Symptom Management in the last weeks & days of life. Facilitator: Vernon Davis RN/Community Team Leader Rowcroft Community Team

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1 Symptom Management in the last weeks & days of life Facilitator: Vernon Davis RN/Community Team Leader Rowcroft Community Team

2 Session objectives To identify common symptoms at the end of life To increase confidence in assessing and managing symptoms working with priorities of care guidance To expand knowledge of pharmacological and nonpharmacological symptom control To compliment practical training on T34 ambulatory syringe pump

3 Priorities of Care for the Dying Person Published June 2014 by the LACDP (Leadership Alliance for the Care of Dying People) GMC,RCN,NICE, CQC, NHS England, et al One Chance to Get it Right document Five new Priorities of Care.

4 5 Priorities of Care The possibility that a person may die within the coming days/hours is recognised and communicated clearly, decisions about care are made in accordance with the person s needs/wishes and these are reviewed and revised regularly Sensitive communication takes place between staff and the person who is dying and those important to them The dying person and those important to them, are involved in decisions about treatment and care The people important to the dying person are listened to and their needs are respected Care is tailored to the individual and delivered with compassion with an individual care plan in place

5 So what are the more common symptom control issues?

6 Prevalence of Symptoms Pain Nausea Vomiting Dyspnoea Constipation Anorexia Weakness/Fatigue Anxiety Depression Insomnia

7 Principles of Symptom Control & End of life Care Assess LISTEN Communicate, discuss, explain, reassure. Prioritise (Who s priority?) Reverse the reversible Dying is inevitable: Are grandad s batteries running out? Give patient control where possible Don t limit treatment to drugs Prescribe prophylactically anticipate side effects Keep simple Seek advice Supervise REVIEW!!! REVIEW!!!

8 What are the challenges to symptom control/end of life care in your setting? Work In pairs

9 Palliative care interventions are a constant seeking of balance BURDEN BENEFIT

10 Legal issues in palliative care Doctrine of double effect - intention of benefit versus harm Evidence based practice versus best established practice - variations in practice - lack of research/inability to perform trials - lack of legal precedents

11 Did you know? 25% of all prescriptions used in palliative care are for licensed drugs used for unlicensed indication or given by unlicensed route

12 Palliative care prescribing Patient/family beliefs Expectations (Unrealistic. Grandad s batteries ) Fear of certain drugs (morphine, diamorphine, methadone) Fear of certain routes (subcutaneous syringe ) Keep simple risks of polypharmacy Palliation not cure Patient agenda v family agenda to cure versus palliate consent issues

13 Palliative care prescribing considerations Absorption Route Distribution Decreased plasma proteins ie liver damage due to metastases Decreased perfusion Changes in body mass and body fat Metabolism Decreased liver mass Decreased hepatic blood flow i.e. obstruction Chronic liver failure cirrhosis Decreased liver enzyme function Excretion Chronic renal failure Cardiac factors Decreased renal blood flow Weight loss

14 PAIN CONTROL

15 Misconceptions re. pain management Non drug treatments don t work Morphine is always the best drug Injections are stronger The patient must look in pain Morphine is addictive if taken for pain Morphine means the end is near

16 SQITARS Site Quality Intensity Timing Aggravating factors Relieving factors Secondary pain

17 Influences on pain Psychological Physical Spiritual Social

18 Spiritual factors influencing symptom control Perception of need for answers why is this happening? Feelings of pointlessness loss of hope Meaning of pain Regret/Self recrimination am I being punished? Doubt Spiritual isolation no-one understands Religious issues

19 Psychosocial influences on pain Anger Disfigurement Fear never assume cause Perceived helplessness Previous experiences of death, illness, pain Personality factors/ coping strategies Anxiety/ depression

20 Physical factors influencing pain Disease progression tumour invasion bone pain nerve compression nerve destruction muscle spasm colic ischaemic pain

21 Other physical factors influencing pain Other symptoms e.g. insomnia, depression, anxiety constipation etc Adverse effects of treatments Positional factors Incidental pain pain on movement, defaecation etc Other causes of exacerbations e.g. infection

22 Factors to increase pain threshold Companionship Other symptoms controlled Normality Treatments (understanding) Rest/sleep Other distractions Listening empathy/lessened anxiety CONTROL

23 Drug management of pain Step Ladder

24 Analgesic step ladder Non-opioid +/- adjuvant Weak opioid +/- adjuvant Strong opioid +/- adjuvant

25 Which opioid and why? How many do you know? Why were they used/chosen? Which ones would you not use/avoid in palliative care/ EOL care? Which one(s) is/are the drug of choice in known/end stage renal failure? (GFR <30ml/mim) What precautions do you need to take in renal failure? Can more than one opioid be used simultaneously? What are the common side effects of opioids?

