Dyspnoea
Assessment : Identify cause to guide treatment.Non-Pharmacological Measures :
Positioning (upright position).
Use of fans to improve airflow.
Breathing exercises and relaxation techniques.
Pharmacological Measures :
Opioids :
Morphine : Start with 2.5–5.0 mg orally every 4 hours. Titrate based on response and side effects.Monitor for constipation and treat with standard laxatives (e.g., coloxyl and senna).
Benzodiazepines :
Lorazepam : 0.25–0.5 mg sublingually for anxiety-related dyspnoea.If regular anxiolytic is needed, consider:
Diazepam : 2–5 mg orally once or twice daily.Clonazepam : 0.5 mg orally twice daily.
Monitoring : Watch for signs of hypercapnia (drowsiness, confusion, decreased respiratory rate).
Nausea
Antiemetics :
Metoclopramide : 10 mg orally or subcutaneously three times daily.Haloperidol : 0.5–1.5 mg orally or subcutaneously once or twice daily.Cyclizine : 50 mg orally or subcutaneously three times daily.
Combination Therapy : Use maximal doses of one antiemetic before adding another; avoid combining drugs of the same class.Severe Cases :
Subcutaneous infusion of metoclopramide with haloperidol using a Grasby pump.
General Measures : Address odours, dietary changes, food presentation, and avoid triggers.
Constipation
Laxatives :
First-line :
Coloxyl and Senna : 2 tablets orally twice per day.
Add-ons :
Movicol : 1–2 sachets orally up to 4–6 times per day.Lactulose : 10–20 mL orally up to 2–3 times per day.
Early and Sufficient Use : Start laxatives early and adjust doses based on response.
Delirium
Investigations : Pulse oximetry, blood tests (including electrolytes, liver function tests), urine analysis, chest X-ray if needed.Environmental and Supportive Measures : Provide a calm environment, reorientation, and familiar objects.Medication Review : Assess and potentially change opioids, particularly if the onset of delirium coincides with opioid changes.Neuroleptics :
Haloperidol : Start with 0.5–1.0 mg orally or subcutaneously, can be titrated up to 10 mg per day.Alternatives if Haloperidol is not tolerated :
Olanzapine : 2.5–5 mg orally, titrate to 5–10 mg per day.Risperidone : 0.5–1 mg orally, titrate to 1.5–4 mg per day.
Depression
Screening and Diagnosis : Use standardized tools to screen for depression.Antidepressants :
Mirtazapine : 15 mg orally at bedtime, increase to 30 mg per day as tolerated.Methylphenidate : 2.5–5 mg orally in the morning and at noon for rapid symptom relief if survival time is limited.
Pruritus
Treat Underlying Disease : Manage renal, liver failure, or other underlying conditions.Medications :
Antihistamines :
Hydroxyzine : 10–25 mg orally at bedtime or as needed.Chlorpheniramine : 4 mg orally every 4–6 hours.
Serotonin Receptor Antagonists :
Ondansetron : 4–8 mg orally up to three times daily.
Topical Treatments : Emollients, anti-itch creams (e.g., menthol or camphor-based).
Fatigue
Treat Reversible Causes : Address depression, anaemia, infection.Non-Pharmacological Measures :
Exercise Program : Encourage gentle, regular exercise.Information and Support : Provide education and psychological support.
Pharmacological Measures :
Glucocorticoids :
Dexamethasone : 4–8 mg orally in the morning.
Methylphenidate :
Starting dose : 2.5 mg orally in the morning, titrate to 5–10 mg twice daily.
Secretion Management
Methods :
Suction : For immediate relief of excessive secretions.Postural Drainage : Effective in non-terminal stages.Saline Nebulisers : To loosen secretions.Mucolytics : E.g., acetylcysteine nebulisers.
Anticholinergic Medications :
Atropine Eye Drops : 1% solution, 1–2 drops orally four times per day.Hyoscine Hydrobromide : 0.4 mg subcutaneously three times per day.Glycopyrrolate : 0.2 mg subcutaneously 2–3 times per day.
Advanced Interventions :
Botulinum Toxin Injections : To salivary glands for persistent secretions.Low Dose Radiotherapy : To salivary glands if other measures fail.
Pain
Why Introduce an Opioid Now?
Severe Cancer Pain : Patients with severe or rapidly escalating cancer pain benefit significantly from potent opioids.Efficacy and Tolerability : Codeine has no advantage over an equipotent dose of morphine.Therapeutic Ceiling : Opioids like morphine have no therapeutic ceiling, making them suitable for escalating pain.Addiction Risk : Well-conducted studies show no significant risk of addiction in cancer pain management.Administration : Slow-release nonparenteral routes are preferred for chronic opioid therapy.First-Line Therapy : Morphine is well-established in cancer pain management, inexpensive, and available in multiple formulations.Backup Availability : Injectable morphine is readily available for emergencies in doctors’ bags.
Options for Opioid Therapy
Alternate Potent Opioids :
Oxycodone : Available for opioid initiation or substitution.Hydromorphone : An alternative for inadequate analgesia or side effects with morphine.Fentanyl : Transdermal patches are useful for patients with difficulty in oral dosing (e.g., head and neck malignancies, vomiting, bowel obstruction).
