Palliative care - Teaching Clinic Flashcards
(38 cards)
Functional assessment metrics
Basic and instrumental Activities of daily living
- Basic: Dressing, Ambulation, Bathing, Eating, Transferring, Toileting
- Instrumental: Food prep, housekeeping, laundry, grocery shopping, using phone, managing medication, managing finances, using transport
ECOG performance status:
- ECOG <= 2: Asymptomatic, rarely a/w sudden death
- ECOG >= 3: Start of physical deterioration esp weight loss
- Higher ECOG = shorter median survival rate
Additional questions
Their ability to walk a half mile; stoop, kneel, or crouch; climb a flight of stairs; and do heavy housework, such as washing floors
Illness trajectories types
ECOG performance status trajectory with cancer progression
Predictors of life-expectancy of a cancer patient
- Median survival rate: guide only, survival range is vast
- Time to tumor growth (TTG)
- tumor size ratio (TSR)
- tumor growth rate (kG)
WHO definition of palliative care
Palliative care is:
- Active care of patients
- Whose disease is not responsive to curative treatment
- Control of pain, psychological, social, spiritual problems
- Acheivement of best possible QOL for patient and their family
- Applied early in the course of the illness with anti-cancer treatment
Cancer pain
- Prevelance
- Components of total pain
Prevalence
- 30-45% moderate to severe pain at diagnosis
- 65-90% pain at advanced disease
Total pain:
- Physical: cancer symptoms, treatment S/E, insomnia, chronic fatigue, cachexia, delirium
- Social: worry about family and friends, loss of job/ title/ income, Loss of social position, Feeling of abandonment and isolation
- Spiritual: point of life? purpose? God?
- Psychological: Anger at therapeutic failure and delays in diagnosis, disfigurement, fear of pain and death, helplessness
Cancer pain
Physical assessment
WHO pain ladder
- Define tiers
- Standard drugs in each tier
- Analgesic use recommendations
If pain occurs, there should be prompt oral administration of drugs in the following order:
1. non-opioids: Paracetamol 500-1000mg QID, NSAID conventional doses
2. then mild opioids: Tramadol 50-100mg QID; dihydrocodeine (e.g. DF118) 30mg Q4-6hrs
3. then strong opioids, until the patient is free of pain: Morphine (oral) 5mg Q4H PO, No ceiling dose
Recommendations:
- Oral route
- GIven on fixed dose schedule, not on as-need basis
- Dosage titrated against particular pain
- Adjuvant drugs should be used for specific pain etiologies
- Give laxatives (Senokot 2 tab nocte PO and/or lactulose 10ml TDS PO) for long-term opioid use
- Prescribe antiemetics to control nausea during the first week of opioid use: metoclopramide 10mg TDS or haloperidol 1.5mg - 3mg daily
List weak and strong opioids
Weak opioid
* Codeine
* Tramadol
* DF118 (Dihydrocodeine), oxycontin
Strong opioid
* Morphine
* Oxycodone
* Fentanyl
* Methadone
Tramadol
- Dose
- PK
- S/E
- D/D interactions
Dose: 50-100mg TDS-QID PO
* For elderly max dose <300mg/day
* For patients with mild renal impairment: <200mg/day
Half life: 6 hours. Prolonged in liver failure
Kidney excretion of metabolite
Side effects:
* Nausea/vomiting, dizziness, sweatiness, dry mouth
* Constipation, convulsion (rare)
Drug interactions
* Tricyclic antidepressants (TCAs)
* Serotonin selective receptor inhibitors (SSRI)
* Monoamine oxidase inhibitors (MAOIs)
Morphine
- Starting dose
- PRN dose
- Adjunct drugs
Starting dose: use short-acting morphine syrup first
* Morphine 5mg QID + 10 mg Nocte/zolpidem (or 5mg Q4H PO)
Consider 2.5mg Q4H in elderly patients or patients with marginal renal function
Always prescribe prn dose of morphine: 50-100% of regular dose, e.g.