26 Ready for some pharmacology?

27 Opioid receptors, ligands (agonists) & effects Receptors Mu (u) Delta (d) Kappa (k) ORL-1 Endogenous opioid Exogenous agonist Antagonist Effects B-endorphin Endomorphins Morphine (DM) Buprenorphine Fentanils Oxycodone Methadone Tapentadol Naloxone Naltrexone Analgesia Euphoria Confusion Sedation Nausea Constipation Resp dep Miosis Enkephalins Dynorphins Nociceptin Morphine (DM) Methadone Fentanils Buprenorphine Naloxone Similar to u but less marked Morphine (DM) Oxycodone Buprenorphine Naloxone Analgesia Aversion Diuresis Buprenorphine Mixed analgesia (spinal) and anti-opioid (brain)

28 Which opioid? Factors influencing choice Physician knowledge/confidence Availability of drug Patient preference Patient compliance Other patient-related factors e.g renal failure nausea & vomiting/bowel obstruction dysphagia

29 Morphine Acts within 30 minutes. Lasts around 4 hours Available as tablets, liquid, slow release oral forms, injection and suppository Starting dose in opioid naive patients 2.5-5mg every four hours of a non slow release formulation(less in elderly or frail). No maximum dose Oramorph 10mg/5ml not classed as CD! Drowsiness should decrease Breakthrough doses are vital and must be enough! Convert to slow release product when patient stabilised; still need breakthrough doses.

30 Side effects Nausea Constipation Sedation Myoclonus Hyperexcitability Respiratory depression

31 Morphine - side effect management Try to prevent Treat the side effect. - antiemetic, laxative Use alternative opioid Use non opioid May need antiemetic especially at first

32 MORPHINE Morphine - first line opiod Oral route where possible Regular administration by the clock + prn only prn means pain relief nil! Haloperidol prophylactic anti-emetic 5 days Injections do not increase effect - unless there is absorption /swallowing problem No addiction if has pain no ceiling dose Early use

33 Diamorphine Di-acetylmorphine, heroin Converted to morphine in body Much more soluble than morphine hence main use in syringe drivers More lipid soluble hence more potency than morphine by the injectable route

34 Oxycodone Can be useful as alternative in patients who HAVE developed side effects to morphine Studies give conflicting information Very expensive compared to morphine Subject to prescribing errors, mainly due to differing names and conversion factors Oxycontin, Oxynorm! Longtec, Shortec! Oxycodone orally up to twice as potent as morphine orally Oxycodone subcutaneously twice as potent as oxycodone orally May be of use in renal failure (?)

35 Opioids and renal impairment (egfr <30) Morphine - active metabolites excreted by the kidneys with increase in plasma ½ life leading to accumulation/toxicity. Not suitable in poor renal function Diamorphine - as for morphine Alfentanil - metabolised by the liver to inactive metabolites, excreted in urine. Drug of choice in poor renal function Fentanyl - as for alfentanil Buprenorphine - active metabolite excreted by kidneys but does not accumulate in renal failure Oxycodone - as for morphine

36 So, what about patches? What analgesic patches are available? When would you consider using/prescribing one? Which one would you consider? What are the advantages? What are the disadvantages? Good or bad thing at end of life? (in pairs)

37 Clinical indications for patches Difficulty or pain on swallowing Persistent nausea and/or vomiting Gastrointestinal obstruction Poor compliance with oral meds Tablet/morphine phobia Unacceptable morphine side-effects

