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Palliative Care for Family
Medicine Trainees
Dr Tan Chai Eng
Dept of Family Medicine, UKMMC
21/9/2015
Objectives
• Definition and concepts of palliative care
• Pain control
• Non-pain symptoms
• Prognostication
• Role of community-based palliative care providers
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
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/
• 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
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.
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!
Types of palliative care
Palliative medicine
General palliative
care
Palliative care
approach
All healthcare
professionals!
Additional training
Specialised settings,
hospice
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)
Pain Control
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)
Concept of Total Pain (Cicely Saunders, 1978)
http://www.iasp-pain.org/
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
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
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
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
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
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.
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
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
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
Non-pain symptoms
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.
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
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
Prognostication
Performance status
• Karnofsky Performance Status
TablefromPéusetal.BMCMedicalInformaticsandDecision
Making2013,13:72http://www.biomedcentral.com/1472-
6947/13/72
Performance status
• Eastern Cooperative Oncology Group (ECOG)
TablefromPéusetal.BMCMedicalInformaticsandDecision
Making2013,13:72http://www.biomedcentral.com/1472-
6947/13/72
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
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
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
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
Role of community-based
palliative care providers
Palliative care uses a team approach to
address the needs of patients and their
families
• Multi-disciplinary care to
provide comprehensive
care for patients
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
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/
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
Thank You

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Palliative care for family medicine trainees 2015

  • 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)
  • 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
  • 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
  • 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
  • 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