OPIOID ANALGESICS

CLASSIFICATION
EQUIANALGESIC DOSES
OPIOID SUBSTITUTION
OPIOID OVERDOSE
ADVERSE EFFECTS
TOLERANCE, PHYSICAL DEPENDENCE
AND PSYCHOLOGICAL DEPENDENCE
OPIOPHOBIA
WEAK OPIOIDS
STRONG OPIOIDS

The opioid analgesics are defined as drugs having morphine-like effects and act by interaction with the opioid receptors.

Classification

☛   Weak opioids—opioids for mild to moderate pain

codeine
tramadol

☛   Strong opioids—opioids for moderate and severe pain

buprenorphine
fentanyl
diamorphine
hydromorphone
methadone
morphine
oxycodone
meperidine (pethidine)

Equianalgesic doses of opioids

☛   The equianalgesic doses of different opioid drugs

o are only approximations
o do not take into account individual patient variation (differences in absorption, metabolism, excretion) some are derived from studies of single doses rather than continued therapy

☛   Each drug must be titrated against pain and side effects for each individual patient

 

Opioid substitution: switching from one drug to another

With the increasing availability of a range of opioid drugs, it has become common practice for patients with inadequate analgesia or troublesome adverse effects to be tried on a different drug. Substitution of one opioid drug for another has been termed opioid switching or opioid rotation. Opioid substitution results in improved analgesia and fewer adverse effects for many patients.

Opioid overdosage

Severe sedation or narcosis, with loss of consciousness and respiratory depression, can occur

☛   if the dose prescribed is too large
☛   if the patient takes an intentional overdose (likely to be more severe)

The risk factors for narcosis are

☛   elderly or frail patients
☛   renal impairment
☛   other causes of CNS depression, including other medications
☛   opioid naive patients
☛   patients with only mild pain
☛   patients whose pain has been acutely relieved by a procedure such as a nerve block

Opioid overdosage is very uncommon in palliative care if appropriate care is taken with selecting and titrating the dose.

Assessment of narcosis

☛   respiration rate (RR)
☛   oxygen saturation: SaO2. Is the patient cyanosed?
☛   is the patient rousable?
☛   has time of peak plasma level of last dose of opioid been reached?

Treatment of narcosis

☛   General

o stimulate the patient
o give oxygen
o stop/withhold further opioid therapy

☛   RR < 5/min

o naloxone 0.4mg IV or SC stat

☛   RR 5-7/min ± barely rousable/unconscious ± SaO2 <90%

o naloxone 0.4mg in 10ml saline: 1-2ml IV or SC, q2-3min
o the minimum effective dose of naloxone should be used
o the aim is to improve respiratory function without causing recurrent pain or physical withdrawal

☛   RR = 8/min + rousable + SaO2 = 90%

o Careful observation

Adverse effects of opioids

☛   Gastrointestinal

o nausea and vomiting

" usually settles after several days
" give antiemetic, either regularly or PRN
" if persistent, change to a different opioid

o constipation

" laxatives and dietary advice are required for the
duration of opioid therapy

o gastric stasis

" metoclopramide or cisapride

☛   CNS

o narcosis - see Overdosage
o sedation

" may resolve after a few days
" reduce opioid dose
" withhold less necessary drugs that are CNS depressants
" consider an alternative opioid

o psychotomimetic (agitated delirium)

" reduce opioid dose
" haloperidol
" consider an alternative opioid

o myoclonus

" reduce opioid dose
" benzodiazepine

☛   Respiratory

o severe respiratory depression - see Overdosage
o mild/moderate respiratory depression

" reduce opioid dose
" withhold less necessary drugs that are CNS depressants
" consider an alternative opioid

o suppression of cough reflex

Tolerance, physical dependence and psychological dependence

Tolerance

☛   is a normal physiological response to chronic opioid therapy in which increasing doses are required to produce the same effect
☛   is uncommon in cancer patients with chronic pain in whom the need for increasing doses usually relates to disease progression
☛   is not a reason for "saving up" the use of opioid drugs until the terminal phase
☛   patients concerned that there will be "nothing left" for more severe pain should be reassured that the therapeutic range of morphine is very broad and that there is adequate scope to treat more severe pain if it occurs

