limited due to side effects and comorbidities eg renal / liver impairment. • Rotating different types of opioid may be useful if tolerance is suspected
  20. 20. Pain management with opioids PAINSCORE Time Background pain Breakthrough pain Incident pain – if the pain is associated with a procedure eg dressing, turning Regular dosing of opioids or sustained release Giving short acting opioids before procedure Short acting opioids to be taken when necessary
  21. 21. Pain management with opioids • Regular dosing is important! • Start low dose and uptitrate based on number of breakthrough doses required • Advisable for caregiver to chart down the dose and timing of breakthrough doses given • Refer CPG Management of Cancer Pain 2010 for details
  22. 22. Non-pain symptoms
  23. 23. Other common symptoms Common symptoms Possible pharmacological treatment Nausea and vomiting Metoclopramide, prochlorperazine, haloperidol, granisetron Dyspnoea, cough Morphine, codeine, prednisolone, salbutamol Anorexia, cachexia Treating is controversial. Steroids, medroxyprogesterone, megestrol Fatigue Constipation Bisacodyl, senna, lactulose, enemas Diarrhoea Loperamide, Lomotil, codeine Assess the cause for the symptoms. If the cause can be removed, then treat it first before giving medications for symptoms.
  24. 24. Other common symptoms Common symptoms Possible pharmacological treatment Intestinal obstruction Haloperidol, hyoscine, octreotide Depression SSRI, benzodiazepines Malignant ulcers (foul odour) Crushed metronidazole tablets Minor bleeding Tranexamic acid Oral health issues Oral hygiene, xylocaine viscous, bonjela
  25. 25. Palliative care EMERGENCIES • Hypercalcaemia – may need admission for IV hydration and bisphosphonates • Superior vena cava obstruction • Spinal cord compression – oral dexamethasone can be given to temporarily reduce symptoms. • Pathological fractures – management depends on patient’s performance status
  26. 26. Prognostication
  27. 27. Performance status • Karnofsky Performance Status TablefromPéusetal.BMCMedicalInformaticsandDecision Making2013,13:72 6947/13/72
  28. 28. Performance status • Eastern Cooperative Oncology Group (ECOG) TablefromPéusetal.BMCMedicalInformaticsandDecision Making2013,13:72 6947/13/72
  29. 29. Role of performance status • Reflects the function of the patient • Guides the healthcare provider regarding appropriateness of aggressive or invasive interventions • Serial performance status evaluations can support estimation of survival
  30. 30. Prognostication • Refer to NHS UK’s Gold Standards Framework Prognostic Indicator Guidance at content/uploads/files/General%20Files/Prognostic%20Indicator%20G uidance%20October%202011.pdf • Different trajectories for different health conditions
  31. 31. Discussing prognosis • Doctors are horrible at predicting prognosis (weighted kappa 0.36): mostly overestimate, 25% within 1 week, 27% within 4 weeks (Glare, 2003. BMJ) • Slight improvement in accuracy when the following factors are taken into consideration: • Performance status • Symptoms • Use of steroids
  32. 32. Discussing prognosis • “Doctor, how much time do I have left?” • Explore the reasons for the question being asked: To prepare for death? An opening statement to start a conversation about hope/ disease? • Apply SPIKES principles • Give a time range • Remind that current prognostication methods are still inaccurate • Offer realistic hope of what can be done, but be truthful about what cannot be done. • Refer to: Clayton et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life- limiting illness, and their caregivers. Med J Aus 2007. Vol 186(12):S76-108
  33. 33. Role of community-based palliative care providers
  34. 34. Palliative care uses a team approach to address the needs of patients and their families • Multi-disciplinary care to provide comprehensive care for patients
  35. 35. Community Palliative Care • Available mainly in urban areas • Delivered by palliative care nurses and doctors, other allied health professionals • Allows patients to die at home • Provides nursing and medical care, symptom control, information, practical advice, equipment loan, carer support, preparation for death
  36. 36. Community Palliative Care • Shared care with primary clinician • GPs can play a major role in areas with no community palliative care services
  37. 37. Community Palliative Care • Find out about services available in areas where you practice: ive%20Care%20Providers%20-MALAYSIA.pdf • Training opportunities: workshops by Hospis Malaysia including Communication Skills in Palliative Care, Pain and Symptom Management, Grief and Bereavement Care
  38. 38. Thank You