A.Gonda

Palliative and supportive treatment

Motto

There is a limit to cure but no limit to care

Statistics

World: 7.0 MillionHungary: 33.457

(The need for palliation in the group of thepatient is about 70 %)

What is palliative medicine?

Palliative medicine is a treatment form where the psycho-social and physical well-being should be considered

PC is not organ-specific

Goal of palliation

Active treatment

Palliation

Dia

gnos

is

Death

Active treatment and palliation is reciprocal.

The philosophy of palliation

Main goal: QoL Holistic treatment forms which mind the

patient itselfTreating family members Accepting patient’s mind

Definition

Palliation: Not the cause itself but symptoms are treated/altered (painkilling, rehydration, constipation etc.) Life expectancy is unimportant

Supportation: symptoms that caused by anticancer treatment (hyperemesis, leukopenia, anaemia etc.) are treated

Palliation cont.

The two fundamental outcomes of any cancer therapy are prolongation of survival, and quality of life

One of the challenges of palliation is that we do not expect to achive cure, nor necessarily complete resoluion of all cancer-associated symptoms

The attitude of our health-care

It is focusing on the disease instead of the patient

Somatic symptoms are minded first of all Psycho-social issues are depressedCommunication is insufficient

The main goal is success and whipping is denied

Special aspects of palliative care

PC does not necessarily end with the death of the patient

Some surviving relatives may need support during bereavement period

Those patients whose disease has been controlled need sometimes psycho-social support.

Site of organisations

Hospital-Hospice

Home care

Day clinic

The role of the oncologist in palliation

Organizing infrastructures for the patient and for the family

Collaboration with other disciplines (surgery, radio-therapy, pain-killing, communications etc.)

Members of PC group

PhysicianNurseGymnasticsChaplainPsychologistVolunteerSocial-workerDietetics

Symptoms in cancer patients

Pain 84%Dyspnoe 47%Nausea 51%Insomnia 51%Depression 38%Apetite loss 51%Constipation 47%

Pain

It is pain and the unknown that people most fear in advanced cancer

The word of pain is bound up with the word „cancer”

Pain increases with the duration of illness (although one out of four patients do not experiance significant pain.

Globally at least 4 million people suffer from cancer pain

It is necessary to accurately assess pain

Mechanisms of cancer pain

1, nociceptive pain pain arising from somatic soft tissue

(The tumor margins are often tender and hypersensitive, mediated by tumour products and host prostaglandines

Compression of the host tissues Bone pain Visceral pain

Caused by smooth muscle spasm or direct tumor infiltration with an inflammatory response

The characteristics of nociceptive pain

Pain that is difficult for the patient to localizeIt can be intense, episodic and associated

with other autonomic effects such as sweating, pallor, and nausea

Mechanisms of cancer pain cont.

Neuropathic pain Nerve compression and infiltration by tumour will

initially produce aching pain referred in the distribution of that nerve

it may be associated with numbness or motor weakness It has qualities of burning, shooting, or stabbing and

may have sudden crescendo episodes with no apparent precipitating cause

Often does not respond well to opioid analgesics

It is difficult to manage

Other aspects of pain

1, Physical causes of pain Primary site of malignancy Metastatic sites

2, Emotional, psychological and social causes of pain Anxiety Stress (diagnosis, treatment etc.)

Cancer pain should be considered as being influenced by many factors rather than only by the patient’s physical status. These influences can lower the threshold for pain

Assessment of pain

The detailed history The longer the patient has experienced pain, the more

time is required to unravel the true cause of that pain

Measurement of pain there is no overall acceptable way of measuring pain Measuring of pain from one day to the next is a way of

establishing whether treatment is effective Visual analogue scales ( grade the pain from 1-10) Diagrams of facial expressions (children)

Special problems relating to pain

They may arise when the patient experiences severe, unexpected pain

Panick attack, patient can be frightened or extremly anxious

Background: Bone fracture, spinal cord compression, respiratory

distress, intestinal obstruction, cardiac problems

Management of cancer pain

1,Sysemic medication2,Radiotherapy3, Chemotherapy4, Surgery5,Embolisation6,Ganglion blockade

7, psychotherapy

I. step

II. step

III. step strong opioids non-opioids

adjuvant medication

non-opioids

adjuvant medicines

light opioids + non-opioid

adjuvant medicines

persistant pain

persistant pain

The steps of pain relief

Medications in cancer pain management

Non-opioids paracetamol, metamizol, acetylsalycilsav, Light opioids codein, dihydrocodein, tramadol,

