Palliative care with cancer patients 1

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Palliative care with cancer patients 1

  1. 1. Pallia%ve  care  with  cancer   pa%ents   Hasan  M.   Alkhudairi  
  2. 2. What  is  Pallia%ve  Care?   — Medical  care  that  focuses  on  allevia%ng   the  intensity  of  symptoms  of  disease.     — Pallia%ve  care  focuses  on  reducing  the   prominence  and  severity  of  symptoms.  
  3. 3. W  H  O  describes    pallia%ve  care  as  "an   approach  that  improves  the  quality  of  life  of   pa%ents  and  their  families  facing  the   problems  associated  with  life-­‐threatening   illness,  through  the  preven%on  and  relief  of   suffering  by  means  of  early  iden%fica%on   and  impeccable  assessment  and  treatment   of  pain  and  other  problems,  physical,   psychosocial  and  spiritual."  
  4. 4. Goal  of  Pallia%ve  Care?   — The  goal  is  to  improve  the  quality  of   life  for  individuals  who  are  suffering   from  severe  diseases.     — Pallia%ve  care  offers  a  diverse  array  of   assistance  and  care  to  the  pa%ent.  
  5. 5. Pallia%ve  Care   •  Minimizing  Suffering  (Total  Pain)   • Physical   • Social     • Psychological   • Spiritual     •  Improving  Quality  of  Life   •  Maintaining  dignity  and  respect     •  Caring  for  family  
  6. 6. • not  disease-­‐specific     •   not  restricted  to  a  defined   number  of  months  or  weeks   of  life       • centered  on  quality  rather   than  quan*ty  of  life.    
  7. 7. •  Mme  Jeanne  Garnier  Lyons,  France  1842   •  Irish  Sisters  of  Charity,  Dublin,  Ireland  1879     •  St  Joseph’s,  London  1909   •  Royal  Marsden  Hospital  19  beds  in  1909   •  St  Christopher's  Hospice  1967   •  WHO  Cancer  Pain  and  Pallia%ve  Care  Program   ini%ated  1982   •  European  Associa%on  for  pallia%ve  care  1988   •  Hospice  Movement  in  North  America:  AAHPC   founded  1992   •  La%n  American  Pallia%ve  Care  Associa%on   founded  2000   •  Asian  Pacific  Hospice  Pallia%ve  care  Network   founded  2001   History of Palliative Care Dame     Cicely  Saunders   The  founder  of  modern  PC  
  8. 8. Who  receives  Pallia%ve  Care?   — Individuals  struggling  with  various  diseases     — Individuals  with  chronic  diseases  such  as   cancer,  cardiac  disease,  kidney  failure,   Alzheimer's,  HIV/AIDS  and  Amyotrophic   Lateral  Sclerosis  (ALS)  
  9. 9. Who  Provides  Pallia%ve  Care?   — Usually  provided  by  a  team  of  individuals   — Interdisciplinary  group  of  professionals   — Team  includes  experts  in  mul%ple  fields:   — Doctors   — Nurses   — social  workers   — massage  therapists   — Pharmacists   — Nutri%onists  
  10. 10. Patient and Family Volunteers Physicians Spiritual Counselors Social Workers Pharmacists Home Health Aides Therapists Nurses
  11. 11. Pallia%ve  procedures   •  radiotherapy   •  chemotherapy   •  Surgical   • Debulking   • the  inser%on  of  stents,     • the  drainage  of  effusions     • the  stabiliza%on  of  bones    
  12. 12. What  pallia%ve  care     is  not       •     Care  of  the  Elderly  (Geriatrics)       •   General  prac%ce  (Family  Medicine)     •   Care  of  the  Chronically  Ill       •   Care  of  Cancer  (Oncology)       •     Care  of  the  Incurable       •   Pain  Relief  Service        
  13. 13. Physical Functional Ability Strength/Fatigue Sleep & Rest Nausea Appetite Constipation Pain Psychological Anxiety Depression Enjoyment/Leisure Pain Distress Happiness Fear Cognition/Attention Social   Financial  Burden   Caregiver  Burden   Roles  &  Rela5onships   Affec5on/Sexual  Func5on   Appearance   Spiritual Hope Suffering Meaning of Pain Religiosity Transcendence Adapted  from  Ferrell,  et  al.  1991   Quality   of  Life  
  14. 14.     Pallia%ve  Care     and  Cancer  
  15. 15. Pallia%ve  Care  and  Cancer   §  "Everyone  has  a  right  to  be  treated,  and  die,  with   dignity.  The  relief  of  pain  -­‐  physical,  emo%onal,   spiritual  and  social  -­‐  is  a  human  right,"  said  Dr   Catherine  Le  Galès-­‐Camus,  WHO  Assistant  Director-­‐ General  for  Noncommunicable  Diseases  and  Mental   Health.  "Pallia%ve  care  is  an  urgent  need  worldwide   for  people  living  with  advanced  stages  of  cancer,   par%cularly  in  developing  countries,  where  a  high   propor%on  of  people  with  cancer  are  diagnosed   when  treatment  is  no  longer  effec%ve."  