Physical Dependence

☛   is a normal physiological response to chronic opioid therapy which causes withdrawal symptoms if the drug is abruptly stopped or an antagonist administered
☛   patients whose pain has been relieved by surgical or other means should have their opioid reduced by about 25% per day
☛   patients should be reassured that physical dependence does not prevent withdrawal of the medication if their pain has been relieved by other means, providing it is weaned slowly

Psychological dependence and addiction

☛   is a pathological psychological condition characterized by abnormal behavioural and other responses that always include a compulsion to take the drug to experience its psychic effects
☛   is rare in patients with cancer and pain
☛   even if it is anticipated that pain will be relieved by other means, opioids should not be withheld because of any concerns related to psychological dependence, although patients with a history of drug abuse should be managed carefully

In palliative care, concerns about tolerance, physical dependence or psychological dependence are never a reason to withhold opioid therapy if it is clinically indicated

The Underutilization of Opioids: Opiophobia

Professional opiophobia

Reasons why doctors underprescribe and nurses underadminister opioid drugs

☛   belief that morphine hastens death

↳ morphine may be used for months or years and, correctly administered, is compatible with a normal lifestyle
↳ used properly, it does not hasten death

☛   fear of respiratory depression

↳ used properly, morphine should not cause respiratory depression, although care must be taken with patients who are at risk of respiratory depression for other reasons

☛   "Morphine doesn’t work"

↳ morphine will be ineffective in controlling pain if

☑ it is incorrectly administered
☑ it is used for morphine-insensitive pain
☑ matters of psychosocial concern have not been addressed

☛   Morphine causes unacceptable side effects

↳ side effects should not be severe
↳ respiratory depression is uncommon except in opioid naïve patients commenced on parenteral therapy
↳ constipation occurs inevitably and requires explanation and advice about diet and laxative therapy
↳ somnolence and nausea usually improve after several days

☛   Fear of tolerance, physical dependence, psychological dependence

↳ concerns about these are never a reason to delay treatment with an opioid if it is clinically indicated

Patient opiophobia

Patients and their families may express concerns about opioid therapy:

☛   "That means I’m going to die soon"

↳ requires explanation that morphine can be used for months or years and is entirely compatible with a normal lifestyle

☛   "Nothing left for when the pain gets worse"

↳ requires reassurance that the therapeutic range of morphine is sufficient to allow escalation of the dose if necessary

☛   "I’ll become an addict"

↳ requires explanation and reassurance about physical and psychological dependence

☛   "The morphine didn’t work"

↳ morphine may not relieve pain if

☑ the dose was too low
☑ it was given too infrequently
☑ there were no instructions for breakthrough pain
☑ it was given for opioid-insensitive pain
☑ matters of psychosocial concern have not been addressed

☛   "I couldn’t take the morphine"

↳ unacceptable side effects should not occur
↳ patients should be warned about somnolence and nausea and reassured that they are likely to improve after several days
↳ constipation occurs inevitably and requires explanation and advice about diet and laxative therapy.

☛   "I’m allergic to morphine"

↳ usually relates to nausea or vomiting that occurred when parenteral morphine was given to an opioid naïve patient for acute pain
↳ immunological allergy to morphine is rare

Given explanation, reassurance and the cover of antiemetics, most patients can be started on morphine without ill effect.

 

WEAK OPIOID DRUGS
 

Weak opioid drugs are opioid drugs for mild to moderate pain

CODEINE
TRAMADOL

 

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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NON-OPIOID ANALGESICS

NSAIDs
ACETAMINOPHEN (PARACETAMOL)

NSAIDs

The non-steroidal anti-inflammatory drugs (NSAIDs) are a structurally diverse group of medications that share the ability to inhibit the enzyme prostaglandin synthetase (cyclo-oxygenase, COX).

