2. What
is
Pallia%ve
Care?
— Medical
care
that
focuses
on
allevia%ng
the
intensity
of
symptoms
of
disease.
— Pallia%ve
care
focuses
on
reducing
the
prominence
and
severity
of
symptoms.
3. W
H
O
describes
pallia%ve
care
as
"an
approach
that
improves
the
quality
of
life
of
pa%ents
and
their
families
facing
the
problems
associated
with
life-‐threatening
illness,
through
the
preven%on
and
relief
of
suffering
by
means
of
early
iden%fica%on
and
impeccable
assessment
and
treatment
of
pain
and
other
problems,
physical,
psychosocial
and
spiritual."
4. Goal
of
Pallia%ve
Care?
— The
goal
is
to
improve
the
quality
of
life
for
individuals
who
are
suffering
from
severe
diseases.
— Pallia%ve
care
offers
a
diverse
array
of
assistance
and
care
to
the
pa%ent.
5. Pallia%ve
Care
• Minimizing
Suffering
(Total
Pain)
• Physical
• Social
• Psychological
• Spiritual
• Improving
Quality
of
Life
• Maintaining
dignity
and
respect
• Caring
for
family
6. • not
disease-‐specific
•
not
restricted
to
a
defined
number
of
months
or
weeks
of
life
• centered
on
quality
rather
than
quan*ty
of
life.
7. • Mme
Jeanne
Garnier
Lyons,
France
1842
• Irish
Sisters
of
Charity,
Dublin,
Ireland
1879
• St
Joseph’s,
London
1909
• Royal
Marsden
Hospital
19
beds
in
1909
• St
Christopher's
Hospice
1967
• WHO
Cancer
Pain
and
Pallia%ve
Care
Program
ini%ated
1982
• European
Associa%on
for
pallia%ve
care
1988
• Hospice
Movement
in
North
America:
AAHPC
founded
1992
• La%n
American
Pallia%ve
Care
Associa%on
founded
2000
• Asian
Pacific
Hospice
Pallia%ve
care
Network
founded
2001
History of Palliative Care
Dame
Cicely
Saunders
The
founder
of
modern
PC
8. Who
receives
Pallia%ve
Care?
— Individuals
struggling
with
various
diseases
— Individuals
with
chronic
diseases
such
as
cancer,
cardiac
disease,
kidney
failure,
Alzheimer's,
HIV/AIDS
and
Amyotrophic
Lateral
Sclerosis
(ALS)
9. Who
Provides
Pallia%ve
Care?
— Usually
provided
by
a
team
of
individuals
— Interdisciplinary
group
of
professionals
— Team
includes
experts
in
mul%ple
fields:
— Doctors
— Nurses
— social
workers
— massage
therapists
— Pharmacists
— Nutri%onists
11. Pallia%ve
procedures
• radiotherapy
• chemotherapy
• Surgical
• Debulking
• the
inser%on
of
stents,
• the
drainage
of
effusions
• the
stabiliza%on
of
bones
12. What
pallia%ve
care
is
not
•
Care
of
the
Elderly
(Geriatrics)
•
General
prac%ce
(Family
Medicine)
•
Care
of
the
Chronically
Ill
•
Care
of
Cancer
(Oncology)
•
Care
of
the
Incurable
•
Pain
Relief
Service
13. Physical
Functional Ability
Strength/Fatigue
Sleep & Rest
Nausea
Appetite
Constipation
Pain
Psychological
Anxiety
Depression
Enjoyment/Leisure
Pain Distress
Happiness
Fear
Cognition/Attention
Social
Financial
Burden
Caregiver
Burden
Roles
&
Rela5onships
Affec5on/Sexual
Func5on
Appearance
Spiritual
Hope
Suffering
Meaning of Pain
Religiosity
Transcendence
Adapted
from
Ferrell,
et
al.
1991
Quality
of
Life
15. Pallia%ve
Care
and
Cancer
§ "Everyone
has
a
right
to
be
treated,
and
die,
with
dignity.
The
relief
of
pain
-‐
physical,
emo%onal,
spiritual
and
social
-‐
is
a
human
right,"
said
Dr
Catherine
Le
Galès-‐Camus,
WHO
Assistant
Director-‐
General
for
Noncommunicable
Diseases
and
Mental
Health.