38 Fentanyl v Buprenorphine Fentanyl Onset of action : 3-23 hours Time to peak plasma levels: hours Onset of action (Butrans): hrs 3 days! 60 hours! Onset of action (Transtec) : hrs Plasma ½ life: hours hours hours Duration of action: 72hours 7 days 4 days Patch strength: 12, 25, 37.5, 50, 75, 100mcg Morphine comparison (oral) in mg 30,60,90,120,180,240mgs/24hrs Buprenorphine 5, 10, 20mcg 35, 52.5, 70mcg 12, 24, 48mgs/24 hrs 84, 126, 168mgs/24hrs

39 4 HRS 24HRS MORPHINE (O) 10mg 60mg =30mg bd Oxycodone (O) 5mg 30mg = 15mg b.d. Buprenorphine patch Butrans 10+20mcg Fentanyl patch 25mcg every 72 hrs Morphine SC 5mg 30mg Oxycodone SC 2.5mg 15mg Diamorphine SC 2.5-5mg 20mg In all conversions there is uncertainty. Err on the side of caution

40 Adjuvant analgesics Tricyclic antidepressants: e.g. amitriptyline for nerve pain Anticonvulsants: e.g. gabapentin/pregabalin for nerve pain Steroids: e.g. dexamethasone for nerve root compression/raised ICP Bisphosphonates: e.g. pamidronate for Ca related bone pain Antispasmodics: e.g. buscopan for smooth muscle spasm Benzodiazepines: e.g diazepam for skeletal muscle spasm/cramps Antibiotics

41 Other treatments for control of pain TENS Surgery Chemotherapy Radiotherapy Diversion/meditation/imagery Massage/acupuncture/complementary therapy Nerve blocks/epidurals Topical analgesia

42 What about other symptoms?

43 Nausea Not necessarily the same as vomiting!!

44 Causes of nausea Anxiety Cerebral metastases Gastritis Constipation Biochemical disturbances hypercalcaemia, uraemia, hyponatraemia Obstruction Lessened gut mobility Treatments/drugs Infection

45 Drugs that may cause nausea Opioids often transient Antibiotics Antidepressants Radiotherapy/chemotherapy Anaesthetics NSAIDs Iron Steroids Digoxin Aminophylline Alcohol

46 Pathophysiology Chemical neurotransmiters conduct neural impulses connected to N/V Active in both gut and brain Stimulation of vomiting centre (VC) in brain stem triggers vomiting reflex VC receives input from gut (via vagus nerve), CTZ, Vestibular nuclei, and cerebral cortex Receptor sites involved: Serotonin/5HT (1,2,3,4 subtypes), Histamine/H1, Dopamine/D2, Acetylecholine/Achm, Neurokinin/NK1, Gamma-amniobutyric acid/gaba

47 Body area/receptor sites/agonists involved in vomiting pathway Gut Wall 5HT3, 5HT4, D2 Gastric irritants Abdo DXT Intestinal distension Chemo CTZ 5HT3,NK1,D 2 Morphine/ Digoxin Raised calcium Cerebral Cortex NK1,GABA,5 HT Vestibular nuclei AChm, H1 Fear/Anxiety Movement All Low sodium Vertigo of Antibiotics Raised ICP these Chemo Alcohol Vomiting centre Achm,H1,uopioid,5HT2, NK1 Feed into Uraemia Uraemia V Centre

48 Which antiemetic and why? Drug Receptor site affinity Main sites of action Domperidone D2 in gut Gut only, prokinetic. Metoclopramide D2 in gut and CTZ, 5HT4 in upper gut Central and prokinetic. Haloperidol Potent D2 in CTZ Central not prokinetic Cyclizine H1 and AChm Vestibular system and VC Granisetron, ondansetron Potent 5HT3 Central and gut Levomepromazine 5HT2, D2, AChm, H1 Central broad spectrum Hyoscine hydrobromide AChm Vestibular system and VC

49 Treatment of nausea Treat cause ie. Hypercalcaemia, pain, constipation Treat with antiemetic according to considered mechanism of nausea Combination therapy needed in 1/3 of patients Consider 2 birds with 1 stone i.e. treat insomnia and nausea use side effects to patient s advantage Anticipate and explain side effects

50 Non-pharmacological methods Reversible cause Sea bands/acupuncture Ginger NG tube (but consider carefully the implications? other options) Stents Radiotherapy MDT support e.g. OT for fatigue, SOB Relaxation/hypnotherapy Diversion Accupuncture