There are two isoforms of the COX enzyme, COX-1 and COX-2

COX-1

☛   is constitutively expressed in most normal tissues
☛   produces the prostaglandins necessary for protective and regulatory functions

↳ maintenance of the gastric mucosa
↳ normal renal function
↳ platelet aggregation

☛   inhibition of COX-1 produces the clinically troublesome adverse effects including gastrointestinal toxicity

COX-2

☛   is induced by inflammation
☛   produces the prostaglandins involved in the generation of pain
☛   is also constitutively expressed in the kidney, brain and premenopausal uterus
☛   inhibition of COX-2 is responsible for the analgesic and anti-inflammatory properties of NSAIDs

Non-selective COX inhibitors

☛   are effective analgesics in cancer pain
☛   have analgesic efficacy equivalent to 5-10mg of intramuscular morphine
☛   have a ceiling effect to their analgesic action, but not to their adverse effects
☛   show considerable variation in both efficacy and toxicity between individual patients
☛   the dose needs to be individually titrated and in all cases the lowest effective dose should be used
☛   treatment for several days is required to achieve stable plasma levels and maximal effect

 

Gastrointestinal toxicity

☛   occurs commonly with non-selective COX inhibitors

↳ particularly in palliative care patients

☛   the risk is increased with

↳ advanced age (linear increase in risk)
↳ history of peptic ulcer
↳ higher doses of NSAID, or long-term use
↳ systemic co-morbidity (e.g. diabetes, cancer, hepatic impairment)
↳ co-prescription of

☑ corticosteroids
☑ anticoagulants
☑ aspirin (including low dose aspirin)

↳ bleeding disorder

☑ thrombocytopenia, abnormal platelet function

↳ H. pylori infection

☛   the risk is reduced by proton pump inhibitors (e.g. omeprazole, lansoprazole)

↳ antacids and sucralfate may reduce symptoms but do not protect against ulceration
↳ H2-receptor antagonists protect the duodenal and oesophageal mucosa but not the stomach
↳ misoprostol is effective but causes diarrheal

☛   palliative care patients requiring continued NSAID therapy should also be treated with a proton pump inhibitor

Selective COX-2 inhibitors (coxibs)

☛   were developed to minimize adverse events mediated by COX-1 inhibition
☛   have analgesic activity equivalent to traditional non-selective NSAIDs, both for acute pain and for the chronic pain associated with osteoarthritis and rheumatoid arthritis
☛   are associated with significantly less gastrointestinal toxicity
☛   have no effect on platelet function
☛   have the same renal effects as non-selective NSAIDs

↳ patients with renal impairment, hypertension, or hypovolaemia are at increased risk

☛   can cause acute neuropsychiatric events including confusion, somnolence, hallucinations
☛   do not induce bronchospasm in patients with aspirin- or NSAID-induced asthma
☛   Note: rofecoxib, valdecoxib and paracoxib have been withdrawn from the market in many countries because of an increased risk of cardiovascular side effects (myocardial infarction and stroke). Lumiracoxib was withdrawn because of hepatic toxicity.

Acetaminophen (Paracetamol)

☛   does not cause gastric irritation or bleeding
☛   does not affect platelet function or cause gastric irritation or bleeding
☛   can cause hepatic toxicity, possibly more likely with

↳ reduced glutathione stores e.g. poor nutritional status, the elderly
↳ regular use of alcohol

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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PRINCIPLES OF USING ANALGESICS FOR CHRONIC PAIN

☛   the use of analgesics for the treatment of acute pain is the same as for non-palliative care patients
☛   it is the treatment of chronic pain that is often poorly managed and requires a different approach

CHOICE OF DRUG

The selection of which drug or drugs to use involves

☛   selecting a drug appropriate for the type of pain
☛   selecting a drug appropriate for the severity of pain
☛   using combinations of drugs, not combined preparations
☛   following the analgesic ladder
☛   using adjuvant analgesics
☛   never using placebo

Drug strength

☛   as it is important that pain be controlled as quickly as possible, it is preferable to start with a strong analgesic and subsequently wean the patient to a weaker drug

Type of pain

☛   different pains respond to different analgesics:

Drug Combinations

☛   when prescribing more than one drug, the different drugs should be given independently and compound preparations avoided
☛   if it is necessary to escalate the dose of one of the drugs in a combined preparation, the dose of the second will also be increased and may cause unwanted toxicity

The analgesic ladder

☛   if the prescribed drugs do not produce adequate analgesia, treatment is escalated in an orderly manner

↳ from non-opioid to weak opioid to strong opioid, as illustrated in the World Health Organization’s "Analgesic Ladder"

☛   non-opioid analgesic should be continued when opioid drugs are commenced, as their action can be complementary and allow lesser doses of opioids to be used
☛   adjuvant analgesics should be used whenever indicated