Strong opioids morfin, fentanyl, hydromorphon, oxycodon, methadon

adjuvants antidepressants (TCA) amitriptylin, imipramin, clomipramin antiepileptics carbamazepin, valproát, gabapentin,

pregabalin, clonazepam neuroleptics haloperidol, chlorpromazin,

levomepromazin anxiolytics alprazolam, diazepam, hydroxyzin steroids dexamethason, methylprednisolon

Opioids

GY ENGEOPIOIDOK

(TR AMADOL, CODE IN)

ER ŐS OPIOIDOK(MOR FIN, FENTANY L, METHADON)

OPIOIDOK(M OR FINSZER Ű HATÁSÚ GY ÓGY SZER EK)

Hatás

Dózis

Hatás

Dózis

Light opioids

codeindihydrocodein retardtramadol

Side effects: constipation nausea vertigo

Strong opioids I.

morfin Morphinum HCL inj Sevredol M-Eslon caps MST Continus

hydromorphon Palladone SR Jurnista

Strong opioids II.

Fentanyl Durogesic Fentanyl Hexal Matrifen Dolforin Fentanyl inj.

methadon Depridol tbl

oxycodon Oxycontin inj.

buprenorphin Transtec

Opioids effectivity

Name Relative effectivitytramadol 1/10

codein 1/10

dihydrocodein 1/6

MORFIN 1

oxycodon 2

hydromorphon 7,5

buprenorphin 70

fentanyl 70-100

Opioid substitution and rotation

If an opioid causes unacceptable adverse effects, or if the opioid has been used for sometime, and there is no apparent benefit from increasing the dose, it is appropriate to change or substitute that opioid for another. (opioid rotation)

Nutritional care

When we are ill and our appetite may be poor, food and drink can be a source of conflict and take on a greater importance

Giving patients the feeling that they can help with their own well-being through what they eat and drink is important

Cachexia

A characteristic feature of advanced malignacy is cachexia

It presents the clinical picture of weight loss anorexia weakness

It leads to progressive loss of mobility, mental apathy and shortened survival

Paraneoplastic manifestation which is the result of a host responce to the presence of tumor

Symptoms of tumour induced cachexia

LBM decreaseAstheniaAnorexiaDecreased sensitivity to CT and RTDecreased effectiveness of any anticancer

treatment

Metabolic characteristics of cachexia

Negative energy balanceWhile reduced intake is very important, the

underlying program lies in the profound changes seen in protein, lipid and carbohydrate metablism as a result of cancer. Increased protein syntesis in the liver (acute phase

proteins) Fat stores are progressively depleted Tumor-derived lipolytic factor may be partly responsible

for fat breakdown Anaerobic glycolysis in tumor tissue produces lactic acid Increased gluconeogenesis in the liver Reduced insulin response

Other factors in cancer malnutrition

DysphagiaGastrointestinal obstructionNauseaVomitingMucosistisEnteritis

Treatment of tumour induced cachexia

SteroidMegestrol acetateNSAIDThalidomideCanabinoids

Losing of 30 % of body weight could be fatal

Nausea and vomiting

Affecting 40-70% of patientsIt can be very distressingIt may be difficult to control

NauseaAssociated with autonomic symptoms (cold

sweats, pallor, salivation, tachycardia,)Often more unpleasant than vomiting

Features of vomiting

Concomitant nauseaNature of vomitTiming of vomitAbdominal distensionCostipationUrinary symptomsHeadache on wakingDyspepsia

Simple „non-drug” measures

Avoidance of food smells or unpleasant odors

Relaxation

Acupressure

Acupuncture

Causes of vomiting

Gastrointestinal Upper: sore tongue, candidal infection, difficulty

expectorating, oesophagitis, carcinoma of the oesophagus

Mid: peptic ulcer, gastritis, carcinoma of the stomach, pancreas tumor, gall bladder disease, bowel obstruction

Lower: constipation, bowel obstruction

Hepatic disease

Causes of vomiting cont.Chemical

Drugs (opioids digoxin, antibiotics) Biochemical: uraemia, hypercalcaemia, Treatments: radiotherapy, chemotherapy Tumor toxins Infection

Cerebral Anxiety Taste, smell Cerebral tumor Raised intracranial pressure

Vestibular Vertigo, motion, acoustic neuroma

Receptors and their main blocking agents

D2 Phenothiazines, Haloperidol, Metclopramide Domperidone

5-HT3 Ondansetron Granisetron Tropisetron Metoclopramide (weak)

