The Mary Stevens Hospice Stourbridge

1
The Mary Stevens Hospice Stourbridge

• Lucy Martin - Medical Director
• (BCVTS 1997 2000!)

2
(No Transcript)
3
VTS March 4th 2010

• 1.30 Session on Palliative Care and Basics of
  Pain Control, plus discussion and questions
• 2.45 Coffee / Tea
• 3.00 Case discussion 1 feedback
• 3.45 Case discussion 2 feedback
• 4.30 Plenary and close

4
What is Palliative Care?
5
WHO Definition

• 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.

6

• provides relief from pain and other distressing
  symptoms
• affirms life and regards dying as a normal
  process
• intends neither to hasten or 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

7

• 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 an 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.

8
Who provides Palliative Care?
9

• Generalist
• GPs, District Nurses, Hospitals
• Providing day-to-day care in hospital or patients
  home
• Specialist
• Palliative Care Teams based in hospices,
  hospitals, community
• Multidisciplinary Core members are doctors
  nurses, AHPs
• In-patient and Day care facilities, hospice at
  home
• Ongoing advice and support in any setting
• Bereavement support
• Education and training for specialists and
  generalists

10
Day care since 1993, and residential since
1999Referral form _at_ www.marystevenshospice.co.uk

11
Specialist Palliative Care in Dudley

• Hospice in-patient care / day care
• Mary Stevens covers the whole Dudley borough
• Hospital in-patient care
• no dedicated hospital beds
• 0.4 WTE consultant out pt and consultation
• hospital palliative care team MDT meeting
• Community Service
• Macmillan CNS and OT / Physio team
• Palliative Care end of life team

12

• What you know about pain management?
• What do you feel confident about?
• What makes you nervous?

13

• WHO ladder / lift
• Cancer and non-cancer chronic pain
• Dudley Pain Management Guidelines

14
Principles of analgesic use

• By the mouth
• By the clock
• By the ladder
• Refers to WHO analgesic ladder
• Treatment should be individualised
• Use adjuvants
• Drugs for specific situations e.g. Neuropathy
• Drugs to control side effects
• Psychotropics
• Twycross, R Introducing Palliative Care,
  Symptom management of advanced cancer

15
(No Transcript)
16
Strong opioids

• Should be given according to need and response
• Should not be given according to prognosis
• Administration still surrounded by concern

17

• Little clinically significant respiratory
  depression, tolerance not a problem, dependence
  does not occur
• Naloxone very rare
• Patients generally have been receiving weak
  opiates first
• Dose gets titrated start low, go slow
• Pain is an antagonist to central depressant
  effects of strong opiates
• Therapeutic dose vs. toxic / lethal dose

18
Opioids in the well person (or How I did it by
H. Shipman)
19
Opioids in Cancer Pain (and probably non-cancer
pain too)
20
Morphine

• Pros

• Cons

• 200 years of experience
• Cheap
• 4 formulations IR elixir and tablet, SR liquid
  and tablet / capsule
• Flexibility in dosing, multiple strengths
  available, flexible routes
• Predictable titration schedule

• Metabolites accumulate in brain and CSF if renal
  dysfunction
• 20 30 population do not tolerate

21
Equivalent Doses

• Comfortable Dose for Rx
  

• Equivalent 24hr Morphine Dose

• Morphine 25mg
• Morphine 25mg
• Morphine 25mg
• Morphine 40 - 80mg
• Morphine 60mg
• Morphine 7.5mg p.o. every 30 mins

• Codeine 60mg qds p.o.
• Dihydrocodeine 60mg qds p.o.
• Pethidine 50mg qds p.o.
• Tramadol 100mg qds p.o.
• Fentanyl 25mcg t.d.
• Diamorphine 2.5mg s.c. every 30 mins

22
Titrating in the community

• Easiest method is the 4-hourly plus rescue
• Calculate current morphine equivalent / 24hr
• /- make allowance for uncontrolled pain
• Divide by 6
• 4 hourly dose / rescue dose
• 2 3 days record
• Review, then divide and convert to sustained
  release prep, plus rescue (1/6th of total daily
  dose)

23
Increasing doses of opioid

• Gradual escalation of doses if pain control
  inadequate
• Dose escalations of less than 30 50 are
  unlikely to have much effect
• Experience shows 30 50 dose increases are safe
• Absolute dose is immaterial as long as balance
  between analgesia / side effects
• Less is known about titration for dyspnea

24
Why / when to switch opioid

• Intolerable side effects
• Itching, neurotoxicity, that persist despite
  appropriate intervention
• Lack of desired analgesic effect
• Even with rapidly escalating doses
• Moderate or severe renal disease
• Egfr lt60 ??
• Alternative route is required
• Unstable pain on a patch
• Patients personal choice / opiophobia

25
Diamorphine

• Pros

• Cons

• Cheap
• May work via receptors other than µ - explaining
  the apparent differences with morphine
• More soluble / lipophilic than morphine
  parenteral use /small volumes
• Quicker action, less vomiting

• Not useful orally
• More sedating than morphine
• Fear / preconceptions of patients and HCPs

26
Oxycodone

• Pros

• Cons

• Potent drug orally
• Flexibility in SR dose formulations
• Effective levels within 1 hour good for
  titration
• Rectal formulation
• Metabolites not part of the analgesic picture
• Possibility of neuropathic effect

• Differing views in different countries USA see
  it as a step 2 drug
• Common drug of abuse in USA

27
Hydromorphone (palladone)

• Pros

• Cons

• Multiple routes of admin oral, parenteral,
  rectal and intraspinal
• Very soluble good for subcut use

• Oral dosing complicated and oral breakthrough
  dose multiple capsules
• Difficulty predicting dose equivalency with
  morphine

28
Fentanyl alfentanil

• Pros

• Cons

• Transdermal delivery due to lipophilic nature
• Intravenous rapid onset of action
• Buccal / sublingual / intranasal immediate
  release formulation
• Convenience / compliance
• Possibly less constipation

• Delay of effective analgesia 8 -12 hrs initially
• Poor dosing flexibility
• Uncertainty with BMI
• Cost
• Contraindication in uncontrolled pain due to
  titration period
• Patch adhesion problems

29
Methadone

• Pros

• Cons

• Potent orally
• Useful in pain with neurological components

• Unpredictable accumulation / plasma concentration
  rises over long periods unpredictable side
  effects
• Steady state 1 week
• Not really practical in community setting

30
Please dont forget

• Constipation
• senna/ lactulose
• movicol
• co-danthrusate / co-danthramer
• Nausea
• metoclopramide / domperidone
• haloperidol

31
Where to look for information?

• Twycross books are the bibles
• Palliative Care Formulary 3rd Edition
• Symptom management of advanced cancer - 4th
  Edition
• Introducing Palliative Care
• Palliativedrugs.com online version of PCF
• More detail
• Oxford Textbook of Palliative Medicine
• West Midlands pain handbook

32
(No Transcript)