the domains of palliative care and in detail about the most common palliative problems in head and neck cancers are dealt in the ppt.

1. Palliative Care in Head and Neck cancer

2. Content
◦ Introduction
◦ Definition
◦ Domains
◦ Different palliative settings
◦ Pain management
◦ End of life care

3. Introduction
◦ Palliative care is the provision of care that provides relief of suffering
and the maintenance of quality of life for patients with advanced illness
regardless of life expectancy.
◦ Requires a multidisciplinary approach
◦ Palliative care is now a medical specialty in its own right with services.

4. Definition
“Patient and family centred care that optimizes quality of life by
anticipating, preventing, and treating suffering”
◦ Throughout the continuum of illness
◦ Addresses physical, intellectual, emotional, social, and spiritual needs
and to facilitate patient autonomy, access to information, and choice
◦ Eight domains of palliative care has been defined.

5. Palliative care
◦ Appropriate at any stage in a serious illness,
◦ Beneficial when provided along with treatments of curative or life-
prolonging intent.
◦ Provided over time to patients based on their needs and not their
prognosis.
◦ Palliative care can relieve the symptoms of the disease process itself or
it can relieve side effects from the therapies

6. 6
Palliative Care is Delivered Concurrent with
Disease Treatment

7. Benefits of Palliative care
1. Strong evidence that palliative care improves quality,
2. 93 % of patient who receive palliative care are likely to recommend it
to others
3. Reduced readmission and ED visits and there by shown to cut down
expenses by 36%

8. Common terminology in PC
◦ Primary palliative treatment(generalist palliative care)-professionals
who are not palliative care specialists.
◦ Specialist palliative care
◦ Hospice- Specific type of palliative care provided to individuals with a
life expectancy measured in months, not years

9. Domains of palliative care
Domain Description
1 Structure and Processes of Care
2 Physical aspect of care
3 Psychological and Psychiatric Aspects of Care
4 Social aspect of care
5 Spiritual, religious, and existential aspect of care
6 Cultural aspect of care
7 Care of patient at the end of life
8 Ethical and legal aspect of care

10. 1. Structure and processes of the care
Interdisciplinary team
Comprehensive assessment
Palliative care plan
Continuity of Palliative care
Care setting
Interdisciplinary team Education

11. 2. Physical aspect of care
◦ Physical symptoms either due to the disease process or the primary
treatment.
◦ Study by Price et al done at Mayo clinic 2009, (N= 93)
Symptoms Percentage
Pain 58 (62%)
Dysphagia 42(45%)
Fatigue/Weakness 36(39%)
Anorexia/ Weight loss 40(43%)
Breathing difficulty 48(52%)
Bleeding 13(14%)

12. 8. Ethical and legal aspect of care
◦ India does not have legislation yet on end-of-life care
◦ Indian Society of Critical Care Medicine (ISCCM) and Indian
Association of Palliative Care (IAPC).
◦ Non-judgemental approach – not labelling a patient as a bad patient
and good patient.
◦ At current state- we should practice discussing cases at Institutional
ethic committee, where what is ethically right seem doubtful.

13. Specific scenario for palliative care
A. Palliative surgery
B. Palliative chemotherapy
C. Palliative radiotherapy
D. Cancer related fatigue syndromes
E. GI symptoms
F. Cachexia and weight loss
G. Carotid blowout management
H. Pain management
I. Complementary medical options.
J. End of life care

14. A. Palliative surgery
◦ Aimed to provide relief and extend life despite the presence of cancer
◦ Distinction between palliation and therapy is blurred.
◦ The most minimally invasive surgical procedure appropriate is chosen.

15. Examples of palliative surgery
1. Debulking surgery
2. Tracheostomy
3. Vascular stenting/ embolization
4. Reconstructive surgery- exposed carotid, fistula
5. Esophageal dilatation, Percutaneous endoscopic gastrostomy
6. Medialisation thyroplasty
7. Palliative total laryngectomy
8. Tracheo-esophageal voice prosthesis

16. B. Palliative Chemotherapy
◦ In patient with recurrent disease, metastatic disease or those who are
not willing for surgical modality.
◦ Based on patients age and performance status.
Single agent Cisplatin, Taxanes, 5FU,
Gemcitabine, Etoposide,
Methotraxate
Combination Cisplatin+5FU
Cisplatin+5FU+ Cetuximab
Immune checkpoint
inhibitors
Nivolumab, Pembrolizumab,

17. C. Palliative Radiotherapy
◦ In recurrent HNC, when salvage surgery is not feasible.
◦ Used either as a single modality or in combination with chemotherapy
◦ Commonly used in following manner
◦ Hypofractionation-30Gy in 10Fr or 35Gy in 15Fr, 20Gy in 5 Fr.
◦ For those who are irradiated before- chemotherapy is the choice of
treatment

18. D. Cancer related fatigue
◦ “A distressing, persistent, subjective sense of physical, emotional,
and/or cognitive tiredness or exhaustion related to cancer or cancer
treatment that is not proportional to recent activity and that interferes
with usual function.”
◦ Multifactorial- cancer (IL-1, IL-6, TNF-A), RT, CT
◦ How would you rate your fatigue on a scale of 0 to 10 over the past 7
days?

