Managing Palliative Symptoms-Advanced Cancer 2023-PDF

8/31/2023 Managing Palliative SymptomsAdvanced Cancer 2023/1&2 • • • • Pain Nausea and Vomiting Constipation Diarrhea- please read but will be in care of AIDS/Oncological emergencies • Agitation and Delirium Pain: Pain has been defined as “whatever the experiencing person says it is, existing when...

8/31/2023 Managing Palliative SymptomsAdvanced Cancer 2023/1&2 • • • • Pain Nausea and Vomiting Constipation Diarrhea- please read but will be in care of AIDS/Oncological emergencies • Agitation and Delirium Pain: Pain has been defined as “whatever the experiencing person says it is, existing whenever the experiencing person says it does.” M. McCaffery, 1968 -Unrelieved pain is one of the most frequent reasons for palliative consultations . advANCED CANCER WAS PREDICTIVE FOR THE LAST 6 MONTH. Heart failure/neurodegenerative diseases.. palliative unit-have advanced cancer because its predictive second most predictive is neurodegenerative disease/ heart failure, renal s liver failure diarrhea- is HIV ,advanced AIDS delirium pain is most important unrelieved pain is consultation *********************** need special services while delivered palliative care at same time use curative therapy, anti neoplastic therapy, aka target therapy, both chemo surgical and radiation therapy for cancer, - good end results, after pt died then shift to support families- TAMAL ARTICLE 1 pain is fear*** 80-90 % experience pain in paliative care. give strong opiods q1h or BID- address chronic pain... 24 instance of breakthrough pain*** Comprehensive cancer care Antineoplastic Therapy Palliative Care Presentation Symptom Rx Relieve Suffering 6m Death Bereavement Care 2 Pain • Pain is the symptom many people fear most after a diagnosis of advanced cancer. • “My quality of life? Number one is to keep the pain under control. After a while it wears you down. It fatigues you, wears down your will to find pleasure in things. And that’s what the nurses have really helped with. They played around with the medication.” (A patient’s personal experience) 3 1 8/31/2023 Pain Up to 90% of patients with cancer pain could have their pain alleviated by following the treatment guidelines of the WHO analgesic ladder Fitzgibbon et al. “Parenteral Ketamine as an Analgesic Adjuvant for Severe Pain.” J Pall. Med. 8(1) 2005 need consultation to anesthesiologist, pain is out control to bring it down, use NMR scale as sss of assessment grade 3 pain - mild (1-3)-still perform activities moderate 4-6 severe beyond 7 -10 - worst pain 4 Pain “An unpleasant sensory and emotional experience associate with actual or potential tissue damage or described in terms of such damage.” International Association for the Study of Pain (IASP) Prevalence of Pain in Advanced Illness Pain is the cause of much suffering, Cancer -80-90% of the patients -Often multiple pains -Often multiple causes of pain ( Source: The Pallium Project) “Pain is more terrible lord of mankind than death itself.” Albert Schweitzer, Physician 5 Pain: A Multidimensional construct “I have pain” 6 2 8/31/2023 pain is off chart- pain crisis bc in community s pain not under control- need consultation anesthesiologist or surgical procedure.. Cancer Pain dont completely eradicate pain.. just keep pain under control s have good quality of lifeopioids.. • View film clip (Cancer Pain) • View film clip (Chronic Pain) NMR- numerical scale of pain 5 million die with untreated pain ex :video- if touch pt then pain.. neuropathic pain - noxious stimuli cause pain- known as allodynia- causes pt to feel pain even when shouldnt elicit pain with touch fungating wounds- malignant tumor under surface skin to migrating to top of skin=painful/.. when do wound dressing change- give pain medication: 5 to 10 mins before dressing change.. 7 ASSESSMENTS!!!!!!!!!! Approach To Pain Control in Palliative Care (Dr. Harlos) 1. Thorough assessment nmr used but there are • History – including detailed description of pain; psychosocial, multiop spiritual, & cultural context; concerns about what the pain means; medication history burning pain-neuropathic pain psychosocial, cultural - what meds they tries • Physical Examination – don’t forget neuro exam; be careful of risk of path # vs advanced cancer breast s prostate cancer-risk for pathological fractures 2. Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence talk with family is it ASP: C or M.. consideration of investigations and interventions 3. Investigations – X-Ray, CT, MRI, etc - if they will affect care =radiation is widely used- focus on curative but to manage sss 4. Treatments – pharmacological and non-pharmacological • don’t forget about RadTx and interventional analgesia (e.g. spinal) -to deliver meds through spinal cord 5. Ongoing reassessment and review of options, goals, expectations, etc. 8 acute -time limiting pain chronic- more than 2 weeks.. pain never goes away Classification of Pain benign- cause wasnt cancer itself/ other types of pain due to past medical Hx like osteoarthirits s not cancer itself • Based on Embryology * Visceral, deep somatic, cutaneous • Acute vs. chronic (duration)* • Benign vs. malignant (cause) • Nociceptive, deafferentation, hysterical (connections) * • Unifocal vs. multifocal (numbers of locations) • Unilateral vs. bilateral (body location) • Continuous vs. intermittent (persistency) nociceptive- umbrealla term (visceral -organ pain plus bone pain) deafferentation- neuropathic- nerves s nerve plexus hysterical- abd pain when scared due to activities cancer -multifocal pain.. many sides neuropathic pain- one side- burning pain where breast cancer Adapted from Table 4.1- Medical care of the dying 4th ed. VHS 9 intermitten on top of chronic pain- like you give HM.. scheduled plus HM PRN 9 3 8/31/2023 incident pain -q1h orderc q8h, q12h, transdermal application=controls background pain Based on Embryology /dull acting= like colorectal cancer • Visceral pain - organs & tissues from endoderm -e.g. stomach, bowel, liver, pancreas, kidney, bladder /hard to locate -often felt on the body surface (e.g. appendix pain) -referred pain , diffuse and ill-defined -dull & aching (constant, cramping) in nature • Deep somatic pain - mesodermal -e.g. bone , muscle, ligaments, fascia =bone pain*** any cancer go to bone -most common for cancer patients ***localized -site specific and described as dull and aching • Cutaneous pain- ectodermal (nervous tissue) -localized- sharp,burning -clearly localized and described as sharp or burning -dermatome charts are useful to map out this pain (Medical care of the dying -4th edition VHS ) somatic pain relates to bones, joints, connective tissue 10 10 breast cancer s metastasis to bone s spinedid it go to lungs.. visceral is organ pain = head, chest, abd cavity + neuropathic pain women atypical coronary artery - have jaw pain, neck pain, s no mid sternal crushing pain visceral pain = manifests pain somewhere else.s not at exact spot ex stroke pain is central pain, all others are peripheral pain common 11 TYPES OF PAIN NOCICEPTIVE Somatic • • • • • • • bones, joints connective tissues muscles sharp dull & aching can localize site may be worse with movement (“incident pain”) NEUROPATHIC Visceral • difficult to describe; not a typical “pain” =burning, • numb; burning; tingling; crawling; stabbing; etc • allodynia • consider it as a possible element of any difficult pain syndrome • Organs – heart, liver, pancreas, gut, etc. • may be crampy, or dull & aching • referred pain*** • difficult to localize* =specific type of breakthrough pain 12 ex: spine/ribs/ pelvic girgle= predictable** incident pain when moving tingle, allodynia( when non noxious stimuli cause pain) come for ss stabilization =colorectale, breast, liver , pancreatic cancer referred, dulll, acing pain 4 8/31/2023 Somatic Pain • • • • Aching, often constant May be dull or sharp Often worse with movement Well localized Eg/ – Bone & soft tissue eassily tell you tumor in shoulder, muscle, connective tissue 13 Visceral Pain • • • • Constant or crampy Aching Poorly localized Referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction pancreatic cancer s metastasis to liver 14 ex: breakthrough intermittent pain= q1 h, q 30 mins txt: bid, tid, transdermal, not easily identified 15 15 5 8/31/2023 shingles= beginning -irr puss filled vesicles, post- neuropathic pain.. pts immune decreased by cancer, experience outbreaks.. -give antiviral meds, 6 motn after- post herpes neuralgia= get neuropathic pain located to dermatoids where they have brighn come Pain pathophysiology • Acute pain • Identified event, resolves days–weeks • Usually, nociceptive • Chronic pain • Cause often not easily identified, multifactorial • Indeterminate duration • Nociceptive and/or neuropathic • Wolf CJ. Ann Intern Med. 2004 . 16 Faces of Pain FROM: Medical Care of the Dying, 4th edition Victoria Hospice Society ( Learning Centre for Palliative Care) 17 17 Breakthrough Pain • Breakthrough pain (BT) is a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Different subtypes of breakthrough pain: q 1h • Incident pain is precipitated by a movement or a voluntary action, and is predictable or expected. - ex: turn pt, get to commode, wound change = predicatable s expected with • Spontaneous pain is not related to an identifiable precipitant, and so is unpredictable in nature. not rt to 1 identifieble event, no reason, no rhme on top of background pain • End-of-Dose Failure describes an exacerbation of pain that occurs prior to the next dose of the background analgesic, and reflects declining levels of the background analgesic. *BC Centre for Palliative Care (2019). B.C. Inter-professional Palliative Symptom Management Guidelines 18 movement ex: BID chronic pain order : HM - same time same pain when pt calls you, menas background drops from therapeutic to sub therapeutic level to deal with it- if total is 8 mg, then break it 3 times, change dose interval or increase it by 25 to 50 % 6 8/31/2023 12 to 18.. . turnpt q 2 hh- get pain 12 x Incident/Breakthrough Pain Breakthrough Pain- “in cancer patients is very common, and short acting analgesics are often NOT provided and patients do not take as much as is allowed”- Ferrell &Coyle 2019 -several studies of cancer patients showed at end of life an average of 4-5 breakthrough episodes occurring without warning.