Palliative care for progressive neurological diseases

1
Palliative care for progressive neurological
diseases

• Dr Carol Scholes
• West Herts PCT

2
Physical Symptoms in MND

• Weakness 94
• Dysphagia 90
• Dyspnoea 85
• Pain 73
• Weight loss 71
• Speech problems 71
• Constipation 54
• Cough 48
• Poor sleep 29
• Drooling 25

3
MDT working in MND

• Evidence good multidisciplinary working improves
  patient care
• Neurology 2005651264-7
• Neurology 200462S23.003

4
West Herts Neuro-palliative MDT

• ACS
• Community OT
• SALT
• Dietician
• Physiotherapy
• Consultant in Palliative Medicine
• Palliative Care CNSs
• MNDA RDM and volunteer visitors
• Grove House OT and Day Care
• Peace Hospice Day Care

5
MND Referrals to NHS community palliative care
service
PLEASE HELP TO INCREASE FURTHER!
6
Outcomes of MDT

• Transformed timely referral to all relevant
  services
• Co-ordination /Communication of important issues
• Advance Care planning
• No deaths in AE
• Unplanned hospital admission now rare
• Support GPs in keeping complex patients in
  community opioids, ethical issues etc
• Extended beyond MND
• Changed pathway for NIPPV

7
What do we need in West Herts?

• TIMELY placement on GP palliative care register
• GSF involvement - communication / feeding /
  respiratory / planning / support
• Education neurology, rehabilitation, palliative
  care and primary care
• Keyworking

8
Summary

• Progressive neurological conditions need
  specialist palliative care input as much as
  cancer patients
• Please help identify those in palliative stages
  and add to palliative care register

9
Difficult pain

• Dr Carol Scholes
• West Herts PCT

10
Definition

• Pragmatic!
• Pain inadequately relieved by opioid analgesics
  given in a dose that causes intolerable adverse
  effects despite optimal measures to control them
• (10-20)

11
First and most important step

• Retake detailed history of pain / reconfirm
  presumed cause of pain / assess other issues /
  precise effect of medication to date

12
Most common situations

• Neuropathic may regain control for few days at
  a time on opioid increase
• Incident pain regular opioid dose required to
  eliminate pain causes side-effects
• Dose of opioid required results in intolerable
  side-effects
• Pseudo-resistance psychological / spiritual
  aspects, underdosing, etc etc

13
Opioid intolerance

• Could addition of adjuvant analgesic or other
  method of analgesia eg TENS, acupuncture allow
  reduction of opioid dose?
• Can side-effects be managed easily?
• Might opioid switch help?

14
Opioid switch

• Suggest discuss with palliative care team first
• Oxycodone or Fentanyl patch (hydromorphone,
  buprenorphine)
• Methadone for specialist use only

15
When to consider

• Morphine intolerance is genuine cause of
  side-effects nausea / itch / confusion /
  myoclonus
• Patient unable to swallow
• Renal failure (morphine metabolites accumulate)

16
How to change?

• Depends on what switching to / from
• Detailed guidance in Network adult palliative
  care guidance 2006
• Palliative care team can help

17
Thats all I have time for!!

• Reference
• Oliver D et al, Palliative Care of patients with
  motor neurone disease
• Progress in Palliative Care 2007, volume 15,
  number 6, p285-293