PALLIATIVE CARE - PowerPoint PPT Presentation

Loading...

PPT – PALLIATIVE CARE PowerPoint presentation | free to download - id: 3b0c73-ODkxN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

PALLIATIVE CARE

Description:

PALLIATIVE CARE: World Health Organization Definition Palliative care is an approach that improves the quality of life of patients and their families facing the ... – PowerPoint PPT presentation

Number of Views:308
Avg rating:3.0/5.0
Slides: 59
Provided by: Dr1756
Learn more at: http://keiserstudents.tripod.com
Category:
Tags: care | palliative

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: PALLIATIVE CARE


1
PALLIATIVE CARE World Health Organization
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.
2
(No Transcript)
3
Lifetime Risk of
Heart disease 12 men 13 women (age
40) Cancer gt 13 Alzheimer's 12.5 15 by
age 85 Diabetes 15 Parkinsons 140
11
Death
4
EVOLVING MODEL OF PALLIATIVE CARE
Active Treatment
Palliative Care
Cure/Life-prolonging Intent
Palliative/ Comfort Intent
Bereavement
5
(No Transcript)
6
CHALLENGE- Alleviate Suffering for a Condition
Which
  • Ultimately will affect every one of us - Large
    numbers - We have our own death issues as
    care providers
  • Only approximately 10 of Canadians have access
    to specialty care
  • The process outcome are expected to be
    terrible after all, it is death
  • Has a tremendous impact on those close to the
    individual collateral suffering
  • Few physicians or nurses have even basic training
  • No chance of feedback from patient after the
    fact
  • Clinicians dont intuitively know when they need
    adviceThey dont know what they dont know
  • Patients/families dont have the knowledge of how
    things could be, with regards to their rights for
    good symptom control

7
Effective care of the dying involves
  • 1. Adequate knowledge base
  • 2. Attitude / Behaviour / Philosophy
  • Active, aggressive management of suffering
  • Team approach
  • Recognizing death as a natural closure of life
  • Broadening your concept of successful care

8
APPROACH TO THE SYMPTOM CONTROL IN THE
PALLIATIVE PATIENT
Two basic intervention types
  • Non-specific, suffering-oriented
  • Disease-specific

9
NON-SPECIFIC INTERVENTIONS FOR SUFFERING
  • Non-pharmacological
  • Talk about death and dying
  • Calm reassurance
  • Emotional and spiritual support
  • Pharmacological
  • Opioids, other analgesics and adjuvants (eg/
    gabapentin)
  • Sedatives
  • Neuroleptics CPZ, methotrimeprazine
  • Possibly benzodiazepines
  • Corticosteroids reduce inflammation, edema

10
SPECIFIC INTERVENTIONS - TREAT THE CAUSE IF
POSSIBLE AND APPROPRIATE
The illness is like a pack that the patient
carries, which holds various burdens
  • Energy loss and functional decline from the
    disease itself (cachexia/anorexia syndrome)
  • Disease complications infection, hypercalcemia,
    dehydration, anemia, etc.
  • Symptoms such as pain, nausea, dyspnea
  • Emotional drain from anxiety/fear, depression,
    etc.
  • Treatment side effects (medications, radiation
    therapy, etc.)

When possible and appropriate, we can see what is
possible to remove or lighten (treat
complication, change med)
11
Cancer Pain Management An Overview
12
PHYSICAL
SUFFERING
PSYCHOSOCIAL
EMOTIONAL
SPIRITUAL
13
SYMPTOMS IN ADVANCED CANCER
Ref Bruera 1992 Why Do We Care? Conference
Memorial Sloan-Kettering
14
PREVALENCE OF CANCER PAIN
From Portenoy Cancer 632298, 1989
15
TYPES OF PAIN
NOCICEPTIVE
NEUROPATHIC
Visceral
Somatic
Deafferentation
Sympathetic Maintained
Peripheral
16
Somatic Pain
  • Aching, often constant
  • May be dull or sharp
  • Often worse with movement
  • Well localized
  • Eg/
  • Bone soft tissue
  • chest wall

17
Visceral Pain
  • Constant or crampy
  • Aching
  • Poorly localized
  • Referred
  • Eg/
  • CA pancreas
  • Liver capsule distension
  • Bowel obstruction

