Part II: Palliative Care - Symptom Management - Ahmed Jakda MD Regional Lead, Palliative Care Grand River Regional Cancer Centre Cancer Care Ontario

Part II: Palliative Care –
Symptom Management
                  Ahmed Jakda MD
       Regional Lead, Palliative Care
 Grand River Regional Cancer Centre
                Cancer Care Ontario

Disclaimer


   Nothing to disclose

Objectives


   Quick Recap from 2013

   Review model of care

   Review principles of basic symptom
    management

   Case Example with Pain

The Journey (CCO)

Palliative Care Across the Illness Trajectory

                 Treatments to cure or
                 control disease
                                                                 Bereavement
                                        Supportive &             care
                                        Palliative Care
                     earlier phases                 Terminal
 Diagnosis made of                                 phase (EOL)
 life-limiting illness                                      Death
                              Illness trajectory
                                                                               5

Identification


   Gold Standard Framework, UK:

    
   ‘Would you be surprised if this patient were to die in the
        next 6-12 months?
    
   Choice / Need - Patient chooses comfort care approach
        only, not ‘curative’ treatment.
    
   Clinical indicators – Grouped based on cancer, organ
        failure, elderly frail/ dementia
    
   1% of patients in a family practice die each year

Defining a Regional Model of Palliative Care

                         7

Steps


   1. Complete ESAS

   2. Identify Uncontrolled Symptom

   3. Assessment – L,O,P,Q,R,S,T,U,V & PE

   4. Classify as Mild, Moderate, Severe

   5. Choose Pharmacologic and
    nonpharmacologic intervention

   6. Monitor and Reassess frequently

Case Example


   Mr. S, 63 yo male with NSCLC, left Pancoast
    tumour – left chest pain involving shoulder
    and upper extremity to finger tips.


   Print out ESAS form and provide to patient to
    complete

Patients who complete ESAS value this
approach to symptom assessment

Survey of 3,320 patients from 14 Regional Cancer Centres in 2012
                                                                   12

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Evidenced Based Tools to Guide Care

 http://www.cancercare.on.ca/toolbox/symptools/   14

Symptom management point of care decision
support

 Named one of nine ‘Best Medical apps’ by The Medical Post (June 2011)
                                                                         15

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Pain Mechanisms


   Traditional pain categories:
    
 Nociceptive
        
   Somatic
        
   Visceral
    
   Neuropathic
        
   Complex Regional Pain Syndrome (CRPS)
        
   Peripheral neuropathies
        
   Phantom limb

Somatic Pain


   Results from activation of nociceptors in cutaneous
    or deep musculoskeletal tissue

   "Acute warning system" for tissue injury

   Examples include:
    
 Arthritis

    
 Fracture

    
 Bone metastases

    
 Cellulitis

Visceral Pain


   Deep pain originating from visceral structures in the
    thoracic, abdominal, and pelvic cavities

   More common than cutaneous pain

   Much less studied than cutaneous pain

   Includes the property of referred pain

Visceral Pain


   Examples include
    
 myocardial infarction

    
 pancreatitis

    
 peptic ulcer disease

    
 distention from viral illnesses

Visceral Pain


   Visceral pain is often described as a squeezing or
    pressure and can lead to nausea, vomiting, and
    diaphoresis

   It can have a deep, aching quality and be difficult
    to localize, and it can be felt at a cutaneous point
    (referred pain)

Visceral Pain


   Examples of referred pain:
    
 back pain and paraspinal muscle pain as a result
      of endometrial or pancreatic cancer
    
 right shoulder pain from hepatoma or liver mets

    
 abdominal or leg pain with prostatic cancer

Common Patterns of Referred Pain

                     
   Diaphragm, Pericardium,
                         Heart
                     
   Heart
                     
   Digestive tract
                     
   Liver, Gall Bladder
                     
   Kidney, Ureters
                     
   Pelvic Organs

Neuropathic Pain


   Neuropathic pain results from injury to a peripheral
    nerve or to the the central nervous system itself

   Examples include:
    
 herpes zoster (shingles)

    
 diabetic neuropathy

    
 post-stroke pain (e.g. thalamic pain syndrome)

    
 trigeminal neuralgia

Neuropathic Pain


   Qualitatively distinct from nociceptive pain

   Wide range of characteristics, including:
    
 dull ache or burning

    
 tight or vice-like, like a tight band/sock/glove

    
 paroxysmal stabbing or shock-like sensations


   Often the patient experiences a combination of the
    above sensations

Consider the Possible Causes of
the Pain
 •   Classify the pain – nociceptive, neuropathic
     or mixed
 •   Examine the person carefully to complete
     your assessment of the pain
 •   Review recent or consider new imaging to
     clarify the cause of the pain

Left Pancoast Tumour

Mr. S


   Diagnosis: Left somatic and neuropathic pain
    secondary to brachial plexus involvement

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Non Pharmacological
Interventions
 •   Psycho-social-spiritual interventions
 •   Other therapies
     •   PT, OT, massage, aromatherapy, music,
         acupuncture, TENS, hypnotherapy,
         visualisation
 •   Other interventions
     •   Radiation therapy, surgery, anesthetic
         procedures
 •   Education, Education, Education

Pharmacological Treatment
      WHO Analgesic Ladder

                                  31
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Pharmacological Treatment of Pain

                                         32
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Terminology


   Opiate – natural drugs from juice of opium poppy

   Opioid – includes natural, semi-synthetic, and
    synthetic drugs

   Narcotic – includes opioids and drugs of abuse

Sensitivity to Opioids


   Type of Pain   Opioid Responsiveness
     Nociceptive
       -Somatic           +++
       -Visceral           ++
     Neuropathic     +

Opioids
         Infrequent dosing
         Toxicity

         Analgesia

         Pain
Effect

         Time

Opioids
         Adequate dosing
         Toxicity

         Analgesia

         Pain
Effect

         Time

Opioid Adverse Effects

Common              Uncommon
**Constipation**    Bad dreams / hallucinations
Dry mouth           Dysphoria / delirium
Nausea / vomiting   Myoclonus / seizures
Sedation            Pruritus / urticaria
Sweats              Respiratory depression
                    Urinary retention

Do’s


   Do be easily accessible

   Do measure the impact of the pain on patient
    and use as a metric

   Do schedule a frequent follow up in person or
    by phone

   Do use an equianalgesic table

   Do use coanalgesics as appropriate

Don’t


   Don’t start a patient on a long-acting right off the
    bat (NO Fentanyl!)

   Don’t make assumptions about “too much
    narcotic” or “addiction”

   Don’t prescribe time ranges (4-6 hours)

   Don’t use morphine or codeine if there is renal
    insufficiency

   Don’t give only 30 tabs that will only last 3 days

   Don’t get fancy for no reason - KISS

Steps


   1. Complete ESAS

   2. Identify Uncontrolled Symptom

   3. Assessment – L,O,P,Q,R,S,T,U,V & PE

   4. Classify as Mild, Moderate, Severe

   5. Choose Pharmacologic and
    nonpharmacologic intervention

   6. Monitor and Reassess frequently

Questions?


   aijakda@gmail.com
    
   DROPBOX


   CCO Website:
    
   https://www.cancercare.on.ca/toolbox/symptools/