PALLIATIVE MEDICINE AND SYMPTOM CONTROL

Palliative care describes the multidisciplinary approach to patients with advanced end-stage disease. Patients with advanced cancer and chronic non-malignant disease e.g. organ failure (heart, lung and kidney), neurologi-cal disease and HIV infection, all benefit from this approach, which aims to achieve the best possible quality of life. It includes management of symp-toms, access to support services, involving patients and family in their care and helping them to make decisions about end of life care.

Management of pain

The approach to successful management of pain includes an assessment of patient characteristics (mood, previous problems with analgesia, fear of opioids) and the likely aetiology of the pain. Pain can be controlled in most patients using a simple step-wise approach (the World Health Organization [WHO] analgesic ladder) that guides the choice of analgesia according to pain severity (Fig. 6.1). Morphine is the most commonly used strong opioid and where possible it should be given regularly by mouth.

■ Dose titration of morphine is with a normal release formulation with a rapid onset and duration of action, e.g. 5-10 mg morphine elixir or tablets every 4 hours (depending on body weight, renal function and use of other weak opioids) with extra doses allowed for ‘breakthrough pain' as often as necessary. The daily requirements can be assessed after 24 hours and the regular dose adjusted as necessary.

■ Maintenance of pain relief is with a controlled release morphine prepara-tion. When the stable dose requirement is established by titration the morphine can be changed to a controlled-release preparation e.g. 20 mg morphine elixir 4 hourly = 60 mg of a twice-daily preparation or 120 mg of a once-daily preparation. Side effects of morphine include nausea and vomiting (see below), constipation (lactulose and senna should be co-prescribed), confusion, drowsiness and nightmares.

As pain may be due to different physical aetiologies, an appropriate adjuvant analgesic may be needed in addition to, or instead of, traditional drug treatments:

Management of pain

Fig. 6.1 The World Health Organization (WHO) three-step analgesic ladder is a framework for the prescription of analgesic drugs. The ladder attempts to meet the ceiling effect of analgesic drugs to the degree of pain present. If pain is severe or analgesia ineffective, then an ascent of the ladder is recommended. NSAID, non-steroidal anti-inflammatory drug.

■ Adjuvant analgesics include non-steroidal anti-inflammatory drugs (pain, p. 317) and bisphosphonates (p. 319) used in addition to opioids, for bone pain.

■ Tricyclic antidepressants (e.g. amitriptyline 10-75 mg daily) and anti-epileptics (e.g. gabapentin 600-2400 mg daily or pregabalin 150 mg increasing to 600 mg daily) for neuropathic pain

■ Steroids e.g. dexamethasone (p. 665) for the headache of raised intra-cranial pressure or liver capsule pain.

Palliation of nausea and vomiting

Nausea and vomiting are common symptoms and successful management involves identifying the likely cause and the nerve pathway activated by the trigger:

■ Chemoreceptor trigger zone in the floor of the fourth ventricle where dopamine and serotonin type 3 (5-HT3) receptors are stimulated by drugs and metabolites

■ Vomiting centre in the brainstem where histamine type 1, acetylcholine and 5-HT2 receptors receive sensory input from higher centres, from visceral and serosal stretch receptors and from the VIIIth cranial nerve (p. 735)

■ Afferents from stretch receptors on the liver capsule, peritoneum and bowel input to the vomiting centre.

Nausea and vomiting associated with chemotherapy or opioids is treated with haloperidol (1.5-3 mg daily) or metoclopramide (10-20 mg three times daily by mouth or subcutaneously, both of which block dopamine type 2 receptors. When the risk of nausea and vomiting is high, a specific 5-HT3 antagonist (e.g. ondansetron 8 mg orally or by slow i.v. injection) is used. Vomiting due to gastric distension is treated with metoclopramide but vomiting due to complete bowel obstruction is best treated with physical measures to relief the obstruction (e.g. stent insertion or defunctioning colostomy in large bowel obstruction) and an antispasmodic e.g. hyoscine hydrobromide, at the end of life.

Care of the dying patient

The dying patient requires appropriate care in their last hours or days of life. The Liverpool Care Pathway for the Dying Patient (LCP) provides a framework for the delivery of appropriate care for dying patients and their relatives during the last 2-3 days of life. The aim is to ensure physical, psychological and spiritual comfort of patients and their relatives by a multiprofessional approach. The LCP provides guidance on the different aspects of care required, including comfort measures, anticipatory prescribing and discon-tinuation of unnecessary interventions such as withdrawal of blood for tests (the results of which would make no difference to patient care). A key element of the LCP is control of symptoms such as pain, agitation, nausea, vomiting, breathlessness and respiratory secretions.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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