Pain and Palliative Care

PRINCIPLES OF PALLIATIVE MEDICINE

Rebecca T. Armendariz

Stacy M. Stabler

What is Palliative Care?

Definition: Palliative medicine is a specialized medical care for people w/serious or life-threatening illnesses. It improves the QoL of pts & their families by focusing on tx of pain & other physical sx as well as relief of the psychosocial & spiritual distress that comes w/a dx of a serious illness.
The palliative care IDT includes physicians, nurse practitioners, nurses, pharmacists, social workers, case managers, psychiatrists, psychologists, & spiritual care counselors who work together w/the pt’s 1° doctor(s) to provide an extra layer of support
Palliative care is appropriate at any age & at any stage of a serious illness & can be provided along w/curative or palliative tx in an outpatient clinic, hospital, nursing home, skilled facility, or at a pt’s home
Hospice care is a delivery system that provides palliative care to terminally ill pts

(usu <6 mos life expectancy) in the home, nursing home, or inpt facility

The Palliative Care Consult

Request a palliative care consult for assistance w/pain & sx management, advance directives, capacity assessment, establishing GOC, breaking bad news, prognostication, withdrawal of life-sustaining tx, disposition planning, addressing end-of-life nutritional support, initiating family meetings, identifying existential distress, addressing spiritual & cross-cultural issues, making appropriate hospice referrals & evaluation for bereavement care

Core Principles for End-of-Life Care

Assessment is focused on what the pt feels are the most important sx/issues that they need assistance w/
Respect for the dignity of both the pt & caregivers
Use of the most appropriate tx c/w pt choice
Alleviation of pain & other physical sx
Assess & manage the psychological, social, & spiritual difficulties
Provide access to therapies that may realistically improve the pt’s QoL, including alternative or nontraditional tx
Respect the pt’s right to refuse tx
Respect physician’s professional responsibility to d/c tx when appropriate
Offer continuity of care (ie, pt should be able to be cared for by his or her 1° care and/or specialist provider)
Promote clinical & evidence-based research on providing care at the end of life
Provide access to palliative care & hospice care

Palliative Care Family Meeting

The main purpose of a family meeting is to improve communication & address any conflicting goals & values between the clinicians, pt, & families. It is a key instrument in sharing medical info, disclosing prognosis, establishing GOC based on the pt’s desires, discussing advance directives & disposition planning in conjunction w/what is medically feasible. This serves as an extra layer of support for the pt, the family, & the medical team.
Please see “SPIKES” model for breaking bad news

“SPIKES” Model of Breaking Bad News^a
Setup	– Analyze key medical info w/1° team beforehand & invite key family and IDT members – Arrange proper physical setting w/quiet private room & make introductions
Pt Perspective	– Ask pt and/or family what is their understanding of the current medical situation
Info/Invitation	– Ask if it would be OK to share the medical info w/the pt & ask how much the pt wants to know
Knowledge	– Be direct, avoid medical jargon, speak clearly but sensitively & use silence after breaking bad news – “Unfortunately the tests did not reveal what we hoped for” – “Given what’s happened & what you’re your perspectives & goals are, I would recommend X.”
Empathize/Explore Emotions w/“NURSE” acronym^b	– Name Emotion: “You seem very upset by the news” – Understand: “Your rxn is completely natural” – Respect: “You have shown a lot of courage in this situation” – Support: “No matter what happens we are going to be here to support you & your family through this” – Explore: “We have discussed a lot. Tell me more about what you are feeling right now.”
Strategize/Summarize	– Summarize next steps, appointments, & reiterate availability of team for pt – “What questions do you have?”
^a(Adapted from Baile et al. Oncologist 2000;5:302-311) ^b(Adapted from Pollack et al. J Clin Oncol 2007;25:5748-5752)

Palliative Care Prognostication

Physicians tend to be optimistic when determining prognosis & can overestimate by a factor of five (BMJ 2000;320(7233):469-472)
Pts & physicians make different care decisions based on prognosis so it is essential that it is as accurate as possible
There are certain common s/s typical indicative of end-stage illnesses (Am J Soc 1992;93:663, Cancer 1984;53:2002)
- Evidence of disease progression
- Multiple emergency depart visits or hospitalizations in last 6 mos
- Involuntary wt loss of >10% of BW in previous 6 mos
- Karnofsky PS of <50%
- Dependence in at least 3 of 6 ADLs

Karnofsky Performance Status Scale Definitions Rating (%)
Able to carry on nl activity & to work; no special care needed	100% nl to no complaints, no evidence of disease 90% nl activity, minor s/s 80% nl activity w/effort & signs or sx
Unable to work; but able to live at home & care for most personal needs w/varying amount of assistance	70% cares for self, unable to do nl work 60% requires occasional assistance & frequent medical care 50% requires considerable assistance & frequent medical care
Unable to care for self, requires institutional or hospital care level	40% disabled, & requires special attention 30% severely disabled & hospital admission is indicated although death not imminent 20% very sick, necessary hospital admission requiring active support tx 10% moribund, fatal process progressing rapidly
Oxford Textbook of Palliative Medicine, Oxford University Press. 1993;109.