WHO Analgesic Ladder

Placebo

☛   there is no place for the use of placebo medications in the treatment of chronic pain in palliative care
☛   it is unethical and will lead to distrust if discovered by the patient
☛   whether or not a response occurs provides no useful information

DRUG ADMINISTRATION

The principles of analgesic administration for chronic pain are

☛   give in adequate dosage
☛   titrate the dose for each individual patient
☛   schedule administration according to drug pharmacology
☛   administer on a strict schedule to prevent pain, not PRN
☛   give written instructions for patients on multiple drugs
☛   give instructions for treatment of breakthrough pain
☛   warn of, and give treatment to prevent, adverse effects
☛   keep the analgesic program as simple as possible
☛   use the oral route wherever possible
☛   review and reassess

Dose

☛   the selected drug or drugs are prescribed in a dose adequate to relieve the pain
☛   the dose needs to be titrated against the pain for each individual patient

Schedule

☛   drugs are given according to a strict schedule, determined by the duration of drug action, in order to prevent the recurrence of pain — Not PRN
☛   drugs given on an "as required" basis or pro re nata (PRN) usually results in poor pain control

Instructions for breakthrough pain

☛   it is essential to give instructions for the treatment of breakthrough pain

↳ it is reassuring
↳ avoids the despair that occurs if an analgesic program is ineffective
↳ helps the patient feel in control

Keep it simple

☛   avoid multiple analgesics
☛   it is usually possible to simplify the analgesic program, even for patients with severe pain

Oral

☛   Oral medication should only be abandoned if the patient is unable to take or retain them

Reassessment

☛   continued reassessment is necessary and a number of dose modifications are often needed before optimal pain control is achieved

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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GENERAL PRINCIPLES OF TREATMENT

Acute pain

☛   treatment of acute pain in palliative care is the same as for patients not requiring palliative care
☛   palliative care patients may recover more slowly and require analgesics for longer periods if their general condition is poor

Incident pain

☛   occurs only in certain circumstances, such as after a particular movement or on standing
☛   where possible, it should be treated with local measures
☛   analgesics may be used if the pain is mild and the side effects of constant administration tolerable
☛   if the pain is severe, modification of the patient’s activity may be preferable to taking strong opioid analgesics on a regular basis for pain that occurs infrequently

Chronic pain

☛   the aim of treatment is the prompt relief of pain and prevention of its recurrence
☛   the principles involved in the treatment of chronic pain are

↳ thorough assessment
↳ good communication reassurance about pain relief
↳ discourage acceptance of pain
↳ encourage patient participation

☛   the treatment of chronic pain in palliative care is

↳ an integrated part of the interdisciplinary plan of total care

☑ including management of psychosocial issues

↳ should be appropriate to the stage of the patient’s disease

☑ treatment for an ambulant patient will differ from one confined to bed

↳ employs the appropriate modality or modalities
↳ must be consistent, not variable

☑ avoid repeated changes of analgesics; titrate each drug to its optimal level

↳ requires continuity of care
↳ involves repeated reassessment

☛   the modalities of treatment available for chronic pain are

↳ treatment of the underlying disease
↳ analgesics
↳ adjuvant analgesics
↳ neurostimulatory treatment
↳ anaesthetic, neurolytic and neurosurgical procedures
↳ physiotherapy
↳ psychological therapy
↳ lifestyle modification
↳ treatment of psychosocial issues that cause or aggravate pain

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

☑

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PAIN ASSESSMENT

Comprehensive clinical assessment is fundamental to successful treatment

☛   accept the patient’s description

↳ pain is always subjective and patients’ pain is what they say it is and not what others think it ought to be

☛   thorough assessment of the pain
☛   patients should be asked to describe their pain, in their own words

↳ their expression and any body language whilst describing their pain may provide useful information

☛   this information is supplemented by specific questions to define the exact nature of the pain

↳ the site and radiation of the pain
↳ the type of pain
↳ the duration of the pain and whether it has changed
↳ whether there are precipitating, aggravating or relieving factors
↳ its impact on functional ability, mood and sleep
↳ the effect of previous medications

☛   what the pain means to the patient
☛   physical examination, including neurological assessment, should be recorded both in writing and pictorially
☛   further investigations should be limited to those likely to have a significant bearing on treatment decisions
☛   assess each pain

↳ many patients have more than one pain and each pain requires assessment

☛   evaluate the extent of the patient’s disease

↳ the underlying disease is the most frequent cause of pain, new or worsening pain requires the extent of the patient’s disease be re-evaluated

☛   assess other factors that may influence the pain

↳ physical, psychological, social, cultural, spiritual/existential

☛   reassess

↳ repeated reviews are necessary to both assess the effect of treatment and because the underlying disease is usually progressive

Pain measurement
Pain is a subjective phenomenon for which objective measurement is not possible.