-Ferrell &Coyle 2019 Incident pain- predictably elicited by specific activities-examples 1 study of cancer patients admitted to hospice found 93% had breakthrough pain, with 72% of episodes related to movement or or dyspnea with activities weight bearing. End of Dose Failure- pain that occurs at end of the usual dosing interval of regularly scheduled analgesic (example) How to solve? *Spontaneous breakthrough pain occurs without predictable cause or frequency. 19 increase background meds- then pt will be oversedated.. Incident/Breakthrough Pain • Dr. Craig: I think [healthcare] professionals underestimate the extent of impact that breakthrough pain episodes can have on patients. A recent American Pain Foundation (APF) survey noted that effectively treating breakthrough pain episodes was often more important to cancer patients than treating their cancer diagnosis. Furthermore, many oncology professionals still don't know what breakthrough cancer pain is or how to effectively screen, assess, and treat it. sharp pain is to cover peak, background meds are same s proactive incident pain meds.. so give meds 5- 10 mins before activity to cover the peak but short in duration.. (S. Pal, Cancer Network , June 22, 2010) 20 oral route takes 30 -60 mins to onset to take effect sublingual, intranasal quickiest onset of incident pain Having a steady level of enough opioid to treat the peaks of incident pain... Pain ...would result in excessive dosing for the periods between incidents Incident Incident Incident Time 21 7 8/31/2023 Incident Pain • Pain experienced with movement/activity, e.g.: dressing change; repositioning; bathing; mobilization • Challenging to address the peak pain without adverse effects between painful episodes want opioid stronger s more potent like fentanyl 1st choice or if to severe pain then sulfentanol want rapid onset, like intransal or sublingual choices.. • Ideally use a rapid-onset short-acting analgesic • Commonly use intranasal fentanyl approx. 10 minutes prior to activity – e.g. 25 mcg IN, repeated if ineffective • Sufentanil is a more potent option for consideration if fentanyl fails Dr. M. Harlos (2017) 22 • • • • Rapid Onset Short Acting Fentanyl, Sufentanil Routes: • Sublingual (SL) • Intranasal (IN) SL / IN Doses Drug Dose (mcg) Fentanyl 25 50 25 50 Sufentanil • ($6 each) • q10 -15 min PRN • ** Explain Max. fentanyl is 1st choice start with 20 micrograms, give this q15 mins to 3 x max per hr, if need more then speak with physician use same dose with 3x per hr, s cant change dose between applications 23 Causes of Cancer Pain metastatic cascade causes pain.. 2 third of pts. assess pts how pain impacts their life especially if rating between moderate to severe • **may be related to primary or metastasis in 2/3 of patients • may be resulting from treatment: surgery, chemo, radiation, procedures or causes such as side effects or infection. **Health Care Professionals fail to assess Pain adequately. • The American Cancer Society did a call center survey to better understand the impact of pain on patient's lives. Sixty-five percent of the callers said they were experiencing cancer-related pain at that time with 76% rating it as moderate to severe. But only 58% said they were asked about their pain at their clinical visit (CA: Cancer J Clin 59:285-289, 2009). 75 % caused by cancer metastasis to bone- invade nerves s nerve plexus or spinal cord, or visceeral organs: lunng, common se- N, V in short term but long term is nerve pain with chemo therapy=post chemo s radiation pain or syndrome*** 24 8 8/31/2023 d Causes of Cancer Pain d advanced cancer- all kind of pains, visceral ,bone, somatic pain depernds on trajectory • 75% caused by the cancer: -tumor invasion of bone -tumor invasion of nerves, plexus or spinal cord -tumor involvement of viscera & ductal systems -tumor involvement of blood vessels • 10% related to cancer therapy -post-surgical pain syndromes -post-chemotherapy pain -post-radiation therapy pain • 10% related to cancer-induced debility • 5% unrelated to either the cancer or its treatment Adapted from Table 4.5 - VHS pain is 5th vital source.. HM 5x more potent thsn morphine fentanyl 100 more potent than morphine 25 25 Types of Pain • Nociceptive vs. neuropathic pain • What kind of pain can patients with Cancer experience? • Remember tumor invasion of bone, nerves, tumor involvement of viscera and ductal systems, and tumor involvement of blood vessels • Answer: 26 WRHA Clinical Practice Guidelines for Pain assessment and Management WRHA website Available on the Nursing repository on LEARN Designed to assist health care givers to conduct high quality pain assessment that will lead to effective pain management “Pain the 5th Vital Sign” 27 9 8/31/2023 World Health Organization Pain Ladder Non-opioids Weak opioids +/- adjuvant tx +/- adjuvant tx Strong opioids +/adjuvant tx Interventional pain tx Up to 90% of patients can get adequate pain control Prommer EE: Cancer Control. 