Palliative Care – update for the acute physician

03.04.2014Dr Anne Goggin

Pain management – use of opioids

Update on LCP

Pain management

Evaluation

• Location• Duration• Palliative factors –

‘What makes it better?’• Provocative factors

–’What makes it worse?’• Quality• Radiation• Severity• Timing

Analgesic history

What medication at what dose

Regularly or prnDurationEffect of current

medication on painSide-effects now or in

the past

WHO method for cancer pain relief – is it still valid?

Recommendations for correct use of analgesics to optimise effectiveness

• By the mouth• By the clock• By the ladder

• Individual dose titration• Use adjuvant drugs• Attention to detail

WHO analgesic ladder

Weak Opioids

General rulesIf a weak opioid, given regularly, at maximum

recommended dose, is inadequate

- change to a strong opioid

Do not move sideways from weak opioid to weak opioid

Stepping up from Step 2 to Step 3

• In practice this most commonly involves changing from:

• Codeine 60mg qds to morphine – m/r morphine 10-15mg q 12 hr

• Tramadol 100mg qds to morphine – m/r morphine30- 40mg q 12 hr

• Remember to prescribe prn rescue dose of oramorph at 1/6 24 hour dosage of m/r morphine

• CAVE renal impairment

Switching from strong opioid

Opioids differ from each other in part due to receptor affinity

These properties can be used in patients who are intolerant of morphine by switching to an alternative opioid

Other reasons for alternative opioid:Transdermal route preferablePsychological ‘allergy’ to morphine

Opioid conversion chart

Neuropathic pain

QualitySuperficial burning / stingingSpontaneous stabbing painDeep ache

Often there isAllodyniaSensory deficit

Neuropathic Pain

About 50% of cancer related neuropathic pain respond to the combined use of an NSAID and a strong opioid

The rest need adjuvant analgesicsMost commonly used

AmitriptylineGabapentinpregabalin

Common reasons for unrelieved pain in advanced cancer

• Failure to evaluate each pain individually and to plan treatment accordingly

• Prescription of analgesic to be taken only ‘as needed’

• Failure to monitor patients response to prescribed analgesics

• Changing to an alternative analgesic before optimising the dose & timing of the previous analgesic

Last Days

More care, less pathway

• Response to substantial criticism of LCP in the media & elsewhere

• Panel to review its use in England- Chair Baroness Neuberger

• Independent of Gov & NHS

• Evidence from many quarters

Background to Liverpool Care Pathway for the Dying Patient (LCP)

• About half of all deaths currently take place in in hospital, making care of the dying a core duty of hospital trusts.

• Proportion dying at home will rise but as death rate is rising actual numbers dying in hospital will also increase

• The LCP is an approach to care of the dying intended to ensure that uniformly good care is given to everyone thought to be dying within hours or 2 or 3 days.

Report findings

Principles of the LCPDP - soundWhen the LCPDP is used by well trained, well-

resourced & sensitive clinical teams, it works wellWhere care is already poor the LCPDP is

sometimes used as a tick box exercisePreventable problems of communication –

accounted for substantial part of concerns raised

Report findingsProblems of definitions & terminology

‘end of life’ – can mean between last year of life to last days or hours of life‘pathway’ is clearly being misunderstoodDiagnosis of dying

Leadership Alliance for the Care of Dying People

• Statement -20 March 2014– Focus on what care should be like rather than the

delivery of particular protocols– 5 priority areas– LCPDP to be phased out by July 2014– There will not be a ‘national tool ’to replace the LCP– The priority areas will inform the inspection by CQC

of end of life care– & will inform a new NICE Clinical Guideline on the

care of dying adults

Next Steps

More national guidance to come – late spring/ early summer 2014

Pan – Hampshire group to advise on local care plan

Guidance for last days

• The possibility that a person may die is recognised & communicated

• Continue to visit• Simplify medication• Anticipate a time when the patient will not be

able to swallow & prescribe meds that can be given PR or subcut

• Anticipate symptoms that may arise in dying – pain, excess secretions, delirium.

Contact details

Hospital Palliative Care Team

Mon- Fri 0830 to 1630 ext 4126Sat & Sun 0830-1630 CNS bleep 1477Out of Hours CMH 02380 477414 doctor on-

call