☛   A variety of pain intensity scales have been developed to measure pain.
☛   The instruments in common use are unidimensional and consist of a visual analogue scale, a numerical rating scale, or a verbal descriptor scale:

 
☛   Note: they are used to compare one patient’s pain at different times and are not intended to compare one patient’s pain with another’s.

↳ can be used to follow the course of a patient’s pain
↳ can be used to assess the effect of treatment
↳ may be seen by the patient as indicating concern about their pain

More complex multidimensional instruments are available

☛   e.g. the Brief Pain Inventory (BPI)
☛   includes affective and behavioural associations of pain and interference with function
☛   time consuming for both patients and staff and are best reserved for research projects

Pain in patients with cognitive impairment or dementia can be estimated using the Abbey Pain Scale (www.apsoc.org.au/PDF/Publications/). This is based on the score (0-3) given for six observations—vocalisation, facial expression, body language change, behavioural change, physiological change and physical changes.

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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FACTORS THAT MODIFY THE PERCEPTION OF PAIN

Pain is always subjective and the perception of pain may be modified by problems or influences related to other physical or psychosocial causes of suffering
 

Pain caused by the disease or treatment is modified by these influences, making it either better or worse, resulting in the final clinical pain, which is what the patient says it is, and what has to be treated

The table lists examples of factors that might aggravate pain. Relief or successful management may have the opposite effect and improve pain.

Interaction of Pain and the Other Causes of Suffering

Pain can cause or aggravate problems related to other causes of suffering—other physical symptoms, psychological problems, social difficulties, cultural issues, or spiritual/existential concerns

☛   in this situation, pain has to be controlled before psychosocial problems can be addressed

↳ it is not possible to have meaningful discussions about psychosocial concerns if a patient has uncontrolled pain

☛   alternatively, pain can be caused or aggravated by psychosocial concerns
☛   in this situation, the psychosocial concerns must be addressed before good pain control can be achieved

↳ where psychosocial or spiritual problems are causing or aggravating pain, no amount of well-prescribed analgesia will relieve the pain until the responsible psychosocial issues are identified and addressed

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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CAUSES OF PAIN

In palliative care, there are many different possible causes of pain

Examples of the causes of pain in palliative care patients include pain

☛   due to the primary disease e.g.

↳ tumour infiltration
↳ nerve compression

☛   associated with treatment e.g.

↳ diagnostic and staging procedures
↳ surgery

☛   due to general debilitating disease e.g.

↳ pressure sores
↳ constipation

☛   unrelated to the primary disease or treatment e.g.

↳ arthritis
↳ ischemic heart disease

Determination of the cause of pain is an important part of assessment, as therapy directed at the cause may greatly improve pain control

see Assessment and Principles of Treatment



↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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TYPES OF PAIN

Definitions

☛   Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. (International Association for the Study of Pain).
☛   Pain is what the patient says hurts. It is what the patient describes and not what others think it ought to be.

Acute and chronic pain

Acute pain

☛   is usually due to a definable acute injury or illness
☛   it has a definite onset and its duration is limited and predictable
☛   it is accompanied by anxiety and clinical signs of sympathetic over activity
☛   treatment is directed at the acute illness or injury causing pain, with or without the short term use of analgesics

Chronic pain

☛   results from a chronic pathological process
☛   it has a gradual or ill-defined onset, continues unabated and may become progressively more severe
☛   is said to exist if the pain persists longer than the expected healing time for the injury or illness in question
☛   the patient appears depressed and withdrawn
☛   there may be no sympathetic over-activity and patients are frequently labelled as "not looking like somebody in pain"
☛   requires treatment of the underlying disease where possible, regular use of analgesics to relieve pain and prevent recurrence, as well as psychosocial supportive care