  16. 16. “Cancer  Control:   Knowledge  Into  Ac%on”   — Excerpts  from  the  WHO  guide  for   Pallia%ve  Care:   “Pallia%ve  care  is  an  urgent  humanitarian  need   worldwide  for  people  with  cancer  and  other   chronic  fatal  diseases.     Pallia%ve  care  is  par%cularly  needed  in  places   where  a  high  propor%on  of  pa%ents  present  in   advanced  stages  and  there  is  lijle  chance  of   cure.”  
  17. 17.    More  than  50  million  people  die  every  year  around  the  world        around  20%  due  to  cancer.     v   Based  on  WHO  projec%ons,  cancer  deaths  will  con%nue  to              rise  with  an  es%mated  9  million  people  dying  from  cancer  in            2015,  and  11.4  million  dying  in  2030.     v   80  per  cent  of  these  deaths  will  occur  in  developing  world.       v   Two  thirds  of  the  world's  people  living  with  cancer  live  in            developing  countries  with  barely  any  access  to  pain  and              symptom  management,  let  alone  cura%ve  treatment     v   Many  of  these  people  will  endure  intense  and  unnecessary          suffering  and  pain      
  18. 18. Pallia%ve  Care  and  Cancer  Care   •  Pallia5ve  care  is  given  throughout   a  pa5ent’s  experience  with  cancer.   •  Care  can  begin  at  diagnosis  and   con5nue  through  treatment,   follow-­‐up  care,  and  the  end  of  life.  
  19. 19. SYMPTOMS  IN  ADVANCED  CANCER   0 10 20 30 40 50 60 70 80 90 Asthenia Anorexia Pain Nausea Constipation Sedation/Confusion Dyspnea % Patients (n=275) Ref: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering
  20. 20. Symptom Ca HD COPD RD Pain 96 77 77 50 Depression 77 36 71 60 Fatigue 90 82 80 87 Dyspnea 70 88 95 62 Delirium 93 32 33 -- Anorexia 92 41 67 64 Prevalence    of    symptoms  towards  the  end-­‐of-­‐life   (Solano  et  al  2006)  
  21. 21. §  Pts (all stages) 53% (CI 43-63%) §  Pts (advanced) 64% (CI 58-69%) Cancer Pain is Common
  22. 22. Pain  prevalence  (KFSHRC-­‐R    2011    OPD)    
  23. 23. Pain  Assessment   One  of  the  major  defect  in  pain   management  is  an  inadequate  pain   assessment  and  deficient     documenta%on  by  physicians  and   nursing  staff  
  24. 24. Cancer  pain    Prevalence  of  a  significant  pain   §       30%  in  newly  diagnosed  cancer   §       50%  to  70%  among  pa%ents                receiving  ac%ve  an%cancer  therapy   §       65%  to  80%  in  advanced  disease  
  25. 25. §  History   §  Pain  or  no  pain   §  Type  of  pain,  acute,  chronic,  nocicep%ve,  neuropathic   §  Loca%on  and  Radia%on   §  Severity,  intensity   §  Timing   §  Exacerba%ng  and  Relieving   §  Effects  on  Ac%vity   §  Previous  Therapy   §  Meaning  of  pain   §  Physical  examina%on   §  Related  inves%ga%on   Assessment  of  Pain  
  26. 26. Pain:  The  Fiqh  Vital  Sign    Pain  Standards  of  the  Joint  Commission  on  Accredita%on  of  Healthcare  Organiza%on     •   Recommenda%on  make  the  pain  measurement  a      priority  in  daily  prac%ce     •   Consider  pain  intensity  the  fiqh  vital  sign  along      with  temperature,  respira%on,  and  BP       JCAHO:  1999  -­‐  2000  
  27. 27. Pain  ra%ng  (Intensity)  scales:   Categorical scale Numeric rating scale 0 No pain 1 Mild 2 moderate 3 severe 4 Very severe 5 Excruciating 0 2 4 6 8 101 3 5 7 9 ( 0 = No pain, 10 = Worst pain imaginable )
  28. 28. What  Can  be  Done  to  Relieve  Pain  ?   The  WHO  has  demonstrated  that  most          (  around  75  -­‐  85%)  of  cancer  pain  can  be   relieved     If     we  implement  an  available  pharmacologic   approach   That  is  Inexpensive  &  yet    a  prac*cal  one  
  29. 29. WHO  3-­‐step  Ladder   1 mild 2 moderate 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAID’s ± Adjuvants WHO. Geneva, 1996.
