Palliative medicine may be defined as the active, total care of patients whose disease is no longer responsive to curative treatment. The goal of this care is to achieve the best quality of life for patients and their families by controlling physical symptoms and psychological, social and spiritual problems.
Many symptoms suffered by such patients have a complex aetiology in which the physical component may be overlaid by psychosocial issues which require considerable input from a multidisciplinary team of professionals to resolve. Palliative care for the family unit accepts that death is a normal process which will neither be hastened nor postponed, and provides a support system for the family in bereavement. The first step in providing care is often to deal with physical symptoms.
Pain is the most feared symptom, although only twothirds of cancer patients suffer significant pain throughout the course of their disease. The principles of pain relief are careful assessment and diagnosis of the cause of the pain, use of analgesics according to the analgesic ladder and regular review of the effectiveness of the prescription.
The analgesic ladder, adopted by the Cancer Pain Relief Programme from the World Health Organization, groups drugs into three main classes:
1 Non-opioids, e.g. non-steroidal anti-inflammatory drugs including aspirin and paracetamol
2 Weak opioids, e.g. codeine and dextropropoxyphene or combinations of codeine with paracetamol
3 Strong opioids, e.g. morphine and diamorphine The ladder states that should optimum use of a drug, e.g. paracetamol 1 g 6-hourly, not result in satisfactory pain relief, the prescription should be increased to a weak opioid. If codeine 60 mg 4-hourly is not sufficient to control pain, the patient will require a strong opioid.
Strong opioid drugs
Morphine is the drug of choice and it should be given regularly by mouth. The dose can be tailored to the individual patient’s needs by the addition of ‘as required’ doses; morphine has no ceiling of analgesic effect. A suitable starting dose of morphine is lO mg 4-hourly, with a reduction to 5 mg if the patient is elderly or frail. Patients with renal failure may receive morphine in single doses, but should be carefully observed for the return of pain in order to determine the rate of excretion of morphine metabolites. If the lO mg dose does not last for 4 hours, a 50% increase in the dose should be made, i.e., 10, 15, 20, 30, 45, 60, 90, 120, 180 mg, until satisfactory pain control is achieved.
Once the patient’s 24 hour morphine requirement has been established, the prescription may be converted to a controlled-release preparation, e.g. MST. 20 mg morphine elixir 4-hourly = 120 mg in 24 hours = 60 mg MST twice daily If the patient is unable to take oral medication because of nausea or vomiting, gastrointestinal obstruction or altering levels of consciousness, the opiate should be given rectally or parenterally. In cancer patients in whom longer term treatment is required, continuous subcutaneous infusion is preferred. Diamorphine is used in this situation, because of its greater solubility. By subcutaneous or intramuscular injection diamorphine is about twice as potent as morphine. The conversion from oral morphine may be calculated:
30 mg morphine 4-hourly = 180 mg over 24 hours = 90 mg diamorphine over 24 hours
SIDE-EFFECTS. Constipation caused by opioid drugs is almost universal. The prescription of a stimulant laxative such as co-danthrusate 1-3 capsules at night should be mandatory at the same time as morphine is started. Nausea or vomiting can occur in up to 60% of patients started on morphine. However, for those who have worked up the analgesic ladder and who have no other cause for vomiting, the prescription of an ‘as required’ antiemetic is usually sufficient.
Confusion, nightmares and hallucinations occur in a small percentage of patients. Tolerance to these symptoms does not develop and a change of treatment is usually required.
Not all pains are clinically opioid responsive and in these situations the addition of co-analgesic drugs will result in improved analgesia. Non-steroidal anti-inflammatory drugs are used for bone pain in addition to an analgesic drug. Published studies have most frequently used naproxen (500 mg twice daily) but there is no clear evidence of anyone drug being superior in effect.
