Post on 27-Dec-2015
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Palliative Care for Patients Living
with HIV/AIDSHAIVN
Harvard Medical School AIDS Initiative in Vietnam
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Learning Objectives
By the end of this session, participants should be able to:
Explain what palliative care is and why it is important
Describe how to evaluate pain Explain how to treat nociceptive and
neuropathic pain Describe what end of life care is and
why it is important
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What is Palliative Care? (1)
“Palliative care is a combination of measures to relieve suffering and improve the quality of life of patients through the prevention, early detection, and treatment of pain and other physical and psychosocial problems that the patient and family are encountering.”
Source: Vietnam MOH: Guidelines on Palliative Care for Cancer and AIDS patients
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What is Palliative Care? (2)
The two major goals of palliative care are:
1) To relieve suffering, and
2) To improve the quality of life of the patient
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PAIN
Over 50% of AIDS patients in Vietnam suffer from pain – the majority of which is
undiagnosed and untreated.
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Pain: Definition
“the feeling of discomfort of a patient because of current or potential tissue damage or, it is an actual injury that
the patient is suffering from”
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Etiologies of Pain in HIV/AIDS
Category Type of Pain/Cause
Opportunistic infections
• Headache• Cryptococcal
meninigitis• TB meningitis
• Odynophagia• Esophagitis due
to Candida, HSV• Abdominal pain
• MAC/TB
Malignancies • HBV, HCV• Lymphoma
HIV virus • Distal symmetric polyneuropathy
Medications • d4T (peripheral neuropathy)
• AZT (headache)
Pain is exacerbated by psychological and social stress
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Pain Assessments
Based on patient’s own report Always use same pain assessment
scale to best monitor and compare the progress of pain control
Most common pain assessments include:• Pain Intensity Scale• Wong-Baker Faces Pain Rating Scale
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What are Some Things to Look for When Assessing Pain?
Location Type or quality of
pain: sharp, dull, constant, intermittent
Grade of pain • Pain Scale
Ability to sleep• Good indicator of
comfort level
Effect on functioning:• Ability to eat, swallow • Can walk with or
without assistance Response to
treatment• Pain medications• Non-pharmacological
treatment Heat, cold Acupuncture Massage
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Principles to Follow in Pain Treatment
Deliver pain relief interventions in a timely, coordinated and logical manner
After pain has been treated, assess if intervention worked• If not, may need to increase dose or try
another therapy Pain assessments and interventions
should be documented in patient’s chart so other doctors know what does and does not work
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Categories of Therapeutics
Nociceptive pain Responds well to
opioids and non-opioids
Neuropathic pain Responds better to
adjuvant medications (antidepressants, anticonvulsants) than opioids or non-opioids
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Easing Pain (1)
Mild Pain (1-3 on 0-10 scale)
Non-opioid analgesics +/- adjuvants
• Non-opioid analgesics• Ibuprofen• Aspirin• Paracetamol
• Adjuvants• Amitriptyline• Gabapentin• Carbamazepine
Moderate Pain (4-6 on 0-10 scale)
Weak opioids +/- adjuvants
• Weak opioid• Codeine
Severe Pain (7-10 on 0-10 scale)
Strong opioids with or without adjuvants
• Strong opioids• Morphine• Oxycodone
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Easing Pain (2)WHO three-step “analgesic ladder”
Pain persisting
or increasingPain
persisting or increasing
Pain Relief
3 SEVERE
PAIN
Strong Opioid +/- Non-opioid +/- Adjuvant
2 MODERATE
PAIN
Weak Opioid +/- Non-opioid +/- Adjuvant
Non-opioid
+/- Adjuvant
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MILD PAINAdapted from World Health Organization. Cancer Pain Relief. Geneva: WHO, 1990.
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Dosing Analgesics
Analgesics like all other drugs have side effects, dose carefully to attain useful effect
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Difference Between Oral and Intravenous Opioids
Oral, immediate release opioids have a 30 minute onset of action
Immediate release opioids last 3-7 hours in the blood
IV opioids have a 5 – 10 minute onset of action
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What’s Wrong with the Way this Analgesic is Being Given?