  30. 30.                                                         WHO  Guidelines  for  Cancer  Pain   W.H.O.      Analgesic  Ladder     •  Step  3:  Strong  opioids          (opioids  for  moderate-­‐to-­‐severe  pain)            +/-­‐  non-­‐opioid  +/-­‐adjuvant  therapy       •  Step  2:  Weak  opioids        (opioids  for  mild-­‐  to-­‐moderate  pain)            +/-­‐  non-­‐opioid  +/-­‐  adjuvant  therapy       •  Step  1:    Non-­‐opioid              +/-­‐  adjuvant  therapy   (Adapted from Portenoy et al, 1997) Mild   Moderate   Severe   STEP 1 STEP 2 STEP 3 Pain Persists Pain Persists
  31. 31. Pharmacy of Pain medications Analgesics Adjuvant analgesics • Non-opioid Acetaminpphen, Aspirin • Weak Opioids Tramadol, propoxyphine Codeine, T2, T3, T4 Potent (strong) opioids Morphine Hydromorphone Fantanlye Demarol Oxycodon Methadone -­‐  NSAIDs,   -­‐  An%convulsants,   -­‐      -­‐  An*depressants   -­‐  Steroids   -­‐  Bisphosphonates   -­‐  An*spasmodics   -­‐  Muscle  relaxants      
  32. 32. Pallia%ve  care  in   gynaecological  malignancy  
  33. 33. Problems  with   cancer  of  the  vulva   §  Lower  limb  oedema   §  Funga%ng  wounds  with  odour,     §  pain  and  bleeding   §  Haemorrhage  
  34. 34. §  Neuropathic  pain  from  sacral  plexus   involvement   §  Renal  failure  from  hydronephrosis   §  Peripheral  neuropathy  from  chemotherapy   §  Vaginal  bleeding  or  discharge   §  Pelvic  or  back  pain   §  Urinary  or  bowel  fistulas   §  Lower  extremity  edema   §  Deep  venous  thrombosis  (DVT)   §  Dyspnea  from  anemia  or  pulmonary   involvement   §  Anxiety  and  depression   §  Nausea  and  vomi%ng   §  Diarrhea   Problems  with  cervical  cancer  
  35. 35. •  Pain  from  local  disease   •  Ascites   •  Painful  bone  metastases   •  Pulmonary  metastases   •  Bone  metastases   •  Hypercalcemia   •  Hepa%c  metastases   •  Brain  metastases     Problems  with  in   cancer  of  the  uterus  
  36. 36. Problems  with  in  ovary  cancer   §  Pain  from  pelvic  and  abdominal  disease   §  Ascites   §  Bowel  obstruc%on   §  Peripheral  neuropathy  from  chemotherapy   §  Anorexia   §  Cons%pa%on   §  Fa%gue  and  dyspnea  
  37. 37. Common  issues  for  women  with   advanced  gynaecological  malignancy   §  Body  image   §  Sexuality   §  S%gma     §  Loss  of  role  and   leaving  children  
  38. 38. Pallia%ve  medicine   Challenges    
  39. 39. Ra%o   of   full-­‐%me   pallia%ve   care   physicians   to   popula%on   C o u n t r y N u m b e r o f full time PC p h y s i c i a n s R a t i o o f P C P h y s i c i a n s t o p o p u l a t i o n S w e d e n 3 0 0 1 : 3 0 , 1 4 7 I t a l y 1 0 0 0 1 : 5 8 , 6 0 9 U K 4 4 2 1 : 1 3 5 , 4 9 6 F r a n c e 3 6 1 1 : 1 6 7 , 9 2 2 Saudi Arabia 2 0 1 : 1 , 4 0 0 , 0 0 0
  40. 40. Ra%o   of   dedicated   pallia%ve   care   beds   to   popula%on   (in   million)   C o u n t r y Number of dedicated b e d s R a t i o o f d e d i c a t e d b e d s S w e d e n 6 5 0 7 2 U K 3 1 8 0 5 3 F r a n c e 1 6 1 5 2 7 I t a l y 1 0 9 5 1 9 Saudi Arabia 1 2 0 . 5
  41. 41. Barriers to cancer pain control •  Health professionals •  Patients •  Health system
  42. 42. Health professionals §  Inadequate knowledge §  Poor assessment of pain §  Concerns related to: § Regulations § Side effects § Addiction § Tolerance
  43. 43. Patients §  Reluctance in reporting § Belief that pain = disease progression § Fear of distracting Drs from treating Ca. § Fear of not being a “good” pt §  Fear of: § Addiction § Side effects §  Poor compliance §  Religious concerns
  44. 44. Health system
  45. 45. Addiction! §  11,882 in-patients who received one opioid drug or more §  Four cases of addiction identified Porter & Jick. NEJM. 1980 §  550 pts on morphine for 22,525 treatment days §  One case of addiction Schug et al. JPSM. 1992
  46. 46. • Fellowship  of   pallia5ve  medicine    
  47. 47. Few things a doctor does are more important than relieving pain Marcia Angel. The Quality of Mercy. NEJM 1982
  48. 48. “You  maOer  because  you  are  you.  You   maOer  to  the  last  moment  of  your  life   and  we  will  do  all  we  can  not  only  to   help  you  die  peacefully  but  to  live  un*l   you  die”                            Dame  Cecily  Saunders  
  49. 49. Thank  you  

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