Methadone :
Effective for neuropathic pain, lacks active metabolites.
Long and variable half-life, requiring careful dose titration to avoid accumulation.
Tramadol :
Centrally acting analgesic, less constipation, used in higher doses in palliative care.
Structurally different, weakly stimulates opioid receptors and inhibits noradrenaline and serotonin reuptake.
Buprenorphine :
Not recommended due to mixed agonist/antagonist properties.
Breakthrough Pain Management
Ideal Drug Characteristics : Rapid onset and short duration of action.Fentanyl Lozenges (Actiq) : Designed for breakthrough pain but limited by non-PBS listing.Immediate Release Options :
Morphine : Slow onset and prolonged duration.Oxycodone : Same issues as morphine.Hydromorphone : Similar challenges as morphine.
Managing Opioid Adverse Effects
Constipation :
Most common long-term effect.
Always prescribe aperients (e.g., Coloxyl and senna, Movicol).
Nausea and Sedation :
Common initially, tolerance usually develops within a week.
Prescribe metoclopramide or an alternative antiemetic with the first opioid prescription.
Long-term sedation is rare (<10%), but caution patients about driving during dose initiation or increases.
Other Adverse Effects :
Itch, sweating, urinary retention, anaphylaxis, opioid-induced neurotoxicity.
Managed through dose reduction or opioid substitution.
Management of Visceral Pain
Opioids : Increase doses as needed for chest pain from lung cancer.Paracetamol : Useful addition if not already prescribed.Dexamethasone : Reduces peri-tumour oedema, may decrease visceral pain.Steroids and NSAIDs : Co-prescription increases gastrointestinal risk; consider proton pump inhibitors.
Management of Neuropathic Pain
Opioid Sensitivity : Neuropathic pain is less opioid-sensitive, requiring adjuvants.Adjuvants :
Anticonvulsants : Gabapentin, pregabalin.Tricyclic Antidepressants : Commonly used, with efficacy extrapolated from studies on diabetic neuropathy and postherpetic neuralgia.
MRI for Spinal Cord Compression : Consult palliative care specialist, emergency department, or oncologist if suspected.High-Dose Dexamethasone : For confirmed spinal cord compression (16 mg IV or subcutaneously).
Intractable Pain Management
Clinician and Patient Factors :
Clinician: Opioid phobia, disease focus, lack of guideline awareness.
Patient: Fear of addiction, tolerance, side effects, stoicism.
Specialist Advice : Required for intractable pain.Advanced Options :
Ketamine : Subcutaneous infusion burst protocol.Spinal Analgesia : Consider for refractory pain.Terminal Sedation : For end-of-life care.
Pathology Review : Check for fractures, cord compression, hypercalcaemia, existential distress.Neuropathic Pain and Wind-Up : Assess and manage accordingly.
By introducing a potent opioid now, we aim to provide effective and sustained pain relief for severe or rapidly escalating cancer pain, improving the patient’s quality of life during palliative care.
Chronic Conditions Requiring Palliative Approach
Chronic Obstructive Pulmonary Disease (COPD)
Symptom Management : Dyspnoea, fatigue, pain, insomnia, low mood, anxiety.Support Needs : Daily activities support, emotional and social support, information provision.
Motor Neurone Disease (MND)
Symptom Profile : Similar to cancer patients.Special Considerations : Swallowing difficulties, secretion management, nutrition, respiratory complications.Specialist Input : Neurologist, respiratory physician, dietician, speech pathologist, physiotherapist.Advance Care Planning : Consider nutritional and ventilatory support preferences.
Class IV Heart Failure
Symptoms : Weakness, fatigue, shortness of breath, swelling, nausea, constipation, depression, poor quality of life.Symptom Management : Review medications, optimize heart failure treatment, manage symptoms.Risk of Sudden Death : Up to 50%, include in end of life care discussions.
Renal Disease
Common Symptoms : Pain, fatigue, drowsiness, nausea, anxiety, itch.Advance Care Planning : Discussion of dialysis cessation, addressing clinical, social, and spiritual issues.
Chronic Liver Disease
Common Symptoms : Liver capsule pain, ascites, jaundice, itch, electrolyte disturbances, encephalopathy.End-of-Life Planning : Discuss gastrointestinal bleed risks and management with family.
Key Points
Symptom Management : Focus on control and quality of life improvement.Advance Care Planning : Early discussions about end of life care.Psychosocial Support : Significant support needed due to symptom burden and prognosis uncertainty.Team Approach : Involves multiple disciplines and services for holistic care.
from Reprinted from
Australian Family Physician Vol. 35, No. 10, October 2006 765 Pain management in palliative care An update Kirsten Auret MBBS, FRACP, FAChPM, Australian Family Physician Vol. 35, No. 10, October 2006 767: Palliating symptoms other than pain – Jane Fischer MBBS, DCH(Lond), FAChPM,is Clinical Director, Palliative Care, Calvary Health Care,
Related