Pain
• Doses are not being given frequently enough • Analgesic wears off, and patient feels pain
until next dose is given
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Most short-acting opioids are given every 3-4 hours to maintain pain relief effect
Give Opioids at Right Frequency to Prevent Breakthrough Pain
What if Correct Interval but Patient Still Has Pain?
To treat break through pain give 10% of daily dose of opioids:• every 1 – 2 hours for immediate release oral opioids OR • every 30 – 60 minutes for subcutaneous or intravenous
opioids• Should NOT be substituted for opioid already being given every 3 – 4 hours
Breakthrough pain
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Example: Calculating Breakthrough Pain Dosages
A patient is receiving oral morphine 10mg, every 4 hours
What is her total daily dose? Total daily dose is 10 mg x 6 = 60
mg What is her breakthrough dose? Breakthrough dose: 10% x 60mg =
6 mg every 2 – 4 hours as needed
Tolerance to Opioids Tolerance develops with time in most
patients requiring dosage increases Unlike NSAIDS and most adjuvants, there
is no maximum dosage for opioids.
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Equianalgesic Dosing of Opioids
Sometimes side effects, lack of effectiveness or tolerance requires a change from one opioid to another
When changing to a different opioid one must refer to an opioid table to determine the appropriate dose to start with
This is called the “equianalgesic dose”
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Non-Pharmacologic Pain Treatments
Acupuncture Heat or cold packs Massage Deep breathing exercises
Gets patients and families involved in helping with pain control
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Case Study: Thuy (1)
Your patient, a 37 year-old female named Thuy, is HIV positive and has been on ART for the last 6 months with nearly perfect adherence
She presents with aching right hip pain which worsens at night• no history of trauma or accident
Examination revealed tenderness over the right proximal femur
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Case Study: Thuy (2)
What kind of pain is Thuy having? She is having nociceptive pain as she
describes it as aching pain What steps would you take to further
evaluate and treat her? Treatment would be a nonsteroidal
anti-inflammatory drug (i.e. ibuprofen, diclofenac)
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Case Study: Thuy (3)
6 months later, Thuy returns with burning and shooting pain in both legs• Pain is intermittent, examination of
lower extremities was not remarkable She takes D4T 40 mg plus 3TC/EFV She is also on the continuation phase
of TB treatment Her weight is 55kg
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Case Study: Thuy (3)
What do you think could be going on with Thuy?
What kind of pain is she having? What are the possible causes of her
pain? What steps would you take to further
evaluate her? Do you think paracetamol would help?
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Prevalence of Symptoms in Patients with AIDS*
Fatigue
Weight loss/anorexia
Pain
Anxiety
Insomnia
Cough
Nausea/ vomiting
Depression/ sadness
Dyspnea/ respiratory symptoms
Diarrhea
Constipation
48-77%
31-91%
29-76%
25-40%
21-50%
19-36%
17-43%
15-40%
15-48%
11-32%
10-29%* Based on several published descriptive studies of patients with AIDS, predominantly in patients with late-stage disease, Europe and North America, 1990-2002.
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Addressing HIV-Related Symptoms
Treatments can be: • disease-specific
(e.g. ARV) and/or• symptom-specific
(e.g. anti-emetics, anti-histamines)
Effective treatment of these symptoms:• Reduces suffering• Improves quality of
life• Improves ARV
adherence• Improves clinical
outcomes
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Symptoms Addressed in 2006 Palliative Care Guidelines
Nausea / vomiting Diarrhea Constipation Odynophagia Dyspnea Cough Weakness / fatigue
Fever Insomnia Agitation / delirium Depression Anxiety Pruritus Bed sores
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Overview of End of Life Care
What is End of Life Care? Provision of care during the final
days and hours of life How is it Different from Palliative Care? End of life care is only given at the
very end of a patient’s life with the goal of helping the patient reach death with dignity and with as little pain as possible
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Ways to Provide Support at the End of a Patient’s Life
Provide emotional and spiritual support• Encourage patients to discuss feelings• Listen attentively, be empathetic• Respect patients’ decisions
Provide grief and bereavement support• Once patient dies, family will need support
Provide bereavement counseling
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Key Points
The two major goals of palliative care are to relieve suffering and to improve patient quality of life
Assess pain based on patient’s own report and standard pain assessment
Important to understand pain in order to know how to treat effectively
Emotional and spiritual support are important parts of palliative care