Incident pain

☛   occurs only in certain circumstances, such as after a particular movement or on standing
☛   should be regarded as chronic pain but, as it is intermittent, it is better managed with local measures where possible

Breakthrough pain

☛   is a transitory exacerbation of pain that occurs on a background of otherwise stable and controlled pain

Nociceptive, neuropathic and psychogenic pain

Nociceptive pain

☛   nociceptive or physiological pain is produced by stimulation of specific sensory receptors or nociceptors in the tissues
☛   the neural pathways involved are normal and intact
☛   somatic pain from the skin and superficial structures is usually well localized
☛   visceral pain is less well localized and there is often referred pain to cutaneous sites

Neuropathic pain

☛   is caused by peripheral or central nervous system injury
☛   pain occurs because the injured nerves react abnormally to stimuli or discharge spontaneously
☛   neuropathic pain is described as

↳ a burning stinging feeling (dysaesthesia)
↳ a shooting pain like an electric shock (lancinating)
↳ an aching sensation often relieved by firmly squeezing or gripping the affected area

☛   is less responsive to non-opioid and opioid analgesics and may respond better to an adjuvant analgesic

Sympathetic pain

☛   is caused by damage to sympathetic nerves
☛   is characterized by burning pain and increased sensitivity
☛   there are signs of sympathetic dysfunction in the affected area

↳ vasomotor instability (erythema, pallor, oedema)
↳ sudomotor (sweating) abnormalities
↳ trophic changes (thinning of the skin and atrophy of the subcutaneous tissue)

☛   is less sensitive to non-opioid and opioid analgesics
☛   often responds well to a regional sympathetic nerve block

Psychogenic pain

☛   is pain for which there is no physical basis in a patient who has other evidence of psychopathology
☛   in palliative care, patients are occasionally seen with psychosocial or existential distress in whom psychological factors and not the medical condition are judged to play the major role in the onset and maintenance of the pain, and for whom primarily psychological therapies may be appropriate
☛   however, all chronic physical pain is associated with some degree of psychological distress, for which the treatment should be primarily directed at the cause of the physical pain

Determination of the type of pain is an important part of assessment, as different types of pain may respond better to different treatments

see Principles of Treatment




↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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PAIN - INTRODUCTION

Pain is one of the most common symptoms in palliative care. The aim of palliative care is to allow patients to be pain-free or for their pain to be sufficiently controlled that it does not interfere with their ability to function or detract from their quality of life. In palliative care, the treatment of pain needs to be part of a holistic and multidisciplinary approach to patient care.

☛   Pain can cause or aggravate problems related to other causes of suffering and the pain has to be controlled before the other problems can be addressed and treated.

↳ It is not possible to have meaningful discussions about psychosocial concerns if a patient has uncontrolled pain.

☛   Pain can be caused or aggravated by psychosocial concerns, which must be addressed before good pain control can be achieved.

↳ Where psychosocial or spiritual problems are causing or aggravating pain, no amount of well-prescribed analgesia will relieve the pain until the responsible psychosocial issues are identified and addressed.

Good pain control requires

☛   accurate and detailed assessment of each pain
☛   knowledge of the different types of pains
☛   a different therapeutic approach to chronic pain
☛   knowledge of which treatment modalities to use
☛   knowledge of the actions, adverse effects and pharmacology of analgesics
☛   assessment and treatment of other aspects of suffering that may aggravate pain

↳ physical, psychological, social, cultural, spiritual

☛   fundamental to this is the availability of opioid analgesics

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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JUSTICE AND RESOURCE ALLOCATION

 
Justice

☛   refers to the equitable allocation of health care resources according to need

↳ not according to wealth, class, creed or colour

☛   all patients with active, progressive, far-advanced disease and a short life expectancy, for whom the focus of care is the relief and prevention of suffering and the quality of life, should have access to palliative care

Resource Allocation

☛   some would argue that cure medicine should have priority because it aims to maintain life which may be economically and socially useful and productive
☛   others would argue that palliative care is more important because a society which is not concerned about its incurably ill is not a good society
☛   in many developing countries, the majority of patients are diagnosed with advanced stage disease and/or curative treatments are not available
☛   in some developing countries, expensive chemotherapy drugs and analgesic medications are available, but simple (and affordable) morphine mixture and injections are not

Palliative Care must be prepared

☛   to demonstrate the effectiveness of interventions on quality of life and symptom control and not just on patient satisfaction
☛   to show cost-effectiveness or at least cost parity with alternative forms of care
☛   to demonstrate not only the efficacy but also the efficiency of what it does

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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ETHICS IN RESEARCH

Should terminally ill patients be recruited into clinical trials?

