Chapter 26 Palliative care

INTRODUCTION

When there is advanced disease with no curative treatment, emphasis must be placed on the palliation of symptoms so as to allow the best possible quality of life for patients and their families (World Health Organization 1990).

Specialist palliative care is available as day hospice care, in-patient hospice care and home care teams often known as Macmillan teams. The gold standards framework for community palliative care provides a framework to improve the organisation and quality of care for patients and their families in the community during their last year of life (NHS Education for Scotland [Pharmacy] 2006). The preferred place of care is another concept that contributes to quality of life and of death and can form the basis of care planning (NHS Education for Scotland [Pharmacy] 2006).

Palliative care requires multidisciplinary effort. Its essential components are:

• assessment of the symptoms and needs of the patient

• controlling pain and other distressing symptoms

• helping patients and families cope with the emotional upset and practical problems that arise

• helping people to deal with spiritual questions

• helping people live as actively as possible despite illness

• supporting families and friends in their bereavement.

In palliative care, dying is considered to be a normal process. It is neither hastened nor postponed. Relief from pain and other distressing symptoms is of prime importance. Physical, psychological, social and spiritual aspects of care are integrated to allow the patient to live as actively as possible. Support for the family is provided during the patient’s illness and in bereavement.

PAIN

When tissue is damaged, pain may be felt at the site. Damage to nerve endings in skin or internal organs sends impulses to the brain, which interprets these impulses as pain (Fig. 26.1). Medicines that relieve pain may act at different sites along the nerve pathways; for example, local anaesthetics inhibit conduction in nerves carrying impulses from the painful area, and opioid analgesics act on the central nervous system, reducing the sensation of pain.

Fig. 26.1 Pathways involved in the perception of pain.

(From Greenstein B, Gould D 2004 Trounce’s clinical pharmacology for nurses. Churchill Livingstone, Edinburgh. With permission of Elsevier Ltd.)

The body produces its own chemicals, endorphins, which relieve pain (Hughes et al. 1975). When the body feels pain, it is a warning that something is wrong, an injury has been incurred or the body is unwell. The body has its own means of making the pain more bearable. When severe pain is experienced, the body releases endorphins. They act at m receptors in the central nervous system. Opioid drugs also act at these sites, resulting in analgesia.

PAIN IN PALLIATIVE CARE

Although palliative care comprises several different but complementary elements, the effective relief of pain is perhaps the major challenge facing clinical staff. Multiple pains are often reported by patients with advanced malignant disease. In addition to having pain, the patient may feel depressed and demoralised. Sleep may be prevented. The pain may ‘spill over’ and affect the patient’s family and friends. Just as the presentation of pain can vary, so too can the causes of pain and the sites involved. The treatment chosen will be greatly influenced by the nature of the pain.

As with any treatment programme, it is important to take a careful history and to recognise that the patient will have the expectation of becoming pain-free without reduction in mental alertness. The patient’s previous experience may result in fear due to the expectation of pain. Tensions may result that can greatly increase the patient’s pain and associated problems. Opportunity should be given to talk over worries and fears. A basic principle is to seek to anticipate crises and avoid having to resort to injections if at all possible.

ASSESSMENT OF PAIN

The basis of successful palliative care is assessment. At an appropriate time and without tiring the patient, details of how the illness began and how the patient and family have coped with it should be established.

Assisting the patient in the completion of some form of pain assessment tool can help to identify the location of the pain, when it arises and its exact nature. The effect of medication or any other activity that helps, as well as those things that make the pain worse, can be recorded. The severity and the nature of the pain can vary, and so it is essential that these are continually reviewed and, when necessary, modifications made to the treatment regimen.

PAIN THRESHOLD

The pain threshold is variable. It changes with external and internal influences (e.g. low self-esteem is linked with a low pain threshold). The following can help to raise the pain threshold and make it much more bearable: symptom control, good quality sleep, a feeling of security and support, treatment of anxiety and depression, helpful explanation, relaxation (perhaps through diversional activities) and the resolution of emotional conflicts.

TREATMENT OF PAIN

The management of pain in malignant disease and palliative care is underpinned by the World Health Organization’s pain-relief ladder (World Health Organization 1990; Fig. 26.2). The steps of the ladder represent the severity of the pain and the level of drug therapy required. Analgesics should be given regularly ‘by the clock’ rather than on an ‘as required’ basis. The choice of therapy thus depends on the severity of the pain (Table 26.1). Mild pain is treated with a non-opioid analgesic drug such as paracetamol or a non-steroidal anti-inflammatory drug that, if given regularly, will often make the use of opioids unnecessary. If pain persists or worsens after the maximum recommended dosage has been reached, these may be changed to a weak opioid such as dihydrocodeine or codeine.

Fig. 26.2 The World Health Organization’s pain-relief ladder. NSAID, non-steroidal anti-inflammatory drug.

(Courtesy of the World Health Organization.)