2015;22(4):412-425 28 saunders concept of pain -is not always only physical, but social s financial included= total suffering/ pain: pain can ve related to intellectual painpharm s non pharm txt- if only i exercide then no cancer, emotional (Cancer is anxiety, anxious s what will happen to me), interpresonlal (if dad or mom, cant keep roles in family), cancer is financial ( like driving, parking tickets, is costly), spiritual( this happens a lot, i exercised, and got cancer but why GOD punished me?) , bureaucratic pain (3 docs s 3 nurses teams, s pts have to deal with different teams).. Total Suffering/Pain Several domains merging Pain Spiritual & existential Other symptoms Total Suffering Psychological Cultural 29 Social & financial 29 7 Types of Total Pain • (From Total Pain by M. Downing-Victoria Hospice) • Physical pain • Intellectual pain • Emotional pain • Inter-personal pain • Financial pain • Spiritual pain • Bureaucratic pain 30 30 10 8/31/2023 Common Reasons for Unrelieved Pain (Fault with patient/family) • • • • • • • Belief that pain is inevitable and untreatable Failure to contact MD Pt misleads doctor by putting on a brave face Failure to take meds as prescribed -dont know common SE s how to manage it.. Belief that analgesics should only be taken prn Non-compliance due to fear of addiction Non-compliance due to fear of tolerance- must wait until the pain gets really bad • Meds stopped due to side effects and MD not notified 31 31 Barriers . . . • Poor assessment • Lack of knowledge • Fear of: ➢ Addiction ➢ Tolerance ➢ Adverse effects fentanyl is to control sss.. 32 Opioidphobia • View film clip -Opioidphobia social fear of using this medication.. started by media if you start opioid then get addicted 33 11 8/31/2023 Opioidphobia why does it exist? • Fear of Addiction –unfounded and rare when opioids are used in the treatment of Cancer pain –Explain*** Addiction is : • Psychological dependencedo assessment, give med equivalen to pain level • Compulsive use • Loss of control over drugs • Loss of interest in pleasurable activities . . . Addiction is: • Continued use of drugs in spite of harm • Rare outcome of pain management o Particularly if no history of substance abuse enormous physical pain that opioids dont override respiratory ride but if healthy then shutdown respiratory drive, explain that we monitor them. HM MORE POTENT THAN MORPHINE Source: NCI- National Cancer Institute 34 exclusion criteria: cancer s palliative care= prescribers are skilled at writing opioid orders. be able to proactively discuss it with your pts. TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE corticosteroids (prednisone: like COPD exacerbatious if more than 10 days then need to be lean off, but not in palliative).. rare respiratory depression.. 35 ex figure out baseline drug use 1st.. s going on top+ methadone good opiod to spare the other opiod drug use.= specific consultations are needed Physical dependence vs. Addiction • View film clip –Physical dependence 36 12 8/31/2023 MYTHS ABOUT MORPHINE ◼ Addiction ◼ Respiratory depression ◼ Too soon to start ◼ They have a narrow Therapeutic range. 37 Substance users • Can have pain too • Treat with compassion • Protocols, contracting • Consultation with pain or addiction specialists Source: NCI 38 Barriers to Optimal Pain Assessment-Oxford Textbook know this 39 13 8/31/2023 titrate dose based on your assessment, Why Assess Pain? • Prior to treatment an accurate assessment should be done to determine the cause(s), type(s) and severity of pain and its impact on the patient. • Uncontrolled pain limits a person's ability to perform self care, affects his/her response to illness and reduces his/her quality of life (9). Accurate assessment and diagnosis of the etiology of the pain, type of pain, its severity, and its effect on the person are essential to plan appropriate interventions or treatments, and are an integral part of overall clinical assessment (10-15). • Pain in cancer patients cannot always be attributed to the underlying cancer. For instance, patients may have other chronic illnesses such as arthritis that may also produce pain. However the sudden appearance of new pain may signal new areas of disease or disease recurrence. indigenous health services are used, want healer s traditional herbs, consult SW s spiritual team..