"Pallia%ve
care
is
an
urgent
need
worldwide
for
people
living
with
advanced
stages
of
cancer,
par%cularly
in
developing
countries,
where
a
high
propor%on
of
people
with
cancer
are
diagnosed
when
treatment
is
no
longer
effec%ve."
16. “Cancer
Control:
Knowledge
Into
Ac%on”
— Excerpts
from
the
WHO
guide
for
Pallia%ve
Care:
“Pallia%ve
care
is
an
urgent
humanitarian
need
worldwide
for
people
with
cancer
and
other
chronic
fatal
diseases.
Pallia%ve
care
is
par%cularly
needed
in
places
where
a
high
propor%on
of
pa%ents
present
in
advanced
stages
and
there
is
lijle
chance
of
cure.”
17.
More
than
50
million
people
die
every
year
around
the
world
around
20%
due
to
cancer.
v
Based
on
WHO
projec%ons,
cancer
deaths
will
con%nue
to
rise
with
an
es%mated
9
million
people
dying
from
cancer
in
2015,
and
11.4
million
dying
in
2030.
v
80
per
cent
of
these
deaths
will
occur
in
developing
world.
v
Two
thirds
of
the
world's
people
living
with
cancer
live
in
developing
countries
with
barely
any
access
to
pain
and
symptom
management,
let
alone
cura%ve
treatment
v
Many
of
these
people
will
endure
intense
and
unnecessary
suffering
and
pain
18. Pallia%ve
Care
and
Cancer
Care
• Pallia5ve
care
is
given
throughout
a
pa5ent’s
experience
with
cancer.
• Care
can
begin
at
diagnosis
and
con5nue
through
treatment,
follow-‐up
care,
and
the
end
of
life.
19. SYMPTOMS
IN
ADVANCED
CANCER
0 10 20 30 40 50 60 70 80 90
Asthenia
Anorexia
Pain
Nausea
Constipation
Sedation/Confusion
Dyspnea % Patients (n=275)
Ref: Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering
20. Symptom Ca HD COPD RD
Pain 96 77 77 50
Depression 77 36 71 60
Fatigue 90 82 80 87
Dyspnea 70 88 95 62
Delirium 93 32 33 --
Anorexia 92 41 67 64
Prevalence
of
symptoms
towards
the
end-‐of-‐life
(Solano
et
al
2006)
21. § Pts (all stages) 53%
(CI 43-63%)
§ Pts (advanced) 64%
(CI 58-69%)
Cancer Pain is Common
23. Pain
Assessment
One
of
the
major
defect
in
pain
management
is
an
inadequate
pain
assessment
and
deficient
documenta%on
by
physicians
and
nursing
staff
24. Cancer
pain
Prevalence
of
a
significant
pain
§
30%
in
newly
diagnosed
cancer
§
50%
to
70%
among
pa%ents
receiving
ac%ve
an%cancer
therapy
§
65%
to
80%
in
advanced
disease
25. § History
§ Pain
or
no
pain
§ Type
of
pain,
acute,
chronic,
nocicep%ve,
neuropathic
§ Loca%on
and
Radia%on
§ Severity,
intensity
§ Timing
§ Exacerba%ng
and
Relieving
§ Effects
on
Ac%vity
§ Previous
Therapy
§ Meaning
of
pain
§ Physical
examina%on
§ Related
inves%ga%on
Assessment
of
Pain
26. Pain:
The
Fiqh
Vital
Sign
Pain
Standards
of
the
Joint
Commission
on
Accredita%on
of
Healthcare
Organiza%on
•
Recommenda%on
make
the
pain
measurement
a
priority
in
daily
prac%ce
•
Consider
pain
intensity
the
fiqh
vital
sign
along
with
temperature,
respira%on,
and
BP
JCAHO:
1999
-‐
2000
27. Pain
ra%ng
(Intensity)
scales:
Categorical scale
Numeric rating scale
0
No pain
1
Mild
2
moderate
3
severe
4
Very severe
5
Excruciating
0 2 4 6 8 101 3 5 7 9
( 0 = No pain, 10 = Worst pain imaginable )
28. What
Can
be
Done
to
Relieve
Pain
?