☛   Yes, if the trial objective is to improve the quality of life and

↳ there is possible benefit
↳ the potential for harm is low
↳ the patient is fully informed of all that is involved

☛   No, if it is a phase 1 trial of an experimental anticancer agent or other intervention for which

↳ the chance of benefit is very small
↳ the potential for harm is significant

Informed consent for a clinical trial must include understanding of

☛   the purpose of the research
☛   any foreseeable risks
☛   any possible benefits
☛   any appropriate alternative procedures or treatments
☛   confidentiality of records
☛   participation being voluntary
☛   ability to withdraw at any time
☛   that continuing care is not dependent on participation in the trial

Palliative care patients are particularly vulnerable and susceptible to proposals to enrol in clinical trials

☛   they may be desperate for treatment options
☛   they may be physically ill and exhausted
☛   they may be depressed
☛   they may be cognitively impaired
☛   they may feel obliged to participate, to show their appreciation to the doctors caring for them

There is an ethical responsibility to protect palliative care patients from studies that are not in their best interests whilst preserving the informed patients’ freedom of choice

☛   experience suggests that many terminally ill patients enjoy collaborating in ventures which might help others, feeling that they are still useful members of society

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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EUTHANASIA AND PHYSICIAN ASSISTED SUICIDE

Euthanasia is a deliberate intervention undertaken with the express intention of ending a life so as to relieve intractable suffering

☛   if performed at the person’s request or with their consent, it is voluntary
☛   otherwise it is non-voluntary

Physician-assisted suicide: the physician provides the knowledge and means necessary, but the act is completed by the patient

☛   from the physician’s standpoint, it is a deliberate act with the express intention of ending life and should not be ethically distinguished from euthanasia

Palliative Care

☛   recognizes human suffering and seeks to relieve it

↳ but it does not accept that euthanasia is ever the answer

☛   recognizes that a request for euthanasia is a plea for better care

Withholding or withdrawal of medical treatment

☛   terminally ill patients should not be subjected to futile therapies
☛   there is no requirement or justification to sustain life at all costs

↳ a doctor has no right to prescribe a prolonged or lingering death

☛   withholding or withdrawal of futile treatment from the terminally ill does not shorten life or hasten death

↳ it does not artificially prolong life

☛   withholding or withdrawal of futile therapy from the terminally ill is not euthanasia

↳ the intention is to allow death to occur naturally, not to deliberately terminate life

‘Double effects’

☛   medications given for the relief of distressing pain or symptoms may, on occasions, hasten the moment of death, the so-called ‘double effect’
o there is no evidence that good palliative medicine shortens life
o effective symptom control is just as likely to extend as shorten life
o studies indicate that the appropriate use of sedatives and opioids at the end of life is not associated with life-shortening
☛   providing that appropriate drugs are given for appropriate medical reasons and in appropriate doses, this is not euthanasia

↳ the hastening of death may or may not be foreseen, but it is never intended

Palliative sedation

Palliative sedation is the use of sedating medications at the end of life to relieve refractory and intolerable symptoms (e.g. pain, dyspnoea, agitated delirium) after all other measures have failed.

☛   provided it is performed with the informed consent of the patient or surrogate decision-maker, employing appropriate drugs in appropriate doses and carefully titrated, it is ethically sound and is not euthanasia.
☛   the possibility of a ‘double effect’ exists, although studies of patients treated with palliative sedation in this manner do not demonstrate lifeshortening.
☛   the practice of ‘terminal sedation’ (with the intention of keeping a patient unconscious until they die) and palliative sedation for ‘existential distress’, as reported from the Netherlands, probably constitute euthanasia.