19. ◦ Treatment-
◦ Address the contributing factors
◦ Nutrition deficits and imbalance -Weight, caloric intake, fluid intake,
electrolyte abnormalities, and micronutrient deficiency
◦ Inadequate and/or poor-quality sleep.
◦ Nonpharmacological interventions- relaxation exercise, massage
therapy, psychological therapy
◦ Methylphenidate and modafinil

20. E. GI symptoms
a) Dysphagia- Strictures, mucositis, recurrence.
b) Feeding options- Oral, Enteric feeding, Parenteral feeding.
c) Nausea, vomiting- antiemetic (ondansetran, domperidone)
d) Diarrhea- loperamide, fluid management
e) Constipation- good hydration, fibre rich diet, ispagula, lactulose.
f) Oral candidiasis, Mucositis, Halitosis,

21. F. Cachexia and weight loss
◦ Commonly encountered problem
◦ Higher protein turnover, proinflammatory state
◦ Tx- nutritional rehabilitation, fluid management
◦ Feeding- Oral, enteric feeding, parenteral feeding.
◦ Salivary gland injury, mucositis management

22. G. Carotid blowout
◦ Carotid blowout is the rupture of the extracranial carotid arteries or
their major branches.
◦ Uncommon but devastating complication
◦ Risk- Prior radiation therapy, extensive surgery, wound breakdown,
local infection, tumor recurrence, and pharyngocutaneous fistulae.
◦ Carotid blowout syndrome(CBS) ranges from asymptomatic exposure
of a carotid artery to acute hemorrhage.

24. ◦ Intervention chosen according to patients goals and prognosis.
◦ Ligation, endovascular stenting,
◦ In patient with end of life care-
◦ Careful discussion with family and patient
◦ Minimize the panic and distress during copious bleeding
◦ Ready availability of dark colored linens/towels to cover and absorb
blood
◦ gloves, face/eye protection
◦ rapid patient sedation is indicated to palliate fear, dyspnea, and
suffocation
◦ A plan for whom to call, and whether and where to transport the
patient, if at home

25. H. Pain management
◦ Seen in 62-99% of cases.
◦ Definition – “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in
terms of such damage.”
◦ Types of pain –
◦ (1) somatic, (2) visceral, and (3) neuropathic.

27. • Acute pain Chronic pain
• Well defined temporal onset,
• Subjective and objective signs
present
• Associated with autonomic
dysfunction.
• Self limiting and responds well
to analgesics
• Pain persisting more than 1
month
• Lacks objective signs
• Challenging to treat.
• Negative effect on patient’s
quality of life.
 Baseline pain
 Breakthrough pains

28. ◦ Pain assessment Tools
a) Brief pain inventory
b) McGill pain questionnaire
c) Memorial symptom assessment scale
d) Functional assessment of cancer treatment – General
e) European Organisation for Research and Treatment of Cancer
Quality of Life Questionnaire-C30

29. WHO pain relief ladder

30. Treatment options in pain management
◦ Pharmacological management
◦ Non opioid analgesics
◦ Opioid analgesics
◦ Adjuvants medication
◦ Psychological support
◦ Anaesthetic and Neurosurgical procedures
◦ Neuropharmacological approach
◦ Physiatric approach

31. Pharmacological management
◦ Non opioid drugs:
◦ Acetaminophen and the NSAIDs
◦ Analgesia is limited by a ceiling effect.
◦ Most commonly administered orally.
◦ Tolerance and physical dependence do not occur
◦ Blocks synthesis of PGE2- Peripheral sensitizer
◦ 20% to 40% of cancer patient obtain pain relief

33. ◦ Opioid drugs :
◦ Prototype drug is morphine
◦ Binding to discrete opioid receptors in the peripheral and central
nervous systems.
◦ No ceiling effect
◦ Physical dependence and tolerance on chronic use
◦ Fatal complication with overdose