Table 26.1 Products used in pain relief

Drug	Dose
Step 1: non-opioid analgesics for mild pain
Paracetamol	500 mg–1 g orally 4–6-hourly (maximum daily dose 4 g).
Non-steroidal anti-inflammatory drugs^a
Ibuprofen	400 mg 8-hourly with or after food.
Diclofenac	75–150 mg daily in two to three divided doses with or after food.
Naproxen	500 mg–1 g daily in one or two divided doses with or after food.
Step 2: weak opioid analgesics for moderate pain (plus, when required, non-opioid adjustment)
Dihydrocodeine	30–60 mg 4–6-hourly (maximum 240 mg daily).
Codeine	30–60 mg 4 h (maximum 240 mg daily).
Step 3: strong opioids for severe pain (plus, when required, non-opioid or adjuvant)
Morphine	Strong opioid of choice.
Diamorphine	Very soluble and therefore useful by the parenteral route. It is given subcutaneously (by injection or by syringe driver), intramuscularly and by slow IV injection.
Fentanyl	Initial dose ‘25’ patch or calculated when previous strong opioid has been used. Replaced after 72 h. Apply to non-irritated, non-hairy area in torso or upper arm and rotate site.
Hydromorphone	1.3 mg 4-hourly, increased if necessary according to severity of pain.
Oxycodone	Initially 5 mg every 4–6 h, increased if necessary according to severity of pain, usual maximum 400 mg daily.

a Non-steroidal anti-inflammatory drugs are useful for musculoskeletal inflammatory-type pains. They are contraindicated if there is active peptic ulceration or thrombocytopenia. Caution is required in asthma and in cardiac and renal impairment.

In many cases, strong opioids such as morphine or diamorphine may be anticipated and in these cases step 2 of the ladder is missed. There is no advantage in changing to a different weak opioid or combining two together; the patient should be changed to a strong opioid analgesic.

Pain relief should be:

• by the clock

• by the mouth

• by the ladder.

TREATMENT WITH STRONG OPIOIDS

There is no maximum dose.

The overall aim of treatment is to keep the patient pain-free and alert. This is achieved by regular adminis-tration of the selected dose. Extensive experience has shown that strong opioids are the most valuable drugs in achieving pain relief for many cancer patients with severe pain. Morphine is the strong opioid of choice. The determination of the starting dose will depend on the patient’s previous history of analgesic use and on renal function, as outlined in Table 26.2.

Table 26.2 Determination of initial morphine and diamorphine dose

Patient’s analgesic history	Dose of morphine equivalent	Dose of diamorphine by infusion
Previously controlled on non-opioid (e.g. 1 g paracetamol four times daily)	5 mg of morphine 4-hourly^*	10 mg of diamorphine over 24 h
Previously controlled on weak opioid (e.g. dihydrocodeine 60 mg 6-hourly)	10 mg of morphine 4-hourly	20 mg of diamorphine over 24 h
Poor renal function (glomerular filtration rate less than 50 mL/min; potential problem with the elderly)	Doses given (see above^*) should be reduced by 50%
Poor hepatic function	Severe hepatic failure has an effect on morphine metabolism and there may be a need to reduce the dose of morphine

Treatment should be commenced with an immediate-release preparation (e.g. Oramorph or Sevredol) at a dose of 10 mg regularly every 4 h plus as-required morphine for breakthrough pain. To calculate the dose for breakthrough pain, divide the total daily dose by 6, and this should be administered as required (consider using a lower dose, 5 mg, if the patient is frail or elderly or has renal impairment). Pain should be titrated successfully with 4-hourly oral morphine before the patient is changed to a controlled-release preparation. After 24 h, controlled-release morphine suspension may be used in patients who have difficulty in swallowing controlled-release tablets.

To calculate the controlled-release dose, add the total morphine dose taken in the previous 24 h, i.e. regular doses plus as-required doses.

Convert to a modified-release morphine preparation, for example:

MST (12-hourly = twice-daily administration)

MXL (24-hourly = once-daily administration).

The last 4-hourly morphine dose should be given with the first dose of controlled-release morphine.

An immediate-release preparation should be prescribed as required for breakthrough pain. Regular review is essential. Daily increments of 25–50% are reasonable. If the dose is escalating more quickly, then reassess whether the pain is opioid-responsive and whether addition of an adjuvant would be useful.

CASE STUDY

A 56-year-old woman has metastatic colorectal cancer. Despite regular paracetamol and dihydrocodeine, her pain remains poorly controlled.

PRESCRIBING POINTS FOR OPIOID ANALGESICS

The equivalent single doses of strong analgesics are shown in Table 26.3. Opioid analgesics share many side effects, most commonly nausea, vomiting, constipation and drowsiness. Nausea and sedation usually resolve after 2–3 days. Laxatives should be started as soon as opioids are prescribed. There is no benefit in combining opioid analgesics. Side-effects are not reduced, and assessment of response may be obscured. Oral morphine is available as a solution, suspension, tablets and capsules.

Table 26.3 Equivalent single doses of strong analgesics