This document provides an overview of palliative care for family medicine trainees. It defines palliative care as improving quality of life for patients and families facing life-threatening illness. It discusses pain control using the WHO analgesic ladder and managing non-pain symptoms. It covers prognostication using performance status scales and discussing prognosis with patients. Finally, it describes the role of community-based palliative care providers in delivering multidisciplinary care to allow patients to die at home.

1. Palliative Care for Family
Medicine Trainees
Dr Tan Chai Eng
Dept of Family Medicine, UKMMC
21/9/2015

2. Objectives
• Definition and concepts of palliative care
• Pain control
• Non-pain symptoms
• Prognostication
• Role of community-based palliative care providers

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. 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
http://www.who.int/cancer/palliative/definition/en/

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. 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. 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. Types of palliative care
Palliative medicine
General palliative
care
Palliative care
approach
All healthcare
professionals!
Additional training
Specialised settings,
hospice

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. Pain Control

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. Concept of Total Pain (Cicely Saunders, 1978)
http://www.iasp-pain.org/

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. Pain severity
• Numeric rating scale: 1-10
• Visual analog score
• Wong-Baker Facial
grimace scale
• It is not necessarily using
numbers!
https://c1.staticflickr.com/3/2467/3881981855_7ab2b45f2e_b.jpg

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. 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. 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: http://www.jpalliativecare.com/text.asp?2011/17/4/36/76240

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. 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. 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. 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. Non-pain symptoms

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. 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. 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. Prognostication

27. Performance status
• Karnofsky Performance Status
TablefromPéusetal.BMCMedicalInformaticsandDecision
Making2013,13:72http://www.biomedcentral.com/1472-
6947/13/72

28. Performance status
• Eastern Cooperative Oncology Group (ECOG)
TablefromPéusetal.BMCMedicalInformaticsandDecision
Making2013,13:72http://www.biomedcentral.com/1472-
6947/13/72

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. Prognostication
• Refer to NHS UK’s Gold Standards Framework Prognostic Indicator
Guidance at http://www.goldstandardsframework.org.uk/cd-
content/uploads/files/General%20Files/Prognostic%20Indicator%20G
uidance%20October%202011.pdf
• Different trajectories for different health conditions

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. 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. Role of community-based
palliative care providers

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. 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. Community Palliative Care
• Shared care with
primary clinician
• GPs can play a major
role in areas with no
community palliative
care services
http://www.palliativecare.my/

37. Community Palliative Care
• Find out about services available in areas where you practice:
https://www.hospismalaysia.org/media/files/Hospice%20&%20Palliat
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. Thank You