Palliative Care

INTRODUCTION

The fundamental principles of palliative care are:

• optimal quality of care

• good communication, incl. information giving

• management planning incl. advanced planning

• symptom control

• emotional, social and spiritual support

• medical counselling and education

• patient involvement in decision making

• support for carers

• support for staff

Common symptoms

• Boredom

• Loneliness/isolation

• Fear

• Anorexia

• Nausea and vomiting

• Constipation

• Pain:

  • – physical

  • – emotional

  • – spiritual

  • – social

PAIN CONTROL

Step 1: Mild pain Start with basic non-opioid analgesics:

• aspirin 600–900 mg (o) 4 hrly (preferred) or other NSAID or

• paracetamol 1 g (o) 4 hrly or 1.33 g (o) 6–8 hrly (plus or minus NSAID)

Step 2: Moderate pain Use low-dose or weak opioids or in combination with non-opioid analgesics (consider NSAIDs) and add:

• morphine 5–10 mg (o) 4 hrly (dose acc. to age); next dose should be ↑ 0–50% up to 15–20 mg or

• oxycodone up to 10 mg (o) 4 hrly or CR 10 mg 12 hrly or 30 mg, rectally, 8 hrly or tapentadol 50–100 mg every 4–6 hours or SR 50 mg (o) bd, up to 500 mg/day (refer to Table P1)

Step 3: Severe pain Maintain non-opioid analgesics. Larger doses of opioids should be used and morphine is the drug of choice:

• morphine 10–15 mg (o) 4 hrly, ↑ 30 mg if nec. or

• morphine CR/SR tabs or capsules (o) 12 hrly or once daily

Note:

• The proper dosage is that which is sufficient to alleviate pain.

• Give usual morphine 10 mg with first dose of morphine SR and then as nec. for ‘rescue dosing’.

Guidelines for morphine Ensure that pain is likely to be opioid sensitive.

• If analgesia is inadequate, the next dose should be increased by 50% until pain control is achieved

• Give it regularly, usually 4 hrly, before the return of the pain

• Give it orally if possible (avoid IM morphine)

• Many patients find a mixture easier to swallow than tablets (e.g. 10 mg/10 mL solution)

• Give laxatives prophylactically (see below)

• Order anti-emetics (e.g. haloperidol prn) at first

• Reassure the patient and family about the safety and efficacy of morphine (opiophobia is often a problem)

• If parenteral morphine needed, give subcutaneously

Opioid rotation is useful since different opioids have differences in ...