* Morphine 5mg PO Q4H prn
* Morphine 2.5mg subcutaneous Q4H prn
Always prescribe laxative with opioid: Senokot 2 tab nocte PO, Lactulose 10ml BD-TDS PO
Antiemetics during the first week of opioid initiation: metoclopramide 10mg TDS, haloperidol 1mg - 2mg daily
Titration of morphine
Factors that warrant titration
Typical dose levels
Increase or decrease morphine dose based on
* Patient’s pain score (do not aim for 0 score)
* The need of prn analgesics (as needed)
* Increase the regular dose every 2-3 days/ if severe pain
* Side effects profile: any signs of opioid toxicity, renal function, hydration status
* Consider decrease dose if tumor responded well to treatment (chemo/targeted therapy / radiation therapy) or toxicity significant
* Change to long-acting opioid (MST continuous tablet) if needed
Dose levels commonly used: e.g. 5mg Q4H ↔ 7.5mg ↔ 10mg ↔
15mg ↔ 20mg ↔ 30mg
Morphine titration
Define satisfactory pain control
Titration ratio for oral morphine syrup to SC/ IV/ MST tablet
Satisfactory pain control level
* Pain score 0-3
* Need of prn morphine for breakthrough pain 0-2 times per day
* Patient can sleep well
* Patient’s subjective judgment
Conversion of oral to SC Morphine = 2:1
Conversion of oral to IV Morphine = 3:1
Conversion of morphine syrup to MST = 1:1
Onset time for oral morphine: 30min
Onset time for SC morphine: 15min
Morphine and renal impairment
- Caution
- Dosage
- C/I
- Active metabolite of morphine: morphine-6-glucuronide (M6G)
- Accumulation of M6G occurs in patients with renal insufficiency
- Patient with creatinine clearance / glomerular filtration rate <50ml/min should be initiated with morphine at 50% dosing with high caution. Specialist consultation is recommended
- Use of morphine in patient with CrCl/GFR <10ml/min should be avoided
S/E of opioids
Early (72 hours)/ mild:
- Nausea / Vomiting, treat with prophylactic antiemetics
- Sedation/ drowsiness: transient, self-resolving 2-4 days
- Constipation: treate with laxative prophylaxis, increase dose or combo laxatives (not bulking agent)
- Pruritis: treat with anti-histamine
- Xerostomia: pilocarpine 2%, mouth care
- Urinary retention: resolve in a week
Severe:
- Opioid induced neurotoxicity: hyperalgesia, allodynia, agitation, delirium, hallucinations
- Myoclonus: early sign of neurotoxicity
- Respiratory suppression, decreased consciousness
Patients at high risk of opioid s/e
Signs of OD
Management of adverse effects
High risk: elderly, frail patient, marginal renal function, poor oral intake
OD:
- Pinpoint pupils, LOC, Shallow/ slow respiration, pale skin, cyanosis, snoring/ stretor (tongue obstruction)
Management:
- Withhold 1-2 doses
- Opioid rotation
- Consult pain specialist
- diluted naloxone bolus IV injection - 0.04mg/ml
Fentanyl
- Route of administration
- Advantage
- Disadvantage
- Conversion with morphine
Route: Patch/ SC infusion
Advantage: Less constipating, less sedative, can be used in renal failure patients
Disadvantage: slow onset, very difficult to titrate
Conversion to morphine:
* 25mcg/hr = 4.2mg = 60-90mg oral morphine
Methadone
- Starting dose
- Advantage
- Disadvantage
Starting dose: as low as possible
Long t1/2: 30 hours, given Q12H, takes 1 week to reach static state
Advantage: Spare high dose morphine/ morphine washing effect; lower nephrotoxocity, better at neuropathic pain
Disadvantage: High dose (>40mg/day) causes fatal arrhythmia, difficult to titrate
Palliative RT for pain control
- Indications
- Advantage
- Disadvantage
Indications:
- Uncomplicated bony met.
- Mediastinal obstruction, cough, hemoptysis
- Bleeding control in GIT, GUT, H&N, breast CA
- Control CNS symptoms in cerebral/ leptomeningeal met.
Advantage:
- Non-invasive
- Tolerable
- Brief treatment (1 day to two weeks)
Disadvantage:
- 70% effective
- Ionizing radiation
Intraspinal opioid
Dose conversion
MoA
Indications
Intrathecal versus epidural opioid administration
Dose conversion: intrathecal to PO: 1mg to 300mg
Implanted programmable pump with different programming options
Less systemic side effects
Patient selection:
* intractable pain >5
* daily morphine consumption >200mg/day or intolerable side effects
* life expectancy >4-6 months
Malignant spinal cord compression
Determinants of treatment modality
Spinal Instability Neoplastic Score (SINS):
- SINS > 7 indicate instability and surgical treatment e.g. kyphoplasty/ vertobroplasty
Tokuhashi score: Criteria of predicted prognosis:
- Total score 0-8 : <6m
- Total score 9-11: 6-12m
- Total sore 12-15: >12m
Surgery indicated:
■ Limited levels of cord compression
■ Minimal neurological impairment
■ Spinal instability (leading to mechanical and functional pain)
■ Previous radiotherapy which has been administered at the level of metastatic spinal cord compression
Neurolytic blocks
- Locations of blocks
- MoA
Injection of alcohol or phenol to deaden the nerve causing pain
Celiac plexus block: Pancreatic CA, upper abdominal tumor
Ganglion impair block: Perineal pain
Superior hypogastric plexus block: Pelvic tumor
Breathlessness in palliative care patients
- ATS definition
- Prevalence
- Effects
Breathlessness: also termed Breathlessness, Dyspnea, Shortness of Breath, Chest tightness
ATS definition:
- subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity
- derives from interactions among multiple physiological, psychological, social, and environmental factors
- may induce secondary physiological and behavioral responses
Prevalence: Up to 70% patients with advanced cancer
Effect:
- On patient and family: disabling/ distressing, anxiety/ depression, anorexia, poor concentration, lower QoL, poorer prognosis
- Social: financial burden to healthcare, more adverse events in hospitals, need of sedation, more hospital admission
Pathophysiology of breathlessless in palliative care patients