18
  • bone is the most common site of tumour
    metastases

Mundy GR. In Bone Remodeling and Its Disorders.
1995104-107.
19
Special Considerations in Bone Pain
  • Spinal cord compression in vertebral mets
  • Pain earliest feature
  • Risk of pathological fracture
  • Indications for prophylactic surgery in
    large, weight-bearing bones
  • Cortical Lesions
  • Destruction of gt 50 of the cortical width
  • Axial length of lesion gt diameter of the bone
  • gt 2 3 cm lesion
  • Medullary lesions
  • Lesion gt 50 of the medulla
  • Pain unrelieved by radiotherapy

20
FEATURES OF NEUROPATHIC PAIN
21
PAIN ASSESSMENT
  • Description severity, quality, location,
    temporal features, frequency, aggravating
    alleviating factors
  • Previous history
  • Context social, cultural, emotional, spiritual
    factors
  • Meaning
  • Interventions what has been tried?

22
Assessment of Bone Pain
23
Medication(s) taken
  • Dose
  • Route
  • Frequency
  • Duration
  • Efficacy
  • Side effects

24
W.H.O. ANALGESIC LADDER
Strong opioid
/- adjuvant
Weak opioid
/- adjuvant
Pain persists or increases
Non-opioid
/- adjuvant
25
STRONG OPIOIDS
  • most commonly use
  • morphine
  • hydromorphone
  • transdermal fentanyl (Duragesic)
  • oxycodone
  • Methadone
  • DO NOT use meperidine (Demerolâ) long-term
  • active metabolite normeperidine seizures

26
OPIOIDS and INCOMPLETE CROSS-TOLERANCE
  • conversion tables assume full cross-tolerance
  • cross-tolerance unpredictable, especially in
  • high doses
  • long-term use
  • divide calculated dose in ½ and titrate

27
CONVERTING OPIOIDS
28
TITRATING OPIOIDS
  • dose increase depends on the situation
  • dose by 25 - 100

EXAMPLE (doses in mg q4h)
29
(No Transcript)
30
TOLERANCE
PSYCHOLOGICAL DEPENDENCE / ADDICTION
PHYSICAL DEPENDENCE
31
TOLERANCE
Inturrisi C, Hanks G. Oxford Textbook of
Palliative Medicine 1993 Chapter 4.2.3
A normal physiological phenomenon in which
increasing doses are required to produce the same
effect
32
PHYSICAL DEPENDENCE
Inturrisi C, Hanks G. Oxford Textbook of
Palliative Medicine 1993 Chapter 4.2.3
A normal physiological phenomenon in which a
withdrawal syndrome occurs when an opioid is
abruptly discontinued or an opioid antagonist is
administered
33
PSYCHOLOGICAL DEPENDENCE and ADDICTION
Inturrisi C, Hanks G. Oxford Textbook of
Palliative Medicine 1993 Chapter 4.2.3
A pattern of drug use characterized by a
continued craving for an opioid which is manifest
as compulsive drug-seeking behaviour leading to
an overwhelming involvement in the use and
procurement of the drug
34
In chronic opioid dosing po / sublingual /
rectal routes sq / iv / IM routes
reduce by ½
35
Using Opioids for Breakthrough Pain
  • Patient must feel in control, empowered
  • Use aggressive dose and interval
  • Patient Taking Short-Acting Opioids
  • 50 - 100 of the q4h dose given q1h prn
  • Patient Taking Long-Acting Opioids
  • 10 - 20 of total daily dose given q1h prn
  • with short-acting opioid preparation

36
Management of Bone Pain
  • Pharmacologic treatment
  • Acetaminophen
  • Opioids
  • NSAIDs conventional Cox-2 inhibitors
  • Corticosteroids (not with NSAIDS)
  • Bisphosphonates pamidronate (Aredia?),
    clodronate (Bonefos?), zoledronate (Zometa?)

