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PALLIATIVE CARE
Pain assessment using OPQRSTUV and physical assessment (pain area, pain type, pertinent history, risks of addiction, associated
symptoms-nausea, vomiting, constipation, dyspnoea, tingling, urinary retention)
Recommendations LE GR
Systemic pain management
WHO analgesic ladder step 1: NSAID or para- 1a A
cetamol
Opioid administration
Opioids use (see Cancer pain treatment in 1a A
urology)
Access to breakthrough analgesia 1b A
Tricyclic antidepressant and/or anticonvulsant 1a A
in case of neuropathic pain
Pain due to painful or unstable bony metastases (single
lesions)
External beam irradiation 1b A
Pain due to painful bony metastases (widespread, opioid
refractory)
Radioisotopes (89Sr or 153Sm-EDTMP) 2 B
Bisphosphonates 1b A
Denosumab 1b A
Bladder cancer
LOCAL
METASTASES
IMPAIRMENT
• Act accordingly (TURBT, insert catheter or percutaneous Single lesions Multiple lesions
nephrostomy, treat obstructive ileus if present)
• Consider pallative pelvic exenteration for selected cases of
advanced disease
• Consider chemotherapy for selected cases of advanced disease
• Consider local radiotherapy for selected cases of advanced disease
Recommendations LE GR
Always disclose bladder outlet obstruction as - GCP
source of local pain
In locally advanced bladder cancer, palliative 3 B
cystectomy or exenteration might be an option
for symptom relief.
Use radiotherapy to reduce pain and symptoms 1a B
of locally advanced bladder cancer.
Use radiotherapy to reduce pain due to bone 1b A
metastases.
Bone Brain
• Nephrectomy
• Consider extended operations (nephroureterectomy+bowel/spleen/
abdominal/wall muscle resection) for selected cases of painful
advanced disease
• Consider radiotherapy
Consider radiosurgery
• Consider radioisotopes
Recommendations GR
Obstruction of the upper urinary tract due to haem- GCP
orrhage and subsequent formation of blood clots is
effectively treated by radical nephrectomy in non-
metastatic tumour.
If the patient is physically fit for surgery, this should be GCP
done to increase the QoL, e.g., palliative nephrectomy
in cases of metastatic tumour.
GCP = good clinical practice.
Malignant pheochromocytoma
Consider palliative
131
I-MIBG Symptomatic treatment
radiotherapy
Adrenocortical carcinoma
Consider palliative
Symptomatic treatment
radiotherapy
Adrenal carcinoma
Penile cancer
Pain due to
Pain due to local impairment Pain due to metastases
lymphoedema
Recommendations LE GR
Advanced penile cancer must be approached 2b B
with a multimodal treatment regimen that
includes neoadjuvant chemotherapy, radiother-
apy and surgical resection
Radiotherapy might decrease pain from fixed 3 C
nodes and bone metastases
Testicular cancer
Recommendations LE GR
Systemic chemotherapy is effective for the back 2b B
or flank pain due to retroperitoneal lymphaden-
opathy
Back pain and neurological symptoms due to 3 C
spinal cord compression may require urgent
surgery
Mild (VAS score 1-3) Moderate (VAS score 4-6) Severe (VAS score 7-10)
Recommendation LE GR
Preoperative assessment and preparation of 1a A
patients allow more effective pain management.
Adequate postoperative pain assessment can 2a B
lead to more effective pain control and fewer
complications.
NSAIDs are often effective after minor or mod- 2a B
erate surgery.
NSAIDs often decrease the need for opioids. 1b B
Avoid long-term use of COX inhibitors in 2a B
patients with atherosclerotic cardiovascular
disease.
The use of paracetamol is recommended for 1b B
postoperative pain management because it
reduces consumption of opioids.
Administer paracetamol as a single therapy to 2a B
alleviate mild postoperative pain without major
adverse effects.
The use of intravenous patient controlled 1b A
analgesia is recommended because it provides
superior postoperative analgesia, improving
patient satisfaction and decreasing risk of respi-
ratory complications.
Administer adjuncts in appropriate doses and 1a A
monitored care to improve analgesic efficacy
and reduce opioid-related side effects.
Administer clonidine preoperatively or epi- 1a A
durally postoperatively to reduce opioid
Requirements.
Special populations LE GR
Ambulatory surgical patients
For postoperative pain control in outpatients, 2b B
multimodal analgesia with a combination of
NSAIDs or paracetamol plus local anaesthetics
should be used.
If possible, avoid opioids. 3 B
Geriatric patients
Multimodal and epidural analgesia are prefer- 2b B
able for postoperative pain management in
elderly patients because these techniques are
associated with fewer complications.
Obese patients
Postoperative use of opioids should be avoided 2b B
in obese patients unless absolutely necessary.
An epidural local anaesthetic in combination 2b B
with NSAIDs or paracetamol is preferable.
Perioperative pain management in children
Apply EMLA locally to alleviate venipuncture 1b A
pain in children.
Create the right setting: plan what to say, allow adequate time, and determine who else should be present at the meeting
Establish what the patient knows: Establish what the patient knows:
clarify the situation and context in clarify what the patient can Establish and review the goals of
which the discussion about goals is comprehend; reschedule the talk if care
occurring necessary
Explore what the patient is hoping Establish how much the patient Establish the context of the
to accomplish: help distinguish wants to know: recognise and current discussion: discuss what
between realistic and unrealistic support preferences; people handle has changed to precipitate the
goals information in different ways discussion
Respond empathetically to feelings: be prepared for strong emotions and allow time for response, listen, encourage
description of feelings, allow silence
Make a plan and follow through: Follow up: plan for next steps,
Plan for the end of the treatment:
discuss which treatments will be discuss potential sources of
document a plan for withdrawal of
undertaken to meet the goals, support, share contact information,
treatment and give it to the patient,
establish a concrete plan for follow- assess the patient’s safety and
the patient’s family, and members
up, review and revise the plan support, repeat news at future
of the health care team
periodically as needed visits
Fear LE GR
Distress must be recognised, measured, treated 2b A
and monitored at all stages of the disease.
Depression
Efforts should be made to detect hidden depres- 2b B*
sion.
*Recommendation based on expert opinion.