\\ NRS is not always appropriate, only intensity of pain but doesnt say what it is, like no type of pain or route of pain (Source: Cancer Care Ontario, Aug. 2010) *BC Centre for Palliative Care (2019). B.C. Inter-professional Palliative Symptom Management Guidelines 40 neuropathic pain usually goes down to dermatome , when pain changes location.. Pain assessment Culture /Spiritual • What are the cultural traditions, customs, beliefs and values that influence the expression, meaning and treatment of pain? • Spiritual What is the meaning of pain to the person? What does the person think is causing the pain? How has the pain influenced the person’s hope, meaning and purpose in life? -Are there other spiritual issues affecting the pain experience? (Alberta Hospice and palliative care program-nurses guide) aching, throbbing, cramping = somatic (aching, throbbing) or visceral pain (cramping, squuezing= colorectal cancer) sharp,stubbing, burning pain=neuropathic pain skin sensitive to touch-allodynia0 neuropathic pain 41 NRS “Describing pain only in terms of its intensity is like describing music only in terms of its loudness” von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162 42 14 8/31/2023 Pain assessment questions – CCMB (Simone Stenekes CNS) Where is the pain? • One spot or multiple spots within the body? • Starting in one area and spread to another? • Generalized, and hard to pin down to any one spot? • Deep down, or near the surface or skin? What does it feel like? What words describe it? • Aching, throbbing? • Sharp? Stabbing? • Burning, tingling, crawling, itchy? • Squeezing? • Are there areas of the skin that are very sensitive to touch, so that even gentle contact such as clothing or the spray of a shower is uncomfortable? 43 Pain assessment questions – CCMB (Simone Stenekes CNS) How long does it last? • Is it always there? • Does it come and go? • Is it just a second or two (Like an electric shock)? • Is it crampy (grabs on for a time then goes away)? • Is it stabbing (short spurts of pain over and over again)? • Is it only with movement? • Does it vary? How bad is the pain? (Severity) • Mild, moderate, severe? • Rating pain on a scale from 0 to 10 can be helpful. Zero means no pain. 5 means the pain is there, but you can cope with it. 10 means the worst pain you have ever felt. ( see Tools) 44 VAS, and NRS SXW[ZKHUHIHHOSDLQ 9$6 45 15 8/31/2023 NRS –with verbal descriptors 46 NRS and Victoria Symptometer =older ots, up=worst pain Victoria Hospice Society 47 47 Wong-Baker FACES pain rating scale chronic pain Fig. 29-3. Wong-Baker FACES pain rating scale. Explain to the patient that the first face represents a person who feels happy because he or she has no pain, and that the other faces represent people who feel sad because they have pain, ranging from a little to a lot. Explain that face 10 represents a person who hurts as much as you can imagine, but that you don’t have to be crying to feel this bad. Ask the patient to choose the face that best reflects how he or she is feeling. The numbers below the faces correspond to the values in the numeric pain scale shown in Figure 29–2. 48 16 8/31/2023 edmund symptom assesment is the best to be used = and pain is 10 sss that is common in pts with palliative care with cancer= do check once a week top 3 sss : tiredness, anxiety, pain could be constipation/dysphagia (ear, nose, throuat tumor), advanced (ALS, parkinson) as 10th symptom if you take top 3 ss, not going to wait till next week to do it to reasess take top 3 sss s reassess during qshifts 49 where did you take the information, was PPS enough for pts to talk or from their families or from healthcare professionals.. ex: dysphagia is 10 th sss.. 50 Room # Place patient label here (Must include CR) Today’s Date: / 3. Medications 1. Edmonton Symptom Assessment System Revised (ESAS-R) Please circle the number that best describes how you feel NOW: 0 1 2 3 4 5 6 7 8 9 10 Worst Possible Pain / 1. No Pain 2. No Tiredness D 0 1 2 3 4 5 6 7 8 9 10 Worst Possible Tiredness 2 3 4 5 6 7 8 9 10 Worst Possible Drowsiness (Tiredness = lack of energy) 3. No Drowsiness 0 1 Have there been any changes since your last visit? Yes (If yes, please list): (Drowsiness = feeling sleepy) M 4. No Nausea 5. No Lack of Y 0 1 2 3 4 5 6 7 8 9 10 Worst Possible Nausea 0 1 2 3 4 5 6 7 8 9 10 Worst Possible Lack of 0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 3 4 4 5 5 6 6 7 7 8 8 9 10 Worst Possible Wellbeing 3 4 5 6 7 8 9 10 Worst Possible Appetite 6. No Shortness 8. No Anxiety 0 0 0 1 1 2 2 3 (Wellbeing = how you feel overall) 10. No 0 Worst Possible Shortness of Breath (Anxiety = feeling nervous) 7. No Depression 9. Best Wellbeing No change Appetite of Breath= feeling sad) (Depression 1 2 9 10 Worst Other Possible Anxiety 9 10 Worst Possible Depression in medication in the past six 4. weeks? Yes  No ve you smoked Ha Are you interested in  Yes  No quitting smoking? 