37
Management of Bone Pain ctd
  • Radiation treatment
  • Single (800 cGy) or Multiple fx (200 cGy x 3-5)
  • Effective immediately
  • Maximal effect 4 - 6 wks
  • 60-80 pts get relief
  • Strontium-89

38
Treatment of Neuropathic Pain
  • Pharmacologic treatment
  • Opioids
  • Steroids
  • Anticonvulsants - gabapentin
  • TCAs (for dysesthetic pain, esp. if depression)
  • NMDA receptor antagonists ketamine,
    dextromethorphan, methadone
  • Anesthetics
  • Radiation therapy
  • Interventional treatment
  • Spinal analgesia
  • Nerve blocks

39
ADJUVANT DRUGS
  • primary indication usually other than pain
  • analgesic in some painful conditions
  • enhance analgesia of opioids
  • other roles
  • treat opioid side effects
  • treat symptoms associated with pain

40
CORTICOSTEROIDS AS ADJUVANTS
  • inflammation
  • edema
  • spontaneous nerve depolarization


tumor mass effects
41
CORTICOSTEROIDS ADVERSE EFFECTS
42
DEXAMETHASONE DOSING
  • minimal mineralcorticoid effects
  • po/iv/sq/?sublingual routes
  • can be given once/day often given
  • bid qid to facilitate titration
  • typically administer as follows
  • 4 mg qid x 7 days then
  • 4 mg tid x 1 day then
  • 4 mg bid x 1 day then
  • 4 mg once/day x 1 day then D/C

43
Complementary / Alternative Therapies
  • Acupuncture
  • Cognitive/behavioral therapy
  • Meditation/relaxation
  • Guided imagery
  • Herbal preparations
  • Magnets
  • Therapeutic massage

44
Opioid Side Effects
  • Constipation
  • Nausea/vomiting
  • Urinary retention
  • Itch/rash
  • Dry mouth
  • Respiratory depression
  • Drug interactions
  • Neurotoxicity delirium, myoclonus seizures

45
Opioid-Induced Neurotoxicity (OIN)
  • Potentially fatal neuropsychiatric syndrome of
  • Cognitive dysfunction
  • Delirium
  • Hallucinations
  • Myoclonus/seizures
  • Hyperalgesia / allodynia
  • Increasing incidence practitioners more
    comfortable and aggressive with opioids
  • NMDA receptor involved
  • Early recognition is critical

46
OIN Recognition
  • Myoclonus twitching of large muscle groups
  • Delirium
  • Rapidly escalating dose requirement
  • Pain doesnt make sense not consistent with
    recent pattern or known disease

47
(No Transcript)
48
OIN Treatment
  • Switch opioid (rotation) or reduce opioid dose
  • Hydration
  • Benzodiazepines for neuromuscular excitation

49
The Management of Incident Pain in Palliative
Care
50
What is Incident Pain?
Pain occurring as a direct and immediate
consequence of a movement or activity
51
Circumstances In Which Incident Pain Often
Occurs
  • Bone metastases
  • Neuropathic pain
  • Intra-abdominal disease aggravated by
    respiration
  • incident breathing
  • ruptured viscus, peritonitis, liver hemorrhage
  • Skin ulcer dressing change, debridement
  • Disimpaction
  • Catheterization

52
Barriers to Managing Incident Pain
  • common opioids outlast painful stimulus
  • opioid dose for incident pain may far exceed
  • that needed for background pain control
  • may be little warning of incident
  • effective premedication before activity is
    time consuming

53
Considerations In Managing Incident Pain
  • usually predictable
  • stimulus is usually brief
  • frequency of incidents may vary from
  • several per minute to once per day or less.

54
Approach to Incident Pain
  • treat underlying problem
  • radiation Tx, chemotherapy
  • bisphosphonates
  • orthopedic intervention
  • nerve blocks
  • ideal analgesic
  • easily administered
  • rapid onset
  • short-duration of action
  • in patients control

55
Fentanyl and Sufentanil
  • synthetic µ agonist opioids
  • highly lipid soluble
  • transmucosal absorption
  • rapid redistribution, including in / out of CSF
  • fentanyl 100x stronger than morphine
  • sufentanil 1000x stronger than morphine

10 mg morphine 10 µg
sufentanil
100 µg fentanyl
56
Comparison of Fentanyl and Sufentanil
57
INCIDENT PAIN PROTOCOL
58
INCIDENT PAIN PROTOCOL ctd...
  • fentanyl or sufentanil is administered SL 10
    min. prior to anticipated activity
  • repeat q 10min x 2 additional doses if needed
  • increase to next step if 3 total doses not
  • effective
  • physician order required to increase to next
  • step if within an hour of last dose
  • the Incident Pain Protocol may be used up to
  • q 1h prn
About PowerShow.com