Palliative care monthly meeting

Speaker: Dr Eric Liang

14 June 2011

Seminar A1• “Let me die….”• Our response to the dying patient• Dr JaanYang Kok

Seminar D2• Palliative chemotherapy • Benefit or burden• A/Prof Simon Ong

Seminar D3• Depression & anxiety in Palliative care• A “Normal” response to dying?• Dr Daniel Kwek

Seminar D4• Demoralisation • The impact on patients & caregivers

Seminar E1• Difficult pain (1)• Opioid rotation: not as hard as it looks• Dr Allyn Hum

Seminar E2• Difficult pain (2)• Interventions in complex cancer pain• Dr Kian Hian Tan

Seminar A1 “ Let me die…..”

• What is the patient trying to tell us?

1. Express physical distress

2. Express psychological distress

3. Really wants to die

• How would you respond?

Examples of unhelpful responses

1. “You must be strong….”

2. “You will be OK!.......”

3. “You will get better…….”

4. “You must be positive, don’t say such words….”

5. “Euthanesia is not legal…..”

6. “I don’t have such a medication…..”

Important issue:

1. Recognise that this is a golden opportunity to explore

2. To show empathy and invite the patient to talk

• Practical 3 step approach

1. Assess physical distress & treat accordingly

2. Assess psychological distress & treat accordingly

3. Assess existential issue & assess for suicidal ideation

Example 1

• Lady with ca breast • Increasing L sided weakness secondary to brain met• Was able to walk to toilet but not now• pain from hepatomegaly / poor appetite / impacted stool• Husband & maid supportive but difficult• Pt voiced out “let me die”

• Imp: extensive physical distress main concern / carers distress

• Mx:

• Commode chair• Dexamethasone • Clear bowel• Adjust analgesic• Kept at home • Additional help from house nurse

Example 2

• Man with ca stomach with peritoneal mets / RT tube feeding

• Divorced & remarried 6 month before diagnosis • Tried all possible treatment• Pt felt sorry for his new wife • Wanted to live longer to accompany his wife• Many physical symptom • Voiced out “ Let me die….”

• Imp: • Meaning of “Let me die “ is mainly psychological distress• Tired of the journey and want to die, but yet wants to live

longer for the sake of his wife

• Rx:• Aggressive mangement of pain & symptom• Support wife • Support pt staying home with wife as much as possible

Example 3

• COAD & Ca lung patient / chemo stopped• Progressively getting weaker, walking needs assistance• Activities limited by dyspnoea • Frustrated with all the medication given • “Nurses force me to take medication” • refused all medication & voiced out “Let me die”

• Imp:• More existential issue• Patient is ready to go, but why need so much medication

• Mx:• Review medication• Stop meds except those absolutely necessary• Stop medication may not hasten death but too much me

dication will certainly hasten patient’s suffering

Palliative chemotherapy: benefit or burden?

• What is palliative chemotherapy?

• Chemotherapy given aiming for symptomatic improvement to enhance comforte of patient & to improve QoL

• Not aiming for prolonging survival

What are patient’s attitude towards chemo

• Chance to cure• Chance to prolong survival• Only to relief symptom• Patient may wants to have intensive treatment for small

benefit• (may not be understood by someone who is well)

• General public: expect minimal but large benefit• Health care provider: in between the two above

• Physicians view point:• Doctors appears willing to treatment with small benefits• Due likely to:• Uncertainty in prognostication• Not to decrease patient’s hope

• 18% & 8% of patient received chemotherapy 4 & 2 weeks before death respectively

• Mostly decided by physicians

Benefits:• Symptom control / QoL• Tumour regression ( upto 20% of pt treated)• Longer survival (eg target therapy provide 20-25 month o

f survival)

Burden• Costs (upto US $90,000 in 6 month)• Care giver burden ( psychological, economical, occupati

onal burden )• Drug Toxicity (20-40% mild / upto 10% severe / death 1-

3%)

When to prescribe palliative chemo?