2. Canadian Problem Checklist Please check all of the following items that have been a concern or problem for you in the PAST WEEK INCLUDING TODAY: Other problem (for example: night sweats, wound issues) Physical:  Concentration/Memory  Sleep  Weight  Constipation  Diarrhea  Swallowing Mouth sores Falling/Loss of balance Vision or hearing changes Heartburn/Indigestion Numbness/Tingling Changes to skin/nails Bleeding/Bruising  Bladder problems Spiritual: Meaning/Purpose of life Faith Practical: Work / School Finances Accommodation Getting to and from appointments Child/Family/Elder care Trouble with my daily activities Emotional: Fears / Worries Sadness Frustration/Anger Changes in appearance Intimacy / Sexuality Fertility Coping Loss of interest in everyday things Loss/grief Informational:  Understanding my illness and/or treatment  Talking with the health care team  Making treatment decisions  Knowing about available resource Advance Care Planning: is for everyone and can be done at anytime respected/understood Not feeling worthwhile/valued Feeling like I am no longer the person I once was Social/Family:  Feeling a burden to others  Worry about family/ friends  Feeling alone cwatling  Relationship 2017-05-29 14:16:06 difficulties -------------------------------------------❑ Prefer not to answer Unmarked set by cwatling 1. Do you need information and resources on Advance Care Planning? ❑ Yes ❑ No 2.Do you want to discuss Advance Care Planning at your appointment today? ❑Yes 3.Has there been a change in your Advance Care Plan since your last visit? ❑Yes ❑No ❑ No 51 17 8/31/2023 Dermatome Chart =body map, nerve pain specificically?? allodynia- neuropathic pain , touch thenn pain, s severe, radiates to another location VHS Figure 4.2 52 52 compas assessment tool is esas revised as top half= infant s sss system. s put in 1st half sss. cancer care MAnitoba - look at total pain,physical pain, financial pain. work ss school issues, interpersonal issues? emotional support ? look at loss of controls.. ? Pain assessment questions – CCMB (Simone Stenekes CNS) What makes it worse? • Movement? • Coughing • Certain positions? advanced care plan is last of compass assessment tool -is ESAS (symptom management) .. which assess same sss PQRSTY_ what makes pain worse or better address pain, but 1st find what pain is it, parm s non pharm TXT What makes it better? • Certain positions? • Medications or natural remedies? • Relaxation? • Massage? • Imagery? 53 54 54 18 8/31/2023 Regular Dosing =background pain q8h, q12h, bid or tid- opiod meds, q6h, q4h- is still trying to get pain under control to shorter dose control 55 55 q1h, q15 mins mltpl 3x per hrs (incident), q30 mins(crisis pain) = incident or crisis pain . PRN Doses 56 56 q30 mins, q15 mins mltpl 3x per hour (incident pain but also PRN ), oral bc pts on sustained or long release formulation , HM continuous or sustained release, rarely give IV, oral just allows the pain med under the curve to remain longer in therapeutic threshold Oral & Parenteral Dosing pain out of control-neuropathic pain, doesn't always respond to opioid 57 57 19 8/31/2023 Pain Crisis with End stage Ca • Some neuropathic pains, such as invasive and compressive neuropathies, plexopathies, and myelopathies, may be poorly responsive to conventional analgesic therapies. • Widespread bone metastases or end-stage pathological fractures may present similar challenges. • • • • Treatment may include: Radiotherapy Anaesthetic, Or neuroablative procedures may be indicated 58 Bone pain =neuropathic/ ... somatic • Constant, worse with movement non pharm for bone pain- radiotherapy, anesthetic procedure, deliver meds intrathetically.. • Metastases, compression or pathological fractures • Prostaglandins from inflammation, metastases • Rule out cord compression bone is somatic pain*** . Blum, et al. Oncology. 2003 worst with movemens= bone pain when cancer invates bone, releases osteoclasts which destsroys bone (inflammatory mediators)=lots of pain, bone matrix is stable 59 do dye (kidney/bladder)- black box is cancer to spinal cord into chest area= bone metastasis.. extensive bone metastasis- increase in pain, = same breast s prostate cancer . . . Bone pain . . . drugs of choice : no 1ST LINE THERAPY, then prescribe adjuvents - =pamidronate/zoladronic acid =Txt for osteoporosis , but here is given for bone pain**** • Management – Pharmacological o Opioids HM, fentanyl, sulfenntanyl( incident pain) o NSAIDs- Naproxen, Ibuprofen, Celecoxib,=diclofenac*** choice- is bone pain celebrex/naproxen o o o o Corticosteroids- Dexamethsone, Prednisone = angement=inflam mediators, it keeps the inflamm mediator down=decrease