The antiemetic ladder

Step 1: Try a single agent according to the possible cause of

vomiting

Step 2: If it is partially effective, increase the dose to maximum,

optimizing the dose every 24 hours, If it is necessary change the drug

Step 3 If there is no effect, add together two drugs that act on

different receptor sites

Step 4: If there is no effect, use a less specific antiemetic

(ondansetron), or adjuvant drugs like steroids

Constipation

Over half of all palliative care patients complain of constipation

„straining to pass hard stool”

Common causes of constipation

Patient Poor diet or low fluid intake Lack of exercise Immobility-paraplegia Depression

Gastrointestinal tract Tumor, causing partial obstruction, stricture,

adhesions and decreased motility

Common causes of constipation

Metabolic Hypercalcaemia Hypothyroidism Hypokalaemia

Drugs Opioids Tricyclic antidepreassants Antacides Phenotiazines Chemotherapy-some types

Diagnosis

Patient’s history

Examination of the abdomen

Abdominal X-ray

Rectal examination

Treatment of constipation

Softeners Oral agents: lactulose, magnesium hydroxide, fibre

Stimulants Oral: senna, bisacodyl Rectal: glycerine suppositories, phosphate enemas

Stimulants+softener combinations

Prevention is better than cure !

Diarrhoea

Frequent passage of loose stools

Common causes Colonic tumor, carcinoid tumor Chemotherapy, radiotherapy, antibiotics, NSAIDs Infection, diverticulitis Constipation (false diarrhoea)

Treatment of diarrhoea

Removal of predisposing factors

Loperamide

octreotid

The symptoms of coming death

Extreme weaknessPatient is unable to moveFluid ad food uptake is refusedAglutitionSleepinessLoss of concentrationConfusionTalking to „dead relatives”irritationIncreasing pain

What to do and what not to do

Try to avoid every unnecessary interventionLoving carehygienic care Reduce the number of medications

Medicines in the last hours

1, parenteral morfin (morfin pump, or sc. inj)2, parenteral antiemetics (metoclopramid,

haloperidol)3, furosemid im. or iv.4, atropin sc or iv

Complementary therapies in palliative care

Part of the holistic approachRecognize that the mind, body and spirit are all

connected Massage Aromatherapy Reflexology Relaxation Guided imagery Visualization Meditation Music Hypnotherapy

Supportation

Treatment of symptoms that caused by anticancer treatment (hyperemesis, leukopenia, anaemia etc.)

Where and how to support?

Improving WBC with using colony stimulants (GMCSF, GCSF)

Transfusions-erythropoetinsThrombopoetinsAntibioticsWound healingAphtosis, mucositisNausea, vomiting

CSF

GCSF: Neupogen, Neulasta WBC count will be enhanced in 2-3 days Should be delivered if WBC is less than 200/ul Cease it if WBC is more than 1500/ul Advantage : shorter improves WBC count than

Leucomax Disadvantage: No influence on PLT count and RBC

count

CSF

Could be delivered preventively, but !1. Chemotherapy 2. CSF on day 2.Dosage. 5ug/kg/dayAntibiotics in a preventive way ?

Erythropoetins

Causes of anaemia : bleeding, haemolysis, decrease of EPO – level

Treatment forms : transfusions vs EPO

EPO binds to receptor like IL-2, GCSF and other cytokines

Erythropoetins

There are 2 preparations, ie. alfa and betaS.c. and iv. forms – both effectiveInitial dosasge : 100 U/kg or 5000 U / day or

40.000 U / weekIndications : cancer related anaemia , CT

induced anaemia,Adverse effects : Blood pressure elevations,

seizures

Thrombopoetins

2 forms : in clinical trialsIncreases the size and numer of

megakalyocytes, stimulates nulceic polyploidy, upregulates latelet markers

Dosing : not yet definedIndication : thrombopenia, bone narrow

transplantAdverse events: few side effects,

cardiorespiratory disease?

Nausea and vomiting

Variations : Acut emesis – in the first 24 hour of treatment Delayed emesis – between 2-7 days of treatment Anticipatory vomiting – before treatment – reflexogen

activitiy

Treatment forms : HT3 blockers, steroids, anxiolytics, psychomimetics

During palliation

Do not overtreat the patient!

Holistic treatment is necessary

Improve the quality of life

Do not prolong suffering

Help the family members