51 Restlessness and Agitation Recognise - change in behaviour reduced awareness increased purposeless movement fluctuating disorientation, confusion hallucinations, paranoid ideas mental distress

52 Restlessness and agitation - causes Physical Pain Full bladder Full rectum Breathless Cerebral metastases/dementia Mental anguish Fear Unfinished business Biochemical Liver or renal failure Raised calcium High/low glucose Hypoxia

53 Restlessness and agitation - management Treat the cause Treat the symptom Midazolam Haloperidol Levomepromazine General measures Nursing the patient - reassure, environment, safety Relatives - explanation

54 Respiratory secretions Inability to cough up/swallow secretions Recognise early at risk lung primary and secondary tumours head and neck tumours COPD pneumonia

55 Respiratory secretions - management Explanation and reassurance Nursing measures Position mouth care?suction Drugs Buscopan/Hyoscine Butylbromide Scopolamine/Hyoscine Hydrobromide Glycopyrolate

56 Breathlessness Affects 70% cancer patients in last 6 weeks of life and increases as death approaches More likely with Primary or secondary lung cancer Pleural disease Pre existing cardiopulmonary disease Terminal breathlessness - not reversible

57 Breathlessness: Management General measures Fan, open windows Mouth care Energy conservation Company/call button MDT approach (Physio/OT) Address fears, reassure

58 Breathlessness - management Drugs oxygen opiates: 4 hourly Oramorph, Diamorphine (Syringe pump) Benzodiazepines: Diazepam, Midazolam prn/sp

59 When do we need syringe pumps in palliative care?

60 Syringe pumps in palliative care.why? poor absorption nausea/ vomiting dysphagia confusion confidence concordance If none of above, symptom control may not improve with scsp consider reassessment/ management

61 Common drugs for subcutaneous syringe pumps?

62 Common SCSP drugs Diamorphine Haloperidol Metoclopramide Cyclizine Levomepromazine Hyoscine hydrobromide Buscopan Midazolam Octreotide

63 Sites. scapula abdomen chest arm leg

64 Site considerations ascites cachexia lymphoedema confusion concordance tumour site body image

65 What if site becomes inflamed?

66 What if site becomes inflamed seek advice increase diluent alternative drugs alternative routes Dexamethasone

67 Monitoring the syringe pump What to look for

68 Monitoring the SCSP light flashing crystallisation assess if infusing at correct rate assess time remaining check site document ASSESS SYMPTOM CONTROL

69 Key points to remember consider consent of patient/family takes up to 4 hours to be therapeutic - give loading dose ensure prn meds written for likely symptoms refer to guidelines seek advice

70 Common mistakes in symptom management Failure to distinguish between causes of symptom cancer and non-cancer Lack of attention to holistic issues/failure to use non-drug treatments Failure to assess each mechanismn individually and plan treatments separately Failure to anticipate, monitor and control unwanted side effects Failure to listen to patient and their agenda - terminology Chopping and changing regimens too quickly Reluctance to use morphine/awareness that pain may not be non-opiate responsive Fear of combining appropriate drugs/combining drugs inappropriately

71 What if symptom persists? Have basic principles of symptom control been followed Is diagnosis of mechanism correct Has new symptom developed Are there other factors exacerbating symptom Is patient concordant SEEK ADVICE

72 Summary of symptom control remember non cancer causes of symptoms assess each mechanism of the symptom separately and treat remember combination therapy may be needed remember non pharmacological methods encourage informed decisions monitor for efficacy versus side effects communicate with other members of MDT communicate with patient and family

73 MDT working seamless prescribing too many cooks! who is the key worker? availability of certain drugs out of hours access to palliative care Dynamic nature of progressive disease requires dynamic prescribing

South & West Devon Formulary Chapter 16 https://southwest.devonformularyguidance.nhs.

74 South & West Devon Formulary Chapter 16 This is also available in an app for phones and ipads

75 Our ambition is for everyone across Torbay and South Devon to view this short film. The purpose of the video is to discover people's comfort in talking about death and dying. Talking about dying may not be easy, but could be one of the most important conversations you will ever have. Click on the picture to watch the 6 minute film

Renal Palliative Care Last Days of Life

Renal Palliative Care Last Days of Life Introduction This guideline is an aid to clinical decision-making and good practice for patients with stage 4-5 chronic kidney disease (egfr