bone pain.. dexamethasone is choice***** Bisphosphonates- Pamidronate, Clodronate, zoledronic acid =q1h, q1monthly for bone pain, zolidronic acic is faster to get into body, but pamidronate is it takes longer Calcitonin-Ex why not seen very much. Strontium 89 (Metastron) =prevent pt from going on to this, radiopharmaceutiacla= prevents future metass to bone, not for bone pain Sources: From Care Beyond Cure- Pharmacotherapeutic Guide to Palliative Care and NCI. 60 20 8/31/2023 . . . Bone pain (somatic) • Non- Pharmacological Management o Radiotherapy (choice)= 1x or 2x= increase inflamm maediators- increase bone pain for 2-3x day= get dexamethasone s analgesic.. o Orthopedic interventionFixationstabilize with cast, brace, collar, corset = Sources: From Care Beyond Cure- Pharmacotherapeutic Guide to Palliative Care and NCI. Palliative Radiotherapy =1x or 2x txt, high dose of radiotherapy, and good response rate for increase pain- avr 10 days to feel their bone pain is coming down, useful for: bone pain secondary to cancer deposits relieving pressure of tumour on nerves 61 Palliative Radiotherapy 75% to 85% response rate (decreased pain) Few side effects with palliative therapy Response within 1 to 2 weeks (maximum response up to 4 weeks later) Duration of analgesia is several months 62 . . . Nonpharmacologic pain management- General Pain esas chart top 3 q1 shift, is pain going down, is fatique s anxiety goes down.. • Psychological approaches o Cognitive therapies (relaxation, guided imagery, hypnosis, distraction) o Biofeedback o Behavior therapy, psychotherapy • Complementary therapies o Massage accupuncture s massage is good... consult anesthesiology for nerve loss, surgery for chordotomy, o Music ESAS (has body mpa-nervers)- 1x per week physical therapy, =heat s cold therapy.. Source: NCI, and Cancer Care Manitoba 63 21 8/31/2023 PPS 40 %- means baseline - decreased mobility and overall functioning status declines s prognosis to estimated live is getting less with 30, 20 %...-functional status declines.. ex: if quick change from 40 to 30- prognosis is severely limited.. -only has to be in 10 % increments Controlling the pain :Other ways . . . • Neurostimulation, e.g.: • TENS, acupuncture • Anesthesiologic, e.g.: • Nerve block • Surgical, e.g.: • Cordotomy • Physical therapy, e.g.: • Exercise (progressive muscle relaxation, heat & cold therapy, Source: NCI, and Cancer Care Manitoba 64 Principles of chronic pain control • • • • • • • • • Keep pain in control Focus on the whole family Utilize team approach Treat underlying disease/cause when appropriate Use multiple methods/adjuncts and analgesics For cancer pain give analgesics around the clock and prn for breakthrough pain Maintain oral route whenever possible Treat other symptoms Refer when pain persists 65 65 See Additional Resources 66 22 8/31/2023 Palliative Performance Scale: PPSv2: • 1. quickly describes pt’s current functional level. • 2. provide criteria for workload assessment. • 3. provide prognostic information. * explain • Used extensively across Canada/Other countries. • 67 • Tool designed by the Victoria Hospice Society (2006) to: • See handout- Additional resources section of LEARN 67 -overall estimated prognosis to live. only go in 10 increments.. 40 % less month to live 30% is less than 2 weeks to live cancer or 3 week if not cancer 20% vs cancer may not live more than 1 week 68 69 23 8/31/2023 Delirium • Global cerebral dysfunction • “Brain Failure” • Early signs often mistaken as anger, anxiety, depression, psychosis goes with pain too. ex haloperidol/ methypprimide abrupt change in psycho s neurological staus..1st ask is this a change? and family will say "this is not my mom" , this is not my dad 70 ex: anticholinergic, oiods meds, metabolic abnormalities- hypoxia/hypolecemia, pain =cause delirium alzheimers-develops slowly, but delirium causes fast.. Delirium - Assessment • If clinically appropriate & consistent with goals of care- assess & treat potentially reversible causes of delirium such as: • • • • • • Infections Adverse medication effects Metabolic abnormalities Pain Urinary retention Hypoxia urine-CNS- maybe UTI.. 71 Delirium Types • Hypoactive -not too much meds • confusion, somnolence,  alertness • Hyperactive • agitation, hallucinations, aggression • Mixed (>60%) • features of both 72 24 8/31/2023 Delirium vs. Dementia • Delirium abrupt • Dementia • Reversible? • Irreversible • PREVENTABLE? reversible/ txt delirium-like hypocalcemia,hypoglyce 73 mia Characteristics • Abrupt onset*** • Disorientation, fluctuation of symptoms • Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixed • Changes in sleeping patterns • Incoherent, rambling speech • Fluctuating emotions • Activity that is disorganized and without purpose disorganized activities.. 