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Pharmaceutical care cases: Palliative Care PAIN and Constipation 2013 notes Definition: Definition: (WHO 1990) The

active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. READ UP Pathophysiology of pain and constipation and Nausea and Vomiting PAIN ASSESSMENT e.g. STAS SCALE: Effect of his/her pain on the patient. 0 = none 1 = Occasional or grumbling single pain. Patient is not bothered to be rid of symptom. 2 = Moderate distress, occasional bad days, pain limits some activity possible within context of disease. 3 = Severe pain present often. Activities and concentration markedly affected by pain. 4 = Severe and continuous overwhelming pain. Unable to think of other matters. Pathophysiology of pain Pain: visceral/nerve/bone/other Tissues and organs innervated by sensory receptors (nociceptors), connected to primary afferent nerve fibres of different diameters. Afferent primary fibres responsible for transmission of painful stimuli terminate in the dorsal horn of the spinal grey matter. Pain transmission onwards more complex and less well understood. Modulation or inhibition occurs at the level of the spinal cord (gate theory of pain). (Woolfrey, Kapur; Pain Chapter in Walker & Whittlesea). Neurotransmitters include as glutamate, GABA, noradrenaline, serotonin, opioid peptides, substance P. Other mediators are involved in pain associated with inflammation e.g. prostaglandins. Signs and symptoms of pain: Signs might include: pallor and sweating during acute episodes, redness/swelling at local sites, Symptoms include (depending on type of pain) dull ache to acute sharp episodes, shooting pains, stiffness, breathlessness Pathophysiology of constipation Reduced GI motility e.g. due to opioids suppressing peristalsis, or lack of fluid, causes passage of faeces to slow down or stop in the bowel. Signs and symptoms of constipation: Signs include: reduced frequency or no passage of stools; abdominal distension Symptoms include: abdominal pain, straining at stool, pain, discomfort

Risk factors (causes) of constipation: Lack of preventive use of a laxative in opioid-treated patient Dehydration Immobility Lack of fibre in diet Inadequate hydration Drug treatments (e.g. opioids as above, also antimuscarinics) Medical conditions e.g. stroke, Parkinsons Pathophysiology of Nausea and Vomiting Nausea subjective unpleasant sensation associated with upper GI tract, accompanied by an urge to vomit Vomiting - Forceful expulsion of GI contents though mouth Both result from stimulation of the CTZ and/or Vomiting centre in the brain. VC is the final common pathway for initiation of vomiting. VC not sensitive to chemical but receives impulse from CTZ which is sensitive to many drugs including opioids + tumour factors produced in cancer. Causes: Iatrogenic drugs e.g. opioids in CNS and others e.g. anti-inflammatory drugs irritating the GI tract. Organic e.g. faecal impaction, bowel obstruction, squashed stomach due to enlarged liver Metabolic: raised urea or calcium Psychological: anxiety and fear Also note can have bowel obstruction due to tumour mass and very difficult to manage discuss use of high dose steroids (dex) and octreotide decreasing volume and frequency of vomits. Usually, nausea due to opioids subsides as tolerance develops but may persist due to the other causes above. Discuss the management of pain Pain: Subjective patients description of pain Objective patient appearance, discomfort; could use pain scale for assessment

Pain inadequately controlled appears to have nerve pain and bone pain which are not managed well by opioids Pain: o o o

opioid requirements, using breakthrough analgesic as measure of when and by home much to increase the dose is shooting pain better having started treatment? is back pain better having started treatment?

Characterisitics of Formulations used

Oral: SR tablets (morphine) bd dose Tablets e.g. carbamazepine Capsules e.g. gabapentin Immediate release (morphine liquid), 4 hour duration of effect (why use?) Recommendations? Consideration alternative formulations for opioids for patients who cannot swallow or who are vomiting: transdermal (fentanyl), subcutaneous infusion of opioid (morphine or more commonly diamorphine). Why diamorphine favoured in UK high solubility means low volumes can be administered) Suppositories (if needed, if patient vomiting) e.g. diclofenac, carbamazepine

WHO ladder forms basis of use of analgesic drugs. No opioid for breakthrough pain so difficult to assess how analgesic requirements need to be increased. Morphine SR appropriate choice for chronic pain. For nerve pain consider: tricyclic e.g. amitriptyline (but not advisable in this case due to propensity to cause constipation) carbamazepine or other antiepileiptic e.g. gabapentin other option (usually for local effect only), capsaicin cream (Probably not appropriate here) Add in morphine sulphate liquid 10mg every 4 hours prn for breakthrough pain Start drug for nerve pain e.g. carbamazepine 100mg bd Start NSAID for bone pain (students should give example and dose) Tolerability to treatment; drowsiness, nausea & vomiting, GI effects of NSAIDs, any other drug-specific side effects Renal function (route of elimination for morphine; affected by NSAID) Can patient keep medication down? Can patient manage drug treatment regimen, and dose he understand the need for each drugs treatment? Pharmaceutical care issues - counselling regarding optimum use of analgesics and laxatives

Critically evaluate the planned treatment for constipation, identifying how this problem may have been prevented
Subjective and Objective Constipation: subjective abdominal distension, pain Objective - not passed faeces for days

constipation needs to sorted out immediately and prevented in the future No laxative! Prevention better than cure must have. Preferred combination is a stimulant and softener. For critical evaluation of current drug therapy vs evidence based guidelines (should cite guidelines): [Evidence for laxative given on CKS website] Interventions: Start co-danthramer 10ml bd once faecal impaction cleared (senna and lactulose combination a suitable alternative) Bowel motions Fluid intake Critically evaluate the planned treatment of Nausea and vomiting.

Nausea: Subjective patients description of nausea, and any episodes of vomiting Objective has patient committed? Has this been soon after drug administration? Nausea- probably due to opioid, should become tolerant to it, but if not has implications for routes of administration of all medication Nausea if this is a persisting problem, consider antiemetic. If vomiting, need to consider route of administration of all medication offer alternatives Review nausea consider antiemetic e.g. prochlorperazine or cyclizine. All may contribute to drowsiness

Also note can have bowel obstruction due to tumour mass and very difficult to manage often use of high dose steroids (dex) and octreotide decreasing volume and frequency of vomits Social and Psychological aspects of the disease Fear, anxiety, end of life concerns Depression Concerns for relatives. What support do relatives need to cope with the current and future situation? Pain, if not adequately controlled, can be debilitating Side effects of drugs e.g. drowsiness affect ability to get on with daily activities such as driving Can daily activities be maintained as long as possible Is care integrated, especially if GP, palliative care nurse, and the HOSPICE

Support groups: Local support networks through GP surgeries

Marie Curie website patient information sheets available, plus signposting The gold standards framework http://www.goldstandardsframework.nhs.uk/ to enable a gold standard of care for all people nearing the end of their lives National End of Life Care Programme http://www.endoflifecareforadults.nhs.uk/eolc/, which aims to To improve the quality of care at the end of life for all patients and enable more patients to live and die in the place of their choice NHS direct leaflets for patients