34. Guidelines for Opioid usage
1. Select treatment tailored to individual case
2. Start with specific drug for a specific type of pain
3. Administer the drug on a regular basis.
4. Use combination of drugs for additive analgesia
5. Anticipate and treat the side effects
6. Manage tolerance
7. Prevent and treat acute withdrawal
8. Anticipate complicaitons

35. Common opioid drugs used

36. Tramadol
◦ Opioid drug that binds to μ receptors in CNS and also inhibits the
uptake of Serotonin and norepinephrine
◦ Shown to have better impact on neuropathic pain
◦ Recommended option at level 2 WHO pain scale
◦ Dosage- 25-50mg every (Max 400mg/day)
◦ Fewer adverse effects such as nausea and constipation 4-6 hrly
◦ Caution- seizure, serotonin- syndrome,

37. Fentanyl
◦ Various preparation available ( Intravenous, transdermal patch, oral or
submucosal)
◦ Half life is 1-2 hrs
◦ 10mg of morphine is equivalent to 100μg of fentanyl
◦ Patches are available in 12.5 to 100 μg per hour (changed every 72
hours) (12-15 hours delay in analgesia action 24 hrs for equilibration)

38. Anaesthetic procedure
◦ 10-20% do not achieve pain relief with pharmacological management
◦ Require
◦ Nerve blocks
◦ Neurodestructive procedure
◦ Intrathecal/ intradural drug infusion
◦ Nerves commonly blocked- CN5, CN9, CN10, branches of cervical
plexus.

39. Anaesthetic procedure
1. Occipital nerve block- head ache due to skull base involvement.
2. Trigger point block- Myofascial pain in SCM and trapezius.
3. Superficial cervical plexus block-Post MRND/RND cervical pain.
4. Intrathecal and intradural morphine/ bupivacaine injection for
intractable pain has been tried currently.

40. I. Medical Marijuana
◦ Recent addition to palliative medicine
◦ Legalised in many states of USA and other countries.
◦ CB1 receptors in brain and spinal cord and CB2 in microglial cells.
◦ δ 9 tetrahydrocannabinol (THC) and Cannabidiol (CBD)
◦ Nabilone- antiemetic during CT.
◦ Currently been tired for symptoms such as pain, anorexia and weight
loss, spasticity and anxiety.

41. I. Acupuncture
◦ Traditional Chinese medicine
◦ Putting needles in the skin to stimulate certain points on the body
corresponding to energy (qi) meridians.
◦ Effects are mediated by the neuroendocrine system and brain.
◦ Safe and effective in cancer pain, xerostomia, lymphedema, shoulder
dysfunction, and Anxiety

42. I. Physiatric approach
◦ Rehabilitation medicine plays an important role
◦ Interventions
◦ Transcutaneous electrical nerve stimulation (TENS)
◦ Diathermy (heating pads, Ultrasound treatments,Cryotherapy (ice and
vapocoolants)
◦ Assistive devices and braces

43. J. End of life care
◦ Care provided to patients and their families near the end of life (leading up to
and just after the death of the patient).
◦ Interdisciplinary team management
◦ There is a shift of goal of care from curative intent to increasing the QOL.
◦ Non Beneificial treatment are stopped.
◦ Appropriate disease modifying treatment along with Palliative care is
continued.

44. End of life care
◦ Assessing and managing physical symptoms that are common among patients
nearing the end of life, including, pain, dyspnea, nausea, agitation, delirium, and
terminal secretions
◦ Identifying signs and symptoms of approaching death, and what can be expected
before and after the patient dies
◦ Talking about approaching death with patients and families

45. Components of Good Death
◦ Control of pain and physical symptoms
◦ Clear decision making by knowledgeable physician / palliative care teams
◦ Empowering the patient and family, taking into account their wishes
◦ Reducing fear and knowing what to expect
◦ Appreciating the importance of spirituality and meaningfulness at the end-
of-life
◦ Time with family, saying goodbye and resolving conflicts

46. Summary
◦ Palliative care is an urgent humanitarian need worldwide for people
with cancer and other chronic fatal disease.
◦ Ideally palliative care should be provided from the time of diagnosis of
life threatening illness, adapting to the increasing needs of patients and
their family till their terminal phase.
◦ For effective care services should be integrated to existing health
services, especially home based care and community services.

47. Reference
◦ Scott Brown 8th ed
◦ Cummings Otorhinolaryngology
◦ Jatin Shah 5th ed
◦ Devita principle of oncology
◦ WHO palliative care
◦ Training manual of Indian palliative care training module.
◦ CAPC handbook of palliative care