74 Incidence - delirium • Most frequent neuropsychiatric complication in patients with advanced Cancer • Up to 85 % of patients delirious prior to death Hui et al. JPSM 99;2: 187-196 75 25 8/31/2023 FRAGILE PATIENTS • Inverse relationship between the preexisting vulnerability of the patient, and the severity of the insult necessary to precipitate delirium • Most patients nearing EOL have multiple predisposing factors • Most of these are beyond our control 76 PREVENTION? • Maintain sensorium: hearing aids, eye glasses • Orientation (clocks, calendars, verbally reorient patient) -re-orientate pt... 77 WRHA-Delirium Decision Tree dehydration/ infection/ =common (Dehydration) Txt reversible causes #1.. ut i WHAT ARE THE RISK FACTORS? • Severe Illness • Sensory Impairment (hearing/vision) • Age (age 65 years and over) • Cognitive Impairment (dementia) • Dehydration • Multiple Medications (Sedatives/Hypnotics/Narcotics/Anticholinergics/ Psychotropics) • ETOH/Substance abuse • Previous Delirium • Infection • RECOVERY FROM SURGERY • Impairment of Activities of Daily Living (bathing/dressing/toileting/grooming/feeding) • Pain 78 26 8/31/2023 WRHA DDT-what is it? • Go over the Delirium Decision Tree of the WRHA safety feautures: avoid polyharmcy, aboid benzo alone what is tool to assess Delirium: both of these are the same: this is paart of delirium decision tree- 3 out of 4 of these factors: abrupt change/ difficulty focusing/ altered LOC/ disorganized thinking/ hyper alret / is this abrupt? 79 say : yes= then delirium hypoactive- no meds give, only non pharm interventions hyperactive/mixed- meds: watch sundowing effect, provide welll lit environment, visible clocks.. 80 Management Is the resident agitated, restless or demonstrating responsive behaviours? NO Hypoactive Delirium • Sedation not indicated • Provide non-pharmacological interventions (slides to follow) • Support family 81 27 8/31/2023 Management Is the resident agitated, restless or demonstrating responsive behaviours? YES=Hyperactive Delirium Non-pharmacological •Watch for the “sun-downing” effect (nocturnal confusion), as it may be the first sign of early delirium Provide a well-lit, quiet environment, provide a night light. •Provide a calm, quiet environment and help the patient to reorient to time, place and person (verbally reorient the patient, use visible clock, calendar, well known or familiar objects). 82 Non-Pharmacological Interventions for Delirium • Correct reversible factors-dehydration (encourage sips of fluid if able), infection, alteration in visual or auditory acuity (provide aids), sleep deprivation. • To prevent over-stimulation, keep visitors to a minimum* explain, and minimize staff and room changes**. • Instruct the family (people who are familiar to the patient) to provide gentle, repeated reassurance and avoid arguing with the patient. • Avoid the use of physical restraints and other impediments to ambulation. • Encourage activity if patient is physically able. Sources: Cancer Care Ontario Symptom management Guide/Palliative Care guidelines B.C. 83 Pharmacological Management *First line therapy-Typical AntiPsychotic agents*(1st Generation) ---------commonly haloperidol (less sedative),and methotrimeprazine (more sedative-at night- helps with sundowing effect) = use both, Medication Haloperidol (Haldol®) Methotrimeprazine (Nozinan®) Indications Agitated delirium – Pathway A Agitated Delirium Pathway A Nausea and Vomiting Pathway D Route Dose Frequency Oral or sublingual 1-2 mg* explain diff dosing (0.55mg) q4-8h prn + q1h prn Subcut 1-2 mg* explain (0.5-5mg) q4-8h prn + q1h prn 6.25-25mg q4-6h + q1h prn 6.25-25mg q4-6h + q1hprn Oral/subling /subcut anti-nausea/ 84 28 8/31/2023 haldol is not as sedating- (1st therapy).. Other Drugs to manage Delirium • Atypical Antipsychotic agents (Second generationLess EPS, more expensive, less evidence): -anti nausea-lower dose.. • Olanzapine, • Risperidone, • Quetiapine = • Anxiolytics: Lorazepam vs. Clonazepam vs. Midazolam • What is the role with neuroleptics/Antipsychotic agents? 85 common is oral route- then subcut.. Management Of Delirium In 1st antipsychotic ((2 kinds) s if it doesn[t work then add benzo!!! Palliative Care-Cont’d 2. Fix the Fixable – if possible and appropriate (Investigations- medication review, bloodwork, U/A, and imaging). a) Hydrate? b) mobilize? c) Treat infections? 3. Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible **End Stage management of Delirium-Sedation for Palliative Purposes (SPP) 1. Effective sedation – with frank discussion of anticipated course ▪ ▪ ▪ ▪ If delirium irreversible, goal of care is sedation Sedation does not hasten the dying process Will facilitate meaningful visiting Encourage communication, even though patient not interactive 86 gabapentin anti epileptic drug.... refractory delirium- terminal delirium0 actively dying phase, trying to control it s not referse it when pt is dying sedation for palliative purposes later 29