Palliative care of Head and neck Oncology patients

Magdy Amin Riad

Professor of Otolaryngology . Ain Shams University

Senior Lecturer in Otolaryngology. University of Dundee

Symptom management

• Breaking difficult news.

• Pain control.

• Hydration and feeding.

• Nausea and vomiting.

• Confusion , withdrawal , anxiety or anger.

• Unexpected deterioration.

Breaking difficult news

• SettingCorridors are not appropriateTime and placeprivacy• UnderstandingLanguageHearingAnxiety

Breaking difficult news

• What do they knowMost people have already guessed the seriousness

Denial

• Knowing moreCheck before volunteering

Breaking difficult news

• Warn – pause – check

We found something abnormal

Pause to see response

Check if patient want to know more

Repeat with every statement

Breaking difficult news

• More help

Difficult questions have to be answered immediately

Acknowledge the importance of the question

Check why the question is being asked

Being honest about uncertainty is acceptable

Diagnosing pain

• At rest.

• Related to movement.

• Persisting pain

Pain at rest

• On inspiration?

Exclude pleurisy

= NSAID

Intercostal block for pain localised to 1-3 dermatomes

Exclude rib metastases

=Consider radiotherapy

Nerve block , .

Pain at rest

• Periodic?

Exclude colic from bowel , bladder or ureter.

=Buscopan 10-20 mg SC

+/- NSAID (diclofenac ) 75 mg IM or

100 mg PR

Pain at rest

• Related to eating?

Exclude dental ,pharyngeal or peptic diseases.

Dental

= appropriate dental care.

Oropharyngeal ulcers

=Difflam or antiseptic mouthwash

Peptic

= ranitidine or omeprazole

Pain at rest

• Localised to dermatome ?Exclude nerve compression .

= opioid

Exclude skeletal instability (e.g. vertebral collapse)

= immobilise

Exclude bone metastases

= dexamethasone 8 mg /day + opioid

Pain related to movement

• Active movement only?

Muscle strain or spasm

= inject trigger point with 3-5ml bupivacaine

Pain related to movement

• Slightest passive movement?

Exclude a fracture

=immobilise

Pain related to movement

• By bone strain or pressure?

Exclude bone metastases

= dexamethasone 8 mg/ daily or nerve block

Persisting pain

• Analgesic inappropriate.

• Analgesic incorrectly administered.

• Poor compliance.

• Depression.

• Unresolved fear or anger.

Pain Scales

• Number ScaleDescribe your pain using a number from 0 to 10:0= No Pain and 10= The worst pain you've ever had.

• Word ScaleDescribe the pain using the words that best tell us how much you hurt:No pain; Mild; Moderate; Severe; Very severe; or Worst possible pain.

• Faces ScalePlace an X or point to the face that shows how much you hurt

Some pain medications commonly used include:

• Acetaminophen - Commonly known by its brand name, Tylenol. It takes care of mild to moderate pain. It usually has very few side effects.

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Aspirin and ibuprofen (Motrin), are some NSAIDs you may know. They are commonly used to reduce or prevent swelling. Some NSAIDs are available only by prescription. Others can be purchased over the counter. NSAIDs may not be the best choice for everyone because of some of their side effects.

• Narcotic Analgesics - Also called opiates. These include morphine, hydromorphone, meperidine, codeine, and oxycodone. Some narcotics are commonly combined with acetaminophen. These include Tylenol #3, Percocet, and Lortab. Narcotics are available only by prescription. Side effects may include drowsiness, stomach upset, nausea, itching, and constipation. Stool softeners or laxatives may be given if narcotics are used for more than a few days. Don't drink alcoholic beverages while taking narcotics.

How are pain medications given?