• Create a balance score of benefit vs harm• Note these factor may not be equal in importance• Override by patient’s desire• Given when there is meaningful potential benefit without

unbearable toxicity and taken patients wish into account

• NOT to give pallative chemo as a substitute for antidepressant

Example 1

• 50/F with colorectal cancer• Responded to chemotherapy with minimal side effect • Survived for 3 years

• Palliative chemo has added enjoyable & meaningful years to her life

Example 2

• 50/F ca colon with liver mets• Receiving 2nd line chemo & anti EGRF monoclonal antib

ody• Family is crushed by the financial burden• Although patient’s chemo is able to provide tumour regre

ssion & prolong survival• But the overwhelming economic & psychological burden i

s far exceeding the benefit

Example 3

• 30 yo man with advanced cancer wants to spend more time with his son

• But progressive disease despite chemo x2• Patient still contemplated for further chemo for longer sur

vival to accompany his son

Depression & anxiety in palliative careA “Normal” response to dying?

• Depression:• General population 6-10%• Oncology 45-58%• Palliative care 24%

• Death• Unknown, irreversibility, loneiness, separation, loss of life• Also: confined, pain, SOB, loss of consciousness

• Thanatophobia • =Fear of death• Greek mythology / Thanato =God of death• Is a well recognized entity in human psyche

• Phobia becomes abnormal when:• The fear go beyond the normal intensity, duration, perver

siveness & quality• Interfere with patient’s functioning in life

A spectum of possibility• Normal reaction• Grieve reaction• Illness related symptom• Adjustment disorder• Due to medication • Psychiatric disorder• Organic brain syndrome

• Important to recognise:

• Major depression is best predictor of MI, angioplasty, death 12 months after cardiac catheterization

• In GAD, there is increased risk of VT• Depression increases mortality after stroke

• Important to treat/control anxiety as it will help to:• • Enhance tolerance to other symptoms• Affect compliance• Influence staff & family reaction

• Note:• Also related to procedures & tests• Often physical & somatic symptoms may overshadow

anxiety symptom

Management of anxiety

• Reasuring stance help – knowledge & skill• Education helps• Psychological methods• Pharmacological treatments

• Note:• Assumption that high anxiety is inevitable is not helpful• Use somatic symptoms as cues to inquire about the pati

ent’s psychological states which commonly is fear, worry or apprehension

• Take patient’s subject level of distress

medications

• Benzodiazepam• Anti-psychotic• Antihistamine• Anti depressant• Opioid

• Note on benzodiazepam:• fear of respiratory depression should not prevent the use• Use short acting• Start with small dose• Increase the dose slowly• Switch to long acting ones if appropriate• Alternatively can use low dose antipsychotic

• Other treatment:• Brief psychotherapy• Behavioural techniques

• Patient with high spirituality or intrinsic religiosity is less likely to have psychological disturbance

• Ability to derive the meaning of life & maintain peace internally

DemoralisationImpact on patients & caregivers

• The term demoralization emerged in 2000• Psychosomatics: 2000;41: 418-425• Recent definition:• Loss of meaning, purpose, with helplessness,

hopelessness• Inability to cope, social isolation• Suicidal ideation may develop from hopelessness &

meaninglessness• Absurd to reduce the patient’s entire psychopathology ,

psychosocial & biological contribution to illness in one diagnostic label

Differentiation form depression

• Similar but different• Mood reactivity is usually preserved• (able to respond to happy news)• Treatment of physical symptoms, resolution of

psychological / spiritual or social issues restore hope & spirit rapidly

• Fail to show robust improvement with antidepressant medication

• Demoralisation scale

• J Palliative Care 2004; 20:269-276

Clinical association of demoralization syndrome

• Illness related:• Breaking of diagnosis• At news of disease of progression• High burden of physical symptom• Body disfigurement, paraplegia

• Treatment related• Limb amputation, mastectomy• Chemotherapy• Threatens dignity eg becoming incontinent / dependent

• Patient factor:• Younger age more affected• Past Hx of mental illness• Axis II / maladaptive coping style• Poor relationships

• Countertransference & demoralization

• Demoralization is contagious• Demoralized patient can lead to demoralized care-giver• (and vice versa)• Demoralized patient can also lead to demoralized medic

al & allied health team members

• encountering demoralization:

• Treat physical symptoms• Address social, financial concern• Focus interviewing as a bridge to brief psychotherapy• Concept of presence• Facilitating repair of relationship• Acknowledge suffering “ this is a hard illness to have..”• Restoring value & dignity