Euthanasia may be requested or advocated for various reasons

☛   unrelieved pain and physical symptoms (or fear of)

↳ which should occur infrequently given optimal multiprofessional palliative care
↳ terminal sedation may be considered for patients with pain or other symptoms that are refractory to optimal palliative care; this does not constitute euthanasia

☛   severe anxiety and depression

↳ which should be controlled given optimal multiprofessional palliative care

☛   intolerable suffering, existential distress

↳ which should be controlled given optimal multiprofessional palliative care

☛   carer fatigue

↳ is preventable

☛   autonomy and self determination

↳ in modern society, the existence of a right to request and receive euthanasia is controversial—every ‘right’ is balanced by a responsibility

☛   iatrogenic - the ‘nothing more can be done’ syndrome

↳ would not occur if patients were referred to a palliative care service
↳ requires professional education

Uncontrolled suffering in the terminally ill should be considered a medical emergency and not an indication for euthanasia

Legalization of euthanasia is associated with risks

☛   voluntary euthanasia leads to non-voluntary euthanasia

↳ reports from the Netherlands indicate that as many as a thousand patients a year are subjected to euthanasia without request, never mind consent

☛   euthanasia for the terminally ill leads to euthanasia for those not terminally ill

↳ e.g. the Dutch reports of euthanasia for men with early AIDS and life expectancy measured in years

☛   euthanasia for the terminally ill leads to euthanasia for persons with potentially treatable conditions like depression

↳ as documented in the Dutch and Australian reports

☛   the vulnerable will experience pressure to request euthanasia

↳ the aged, the sick, the disabled and those who feel a burden
↳ as reported from Holland

There is no place for euthanasia in a caring society that provides
palliative care services

Further articles concerning euthanasia are to be found on the Ethics Page of the IAHPC website

↳
Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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ARTIFICIAL NUTRITION

The question is whether or not a particular treatment or intervention will restore or enhance the quality of life for a particular patient

☛   if the answer is yes, and it can be justified on the best clinical grounds, then it is ethically right to do it
☛   if not, it should not be done
☛   in developing countries, cost may be a major additional consideration
☛   ‘You have to do something!’ is never a justification for artificial nutrition

Weight loss and wasting in advanced cancer

☛   is nearly always due to the cachexia syndrome
☛   is caused by changes to metabolism secondary to the cancer
☛   is never responsive to enteral or parenteral nutrition

↳ i.e. they are futile
↳ parenteral nutrition is also associated with

* central venous catheterization
* infections
* expense

↳ enteral nutrition is also associated with

* abdominal cramps
* diarrhoea
* feeding tubes

☛   is occasionally due to malnutrition and starvation

↳ patients with upper gastrointestinal obstruction, not terminally ill from their cancer warrant feeding by a nasogastric tube or gastrostomy
↳ patients receiving therapy that will prevent them eating for 2 weeks or more warrant consideration for parenteral feeding
↳ for patients with persistent or recurrent bowel obstruction, whether parenteral nutrition is warranted depends on individual clinical circumstances

 

Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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ARTIFICIAL HYDRATION

The question is whether or not a particular treatment or intervention will restore or enhance the quality of life for a particular patient

☛   if the answer is yes, and it can be justified on the best clinical grounds, then it is ethically right to do it
☛   if not, it should not be done
☛   ‘You have to do something!’ is never a justification for artificial hydration

Effects of dehydration in terminally ill patients

☛   dry mouth

↳ but this can be well palliated topically

☛   thirst

↳ although dying patients do not complain of thirst

☛   diminished conscious state

↳ several reports and a single randomized controlled trial showed no correlation between hydration and cognition in these patients

Possible benefits of dehydration in terminally ill patients

☛   less urine output means less movement and less incontinence
☛   less pulmonary secretions reduce dyspnoea and terminal congestion
☛   less gastrointestinal secretions will lessen nausea and diarrhoea
☛   less problems with oedema and effusions

Possible disadvantages of artificial hydration in terminally ill patients

☛   may have the opposite effects to the benefits listed above and worsen the patient’s situation
☛   may give an ambiguous signal or false hope to the patient or family
☛   drips act as a physical barrier between patient and family

Dehydration in patients not terminally ill

☛   causes thirst, dry mouth and postural hypotension
☛   patients unable to take or retain adequate fluids warrant parenteral hydration

 

Source:
The IAHPC Manual of Palliative Care 3rd Edition
https://web.archive.org/web/20210122105526/https://hospicecare.com/uploads/2013/9/The%20IAHPC%20Manual%20of%20Palliative%20Care%203e.pdf

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