The
WHO
has
demonstrated
that
most
(
around
75
-‐
85%)
of
cancer
pain
can
be
relieved
If
we
implement
an
available
pharmacologic
approach
That
is
Inexpensive
&
yet
a
prac*cal
one
33. Problems
with
cancer
of
the
vulva
§ Lower
limb
oedema
§ Funga%ng
wounds
with
odour,
§ pain
and
bleeding
§ Haemorrhage
34. § Neuropathic
pain
from
sacral
plexus
involvement
§ Renal
failure
from
hydronephrosis
§ Peripheral
neuropathy
from
chemotherapy
§ Vaginal
bleeding
or
discharge
§ Pelvic
or
back
pain
§ Urinary
or
bowel
fistulas
§ Lower
extremity
edema
§ Deep
venous
thrombosis
(DVT)
§ Dyspnea
from
anemia
or
pulmonary
involvement
§ Anxiety
and
depression
§ Nausea
and
vomi%ng
§ Diarrhea
Problems
with
cervical
cancer
35. • Pain
from
local
disease
• Ascites
• Painful
bone
metastases
• Pulmonary
metastases
• Bone
metastases
• Hypercalcemia
• Hepa%c
metastases
• Brain
metastases
Problems
with
in
cancer
of
the
uterus
36. Problems
with
in
ovary
cancer
§ Pain
from
pelvic
and
abdominal
disease
§ Ascites
§ Bowel
obstruc%on
§ Peripheral
neuropathy
from
chemotherapy
§ Anorexia
§ Cons%pa%on
§ Fa%gue
and
dyspnea
37. Common
issues
for
women
with
advanced
gynaecological
malignancy
§ Body
image
§ Sexuality
§ S%gma
§ Loss
of
role
and
leaving
children
39. Ra%o
of
full-‐%me
pallia%ve
care
physicians
to
popula%on
C o u n t r y
N u m b e r o f
full time PC
p h y s i c i a n s
R a t i o o f P C
P h y s i c i a n s t o
p o p u l a t i o n
S w e d e n 3 0 0 1 : 3 0 , 1 4 7
I t a l y 1 0 0 0 1 : 5 8 , 6 0 9
U K 4 4 2 1 : 1 3 5 , 4 9 6
F r a n c e 3 6 1 1 : 1 6 7 , 9 2 2
Saudi Arabia 2 0 1 : 1 , 4 0 0 , 0 0 0
40. Ra%o
of
dedicated
pallia%ve
care
beds
to
popula%on
(in
million)
C o u n t r y
Number of dedicated
b e d s
R a t i o o f
d e d i c a t e d
b e d s
S w e d e n 6 5 0 7 2
U K 3 1 8 0 5 3
F r a n c e 1 6 1 5 2 7
I t a l y 1 0 9 5 1 9
Saudi Arabia 1 2 0 . 5
41. Barriers to cancer pain control
• Health professionals
• Patients
• Health system
42. Health professionals
§ Inadequate knowledge
§ Poor assessment of pain
§ Concerns related to:
§ Regulations
§ Side effects
§ Addiction
§ Tolerance
43. Patients
§ Reluctance in reporting
§ Belief that pain = disease progression
§ Fear of distracting Drs from treating Ca.
§ Fear of not being a “good” pt
§ Fear of:
§ Addiction
§ Side effects
§ Poor compliance
§ Religious concerns
45. Addiction!
§ 11,882 in-patients who received one
opioid drug or more
§ Four cases of addiction identified
Porter & Jick. NEJM. 1980
§ 550 pts on morphine for 22,525
treatment days
§ One case of addiction
Schug et al. JPSM.
1992
47. Few things a doctor does
are more important than
relieving pain
Marcia Angel. The Quality of Mercy. NEJM 1982
48. “You
maOer
because
you
are
you.
You
maOer
to
the
last
moment
of
your
life
and
we
will
do
all
we
can
not
only
to
help
you
die
peacefully
but
to
live
un*l
you
die”
Dame
Cecily
Saunders