PAIN MEDICATIONS

Lara A. Dunn

Natalie Moryl

Types of Pain

Nociceptive pain
- Somatic pain: Due to nociceptors activation in body surface or musculoskeletal tissues (ie, met bone disease, soft tissue tumors)
- Visceral pain: Due to activation of receptors from compression, obstruction, infiltration, ischemia, stretching, or inflammation of the thoracic, abdominal, or pelvic viscera; not well localized (ie, bowel obstruction, bulky liver mets, urinary retention)
Neuropathic pain: Due to direct injury or dysfunction of peripheral or CNS

tissues (ie, compression radiculopathy, postmastectomy & postthoracotomy pain, postherpetic neuralgia)
Pain emergency: Pain crisis, spinal cord compression, bone fracture, bowel obstruction, & sev. mucositis

Pain Management at the End of Life is a moral obligation to alleviate pain and unnecessary suffering and is not euthanasia. U.S. Supreme Court Chief Justice Rehnquist, “It is widely recognized that the provision of pain medication is ethically & professionally acceptable even when the tx may hasten the pt’s death if the medication is intended to alleviate pain & sev. discomfort, not to cause death.”

Pain Assessment Scales

The pt, not the observer, should complete the scale
Measure pain w/a numeric pain intensity scale of 0-10, verbal rating scale, or a visual analog scale can be used for children or adults

Figure 10-1 Wong-Baker FACES Pain Scale. From Hockenberry MJ, Wilson D, Winkelstein ML. Wong’s Essentials of Pediatric Nursing, 7th ed. St. Louis, MO; 2005;1259. © Mosby. Reprinted with permission.

The World Health Organization (WHO) Analgesia Ladder

Step 1: For mild pain, use acetaminophen, NSAIDs, or another adjuvant analgesic
Step 2: For mild-to-mod. pain, or persistent pain, add a lower potency opioid (codeine) or a low dose of a stronger opioid (morphine)
Step 3: For mod. -to-sev. pain, or worsening pain, use strong opioids (morphine, hydromorphone, or fentanyl) (World Health Organization. Cancer Pain Relief with a Guide to Opioid Availability, 2nd ed. Geneva, Switzerland: World Health Organization; 1996)

Opioids Treatment Guidelines

For mod.-to-sev. pain (w/close supervision):
- In opioid naïve, start w/prn IV morphine 2.5-5 mg (or an equivalent); in opioid-tolerant, start w/20% of the daily dose IV every 15 min-2h prn
- After determining the effective & tolerated daily dose (sum of all doses given w/in the last 24 h), give the opioid around the clock & 10-20% total daily dose q1-2h prn
- Adjust baseline upward daily based on total amount of prn
For chronic use oral route is preferable, then transcutaneous > SC > IV
When converting from one opioid to another, reduce the equianalgesic dose by 1/3-1/2 (see table for rotation to methadone)
In elderly pts, or those w/sev. liver or renal disease, start 1/2 the usual dose (NCCN Clinical and Practical Guidelines in Oncology. Adult Cancer Pain)

Pain Management in a Patient with Addiction

Consider multidisciplinary team approach & a consultation w/an addiction specialist

Opioid Adverse Side Effects

Constipation (no tolerance), N/V (tolerance develops in 3-7 d), urinary retention, hypogonadism, sedation, respiratory depression (only after the onset of sedation), myoclonus, delirium, seizures, respiratory arrest & death

Opioid Overdose

Manifestations: Respirations <6/min, myoclonic twitching, constricted pupils, skeletal muscle flaccidity, cold or clammy skin
Stop administering opioids, wait for the medication to wear off, stimulate pt
Naloxone—0.4 mg diluted in 10 mL NS, give 1 mL q5min to reverse respiratory depression or sev. sedation; may need an infusion to counteract the effect of LA methadone or fentanyl patch

MEDICATION	*USUAL STARTING DOSES Adults >50 kg; for opioid naïve patients (^1/2 dose for elderly, or severe renal or liver disease)**		PAIN
MEDICATION	PARENTERAL	PO/TRANSDERMAL (TD)	PAIN
MORPHINE	2.5-5 mg SC/IV q3-4h (^*1.25-2.5 mg)	7.5-15 mg q3-4h (IR or oral solution) (^*2.5-7.5 mg)	MODERATE TO SEVERE
OXYCODONE	Not available	5-10 mg q3-q4h (^*2.5 mg)
HYDROMORPHONE	0.2-0.6 mg SC/IV q2-3h (^*0.2 mg)	2 mg q3-4 h (^*0.5-1 mg)
FENTANYL	25-50 µg IM/IV q1-3h (^*12.5-25 µg)	Transdermal patch 12.5 µg/h q72h (contraindicated in opioid naïve)
MEPERIDINE	75 mg SC/IM q2-3h (^*25-50 mg) Generally not recommended	50 mg
CODEINE	15-30 mg IM/SC q4h (^*7.5-15 mg)	30-60 mg q3-4h (^*15-30 mg)	MILD TO MODERATE
HYDROCODONE	NA	5 mg/325 mg acetaminophen q4h (^*2.5 mg)	MILD TO MODERATE
^*Info adapted from Drug Facts and Comparisons 2008, 62nd ed., by Facts & Comparisons, 2007, Philadelphia, PA: Lippincott Williams & Wilkins; and Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th ed., by the American Pain Society, 2009, Glenview, IL: American Pain Society.