Neuropathic pains are generally only marginally improved by opiates. Several classes of drug have been found to be helpful. In cases of constant burning dysaesthesiae, the tricyclic antidepressants, usually amitriptyline, are helpful. Amitriptyline 25 mg at night increasing incrementally to 75-100 mg is usually sufficient (unlike the doses required for mood elevation) and a response, if achieved, can be expected in about 1 week.
drugs are useful in the management of lancinating, neuropathic pains. Carbamazepine starting at a dose of 100 mg twice daily is most commonly used, but recent interest has turned to sodium valproate 300 mg twice daily which may cause fewer adverse side-effects. In addition to drugs many other techniques, such as radiotherapy, anaesthesia and neurosurgery, are employed for the treatment of specific pains. Other physical symptoms Anorexia, malaise and weakness are among the most frequently troublesome symptoms. Current research suggests that endogenously produced cytokines, e.g. tumour necrosis factor, are mediators of the anorexia/cachexia syndrome. The approach to therapy at present depends simply on the adequate treatment of associated symptoms such as pain, nausea and psychological factors as well as attention to nutrition and the judicious use of steroids. ausea and vomiting occur in up to two-thirds of cancer patients in the last 2 months of life. The approach to treatment should be similar to that required for pain. It may, however, be more difficult to reach a diagnosis on the cause of the symptom and a somewhat empirical approach to treatment is used. In order to ensure adequate absorption of an antiemetic, parenteral administration for the first 24 hours can be helpful.
Antiemetics are classified according to their pharmacoical effects on neurotransmitters. A gastrokinetic dopamine antagonist such as metoclopramide 10 mg 6-8 hourly would be helpful in vomiting related to upper gastroointestinal tract stasis or to liver metastases. As it increases peristalsis in the upper bowel, metoclopramide should be avoided in cases of intestinal obstruction. Centrally acting antiemetics such as the anticholinergic phenothiazine cyclizine 50 mg 8-hourly or the dopamineantagonist butyrophenone haloperidol 1.5 mg 8-hourly would be the drug of choice in vomiting due to metabolic disturbance or drugs.
Active medical management of malignant bowel obstruction includes the relief of intestinal colic using antispasmodics such as hyoscine butylbromide 60-80 mg daily; treating continuous pain with diamorphine; and vomiting, especially if nausea is a problem, with a centrallyacting emetic, e.g. cyclizine 150 mg daily or haloperidol 5- 10 mg daily.
Patients are allowed to drink and eat low-residue diets which are mostly absorbed in the proximal gastrointestinal tract. It is usually possible, with adequate mouth care, to prevent a sensation of thirst and parenteral fluids are not required. A few patients with intractable vomiting due to a high intestinal block may benefit from nasogastric aspiration.
Respiratory symptoms cause great distress to patients. Management is based on an accurate diagnosis of the cause and active treatment of all potentially reversible situations. Pleural and pericardial effusions should be drained, infections treated and symptomatic anaemic patients transfused. Sensations of breathlessness and a cycle of respiratory panic may be partially relieved by the prescription of diazepam 2 mg at’ night. Regular doses of short-acting morphine 5-20 mg 4-hourly are also helpful, as there may be morphine receptors within the lung. Nebulization of a morphine solution will reduce the sensation of breathlessness in a proportion of patients. Persistent unproductive cough is a very troublesome symptom. Opiates, codeine, methadone or morphine elixir are helpful as antitussive agents. Nebulized local anaesthetic can be helpful.
Communication with all patients and their families is a basic tenet of care, but is particularly important in the stressful situations which surround fatal disease. Basic skills include allowing time for the patient to talk, using language which is appropriate to the circumstances, being prepared to repeat information and being aware that both patients and their families often receive bad news by blocking or denying it. It is important to remember that it is not always necessary to have an answer or a solution to every problem that is presented, but that considerable support may be given by sympathetic listening. Care of cancer patients should be designed to allow them to spend as much time as possible at home. Effective liaison between the hospital and the primary health care team is essential to ensure total care. It is especially important to avoid misinterpretation of information regarding treatment and prognosis that may be given. Approximately 60% of cancer patients will die in general hospital wards under the care of the physician or surgeon who first diagnosed their tumour. Anxiety or depression will be present in up to half of these patients. Caring for this group of patients requires detailed attention to alleviating physical symptoms and establishing a secure environment for the patient and their family to obtain information and support.
The practice of palliative medicine has traditionally been confined to patients with cancer although some services now cover HIV and AIDS and some of the rapidly fatal neurological diseases. These are all conditions in which the clinical situation is changing rapidly and where difficult symptoms exist. There are undoubtedly patients with non-malignant disease who would benefit from a similar multidisciplinary approach to their care. The patient- orientated principles of palliative medicine can however be usefully applied throughout medical practice.
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