Pall Care Scenarios Dr Alison Giles Palliative Medicine

Pall Care Scenarios Dr Alison Giles Palliative Medicine Consultant

Ø Rose, 65 year old lady has breast cancer with bone metastases. She has developed mild rib pain for the past two weeks. She attends her GP. She currently takes no medication. Ø What would you recommend?

Rose… Ø She is started on Paracetamol 1 g QDS and occasional Ibuprofen 400 mg PRN with good benefit. She also starts Omeprazole 20 mg OD Ø However, two months later she returns saying that the pain is a bit worse. Ø What would you recommend?

Rose… Ø Starts taking morphine liquid. She takes Ordine 2. 5 mg every 4 hours. She should continue to take the paracetamol and ibuprofen PRN. Ø She asks you about the side effects of morphine and is worried that she will become an “addict”

Opiate side effects Ø Common l Constipation l Nausea l Drowsiness l Dry mouth l Dose Related: Respiratory depression Ø Rare l Itching l Sweating l Myoclonic jerks l Hypotension

Common concerns about opiates Ø “Addiction” l l common concern, especially among the older age group No evidence that this is a problem in the palliative care setting Ø “I must be dying” l Previous experiences of loved ones

Rose Ø Rose returns 3 days later, she has been taking Ordine 5 mg 4 hrly and the pain is much better. However, she is finding it inconvenient taking the morphine every 4 hours. Ø Thoughts?

Other opiates to consider… Ø Buprenorphine l Transdermal (Norspan) Ø Oxycontin Ø Fentanyl l Ø Available in transdermal patches Change every three days Ok for patients in renal failure Hydromorphone

Rose… Ø She comes back three months later complaining of pain in a particular spot in her ribs. Her morphine has been increased to MST 50 mg BD. Ø The GP telephones the oncologist who suggests radiotherapy may be helpful. Ø She receives a single fraction to the painful spot and two weeks later the pain is improved.

Rose Ø Six months later Rose is much less well. She has lost weight and is very weak. She is admitted to the hospice for terminal care. Rose is no longer able to take the painkillers orally as she is too weak. Ø How else can we administer the medications?

Another example 82 year old man with metastatic prostate cancer. He has bone metastases and has had radiotherapy treatment to a painful hip. He has monthly bisphonate infusions for his bone pain. Ø He is currently taking Paracetamol 1 g QDS and Tramadol 50 mg TDS. He is still complaining of pain in his hip. Ø What is the next step?

Ø Started on MS Contin 15 mg BD. Ø Dose gradually titrated up to MS Contin 40 mg BD with good effect Ø He has issues with ongoing constipation Ø What are the options?

Ø He swaps to Fentanyl 25 mcg/hr patch which he changes every three days Ø His pain is well controlled. Ø However three months later he calls out his GP. He tells him he has now put two patches on because he has terrible lower back pain. He has fallen twice in the last couple of days.

Malignant spinal cord compression…

Mr S… Ø 64 yr man Ø Squamous cell lung cancer – stage 3 Ø Treated with chemo and radiotherapy l Good response Ø 5 months after chemo completed presents with confusion Ø Differential diagnoses…