• Difficult cancer pain

• 3 categories• Poorly responsive to morphine• Episodic breakthrough despite background analgesia• Dose limiting adverse effect

Treatment for difficult cancer pain

• Disease modifying agent• Identify psychosocial, emotional, spiritual suffering• Change route of administration of opioid• Opioid rotation• Use of adjuvants• Invasive analgesic techniques

• Indication for opioid rotation

• Dose limiting adverse effects• Difficult pain syndrome• Poorly controlled pain

Stop & go method

morphine Methadone dose

Day 1 stop 4:1 morphine <90mg/day

8:1 morphine 90-300mg/day

12:1 morphine >300mg/day

• Rescue dose =1/6th of daily dose upto 3/day

3 day Edmonton rotation schedule

opioid Day 1 Day 2 Day 3 Day 4

morphine 135mg decrease 1/3

66mg

decrease 1/3

Cease morphine

methadone 5mg

1/3 target dose

10mg

2/3 target dose

15mg

Target dose

15mg /day

Breakthrough opioid

20mg morphine

20mg morphine

20mg morphine

2.5mg methadone

• Opioid rotation can be successful if….

• The basis for it is clear• It is part of the assessment & therapeutic strategy of the

patient• Equianalgesic ratios are used• Incomplete cross tolerance is account for• Continued assessment of the patient

Management of cancer pain

• WHO analgesic ladder• This manage to relief upto 80-90% of all cancer pain• Levy Oncology 1999;13: 9-14

• Surgical interventions on appropriate nerves may provide pain relief if drugs are not wholly effective

• (Quoted from WHO)

Benefits of interventional techniques

• More targeted & effective• The dose of drugs much smaller than if given iv or po• Intrathecal : intravenous =1: 100• Epidural or intrathecal analgesic usually produce fewer u

nwanted effects eg drowsiness

• Choice of technique

• Life expectancy• Mechanism & type of pain• Site of pain• Patients preference • Support available

Peripheral nerve block

• Limited role• Case series on short term pain relief• Acute pain relief especially during the perioperative perio

d• Catheter infusions but limited time catheter can be left in-

situ

Epidural or intrathecal?

• Trend towards intrathecal• Lower dosages• Less frequent pump refills• Less incidence of cath occlusion or fibrosis

opioids

• Large studies shows improved quality of life, functional capacity & pain scores

• Smith et al J Clinical Oncology 2002;20:4040-49• Asso with lower incidence of side effect as compared wit

h oral or parental routes• Most freq S/E:• Constipation • Urinary retention• Sweating• Nausea /vomiting• Respiratory depression 4-7%

morphine

• Hydrophilic nature• Spread to level distal to the site of injection• Only FDA approved opioid

• Other (not FDA approved)opioid:• Fentanyl• hydromorphone

Local anaesthetic

• Improves pain relief & patient satisfaction• Deer et al. Spine 2002; 2(4): 274-8• Provide pain relief in patient who failed IT opioid therapy• Synergistic effect• Less opioid tolerance • Most common: bupivacaine

Neurolytic technique

• Interruption of nociceptive transmission from peripheral tissue to spinal cord

• Persistent localised pain with limited life expectancy• Less uterised if alternative intervention available• Use as one-off intervention or limited resources or infrast

ructure available for catheter systems• Mainly alcohol or phenol

Intrathecal neurolysis

• Administration of alcohol or phenol into subarachnoid space

• Aims to achieve pure sensory segmental block• Suitable for terminal ca with limited life expectancy with s

omatic pain• Associated with potential devastating complications

Coeliac plexus block

• Main indication for ca pancreas• Also for upper GI cancer• Pain referred to back or upper abdomen• Strong evidence of efficacy upto 90%• Eisenberg et al. Anaesth Anal 1995;80:290-5

Complications

• Diarrhoea 30% & postural hypotension 60%• Short lived 48hrs• Neurological injury or paralysis rare (1:700) but devastati

ng• Trauma /spasm / chemical irritation to Artery of Adamco

wtiz implicated

Other neurolytic blocks

• Superior hypogastric• Ganglion impar• intercostal

Summary

• Intervention should be appiled carefully, appropriately and at the right time

• Improve quality of life • Reduction in medication usage• Good evidence for coeliac block & intrathecal analgesia• Aftercare crucial

• Thank you