• Pain medications are given several ways. They may be given by mouth, or through the nose or rectum. Some may be given by injection or infusion. In some cases., Patient Controlled Analgesia (PCA) may be used. With the use of PCA, you control a pump that gives you a small dose of medication every 10-15 minutes. When pain medications are given by epidural route, medication is given through a very small tube into the spinal column. Finally, pain relief may be provided by administering local anesthetics through a very small tube next to a nerve bundle, into a joint or directly into the surgical incision

Pain killers in advanced disease

WHO analgesic staircase

• Paracitamol

• Codeine or dihydrocodiene

• Oral morphine Start by 10mg/day up to 600 mg /day ,median 120mg

• Titrate opioids.50% increase every third day.

Hydration and feeding

• Anxiety and depression.

• Swallowing problems.

• Orientation , confusion.

• Constipation.

• Nausea and vomiting

• Drugs causing nausea , gastric stasis

Hydration and feeding

• IV Infusions

1-3 litres day , for few days

• Nasogastric tubes.

1-3 weeks

• PEG tubes.

Long term feeding

Nausea and vomiting

• Regurgitation.Inappropriate tube feedingPharyng-oesphageal obstruction

• Delayed gastric emptying.Metoclopramide10-20 mg /8 hours

• Raised intracranial pressure. Cyclizine 50 mg/8hours

Nausea and vomiting

• Chemical causes.

Hypercalcaemia

Morphine

• Bowel obstruction.

Treat obstruction if possible

If inoperable start cyclizine 150 mg/day SC infusion

Agitation

• Do not leave patient unattended.

• Ensure environment is safe.

• Do not use opioids to treat agitation.

• Hypoxia should be excluded .100% Oxygen via facemask

• Midazolam 2-10 mg IV or 5mg IM until settled

Confusion

• Memory failureDementiaCerebral tumour

• Change in alertness.DrugsHypercalcaemiaCardiacPulmonarySubdural

Confusion

Hallucinations.

Altered behaviour

The withdrawn patient

• Usual behaviour

• Refusing help

• Confusion

• Fears ,guilt or shame.

• Clinical depression.

• Organic cause

The withdrawn patient

• Usual behaviourOffer tome to establish trust

• Refusing helpTheir rightAcknowledge refusal and offer help in future

• Confusion

The withdrawn patient

• Fears ,guilt or shame.

• Clinical depression.

Persistent low mood for>4weeks , for>50% of time

4 other depressive symptoms (early morning rise, diurnal variation, hopelessness..)

Lofepramine 70 mg at night up to 140 mg

The withdrawn patient

• Organic cause

Parkinson’s

Severe fatigue

Drugs causing Parkinson’s like symptoms

The angry patient

• Appropriateness of anger.

• Escalating anger.

• Depression

• Persisting anger.

The angry patient

• Appropriateness of anger.

Explore cause

Show understanding without being defensive

Apologise if it is your fault

Do not apologise for others

The angry patient

• Escalating anger

If anger is not defusing or worsening :Position yourself near exit doorSet limitsIf patient cannot accept limits =pathological angerStop interview and leave immediately

The angry patient

• Depression

Anger can be a feature

• Persisting anger.

Consider specialist help

Unexpected deterioration

• Drugs are the cause.

• Uncertainty about treatment.

• Comfort only.

Unexpected deterioration

• Drugs are the cause.

Check medicationsCheck any recent additionsReduce dose

Unexpected deterioration

• Uncertainty about treatment.

Review plans

Hour by hour deterioration review every 3 hours

Day by day deterioration review every 3 days

Further deterioration consider treatment for comfort only

Unexpected deterioration

Comfort onlyRapid deteriorationIrreversible causeVery short prognosisPatient refusing treatment

Sedation if agitatedAnalgesia if in painSupport patient and family +/-staff

End-of-life Care Just as Important as Cures

• Being able to have a peaceful death with dignity can be among the positive milestones in the cycle of life

• Studies show that up to 88 percent of people in our country want to die at home surrounded by their loved ones. Yet the reality is that only about one in four people have a peaceful death at home or in a hospice setting