Palliative and Supportive care in Pancreatic Cancer Patients

Palliative and Supportive care in Pancreatic Cancer Patients

Present by: Dr. Abdolrahim HaziniHematologist, Oncologist, Palliative care Specialist

امروزه طب تسکینی در همه مراحل بیماریهایی مانند سرطان جایگاه خود را

پیدا کرده است:

Early Palliative Care

End of Life Care

طب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم - 1392عبدالرحیم حزینی - دیماه

The Continuum of Palliative Care


Early Palliative Care in Cancer PatientsArticles

Early palliative care for patients with advanced cancer: how to make it work?

Gaertner J, Weingärtner V, Wolf J, Voltz R.Early palliative care in advanced lung cancer: a

qualitative study.Yoong J, Park ER, Greer JA, Jackson VA,

Gallagher ER, Pirl WF, Back AL, Temel JS.


http://www.ncbi.nlm.nih.gov/pubmed?term=Gaertner%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Gaertner%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Weing%C3%A4rtner%20V%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Weing%C3%A4rtner%20V%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Wolf%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Voltz%20R%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Voltz%20R%5BAuthor%5D&cauthor=true&cauthor_uid=23736875

http://www.ncbi.nlm.nih.gov/pubmed?term=Yoong%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Yoong%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Park%20ER%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Greer%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Jackson%20VA%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Gallagher%20ER%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Pirl%20WF%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Pirl%20WF%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Back%20AL%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Temel%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

http://www.ncbi.nlm.nih.gov/pubmed?term=Temel%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=23358690

Early Palliative Care in Advanced Lung CancerA Qualitative Study Jaclyn Yoong, MBBS, FRACP; Elyse R. Park, PhD, MPH; Joseph A.

Greer, PhD; Vicki A. Jackson, MD, MPH; Emily R. Gallagher, RN; William F. Pirl, MD, MPH; Anthony L. Back, MD; Jennifer S. Temel, MD JAMA Intern Med. 2013;173(4):283-290. doi:10.1001/jamainternmed.2013.1874.

Conclusions Early PC clinic visits emphasize managing symptoms, strengthening coping, and cultivating illness understanding and prognostic awareness in a responsive and time-sensitive model. During critical clinical time points, PC and oncologic care visits have distinct features that suggest a key role for PC involvement and enable oncologists to focus on cancer treatment and managing medical complications.


ConclusionsAmong patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)


http://clinicaltrials.gov/show/NCT01038271

Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non–Small-Cell Lung Cancer

Joseph A. Greer⇓, William F. Pirl, Vicki A. Jackson, Alona Muzikansky, Inga T. Lennes, Rebecca S. Heist, Emily R. Gallagher and Jennifer S. Temel

Results The overall number of chemotherapy regimens did not differ significantly by study group. However, compared with those in the standard care group, participants receiving early palliative care had half the odds of receiving chemotherapy within 60 days of death (odds ratio, 0.47; 95% CI, 0.23 to 0.99; P = .05), a longer interval between the last dose of intravenous chemotherapy and death (median, 64.00 days [range, 3 to 406 days] v 40.50 days [range, 6 to 287 days]; P = .02), and higher enrollment in hospice care for longer than 1 week (60.0% [36 of 60 patients] v 33.3% [21 of 63 patients]; P = .004).


http://jco.ascopubs.org/search?author1=Joseph+A.+Greer&sortspec=date&submit=Submit

http://jco.ascopubs.org/content/early/2011/12/20/JCO.2011.35.7996.abstract

http://jco.ascopubs.org/search?author1=William+F.+Pirl&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=William+F.+Pirl&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Vicki+A.+Jackson&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Alona+Muzikansky&sortspec=date&submit=Submit



http://jco.ascopubs.org/search?author1=Inga+T.+Lennes&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Inga+T.+Lennes&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Rebecca+S.+Heist&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Emily+R.+Gallagher&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Jennifer+S.+Temel&sortspec=date&submit=Submit

http://jco.ascopubs.org/search?author1=Jennifer+S.+Temel&sortspec=date&submit=Submit

Palliative Care• Palliative care is specialized medical care for people with serious illnesses.

This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis.

مراقبت تسکینی مراقبت پزشکی تخصصی است برای افرادی با بیماریهای •جدی و وخیم. این نوع از مراقبت بر کاهش عالیم، درد، و استرس ناشی از

بیماری متمرکز است. • The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.

هدف اصلی این طب بهبود کیفیت زندگی بیمار و خانواده اوست. اعضای این •تیم شامل پزشک، پرستار و سایر متخصصینی است که با دیگر پزشکان بیمار

کار می کنند به منظور ارائه الیه های مراقبتی بیشتر. • Palliative care is appropriate at any age and at any stage in a serious illness,

and can be provided together with curative treatment.مراقبت تسکینی در هر سنی و برای هر مرحله ای از بیماریهای جدی •

اختصاص دارد، و می تواند همراه با معالجات درمانی ارائه می شود. طب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم -

1392عبدالرحیم حزینی - دیماه

Palliative Careچارت سادهاداره کردن روح وروان وجسم بیمار

)...مدیریت کردن بیماری او)سرطان-نارسایی قلبی وتوجیه کردن بیمار وبستگان بیمار

پل ارتباطی بین بیمار وپزشک معالج درمانی او

نقش متخصص

طب تسکینی

پیشگیری ودرمان•تحقیقات در مورد •

درمانهای نوین حمایتی وتسکینی

کمک به سیستم •درمانی موجود جهت

باال بردن کیفیت درمان منطقه و استان

ادل وهمبستگی بین بیماری صعب العالج وروح وروان بیمار –جاUایجاد تعانداختن بیماری برای بیمار وبستگان آو وکمک کردن به همکاران

آنکولوژیست درمانی –کمک کردن به همکاران اورژانس های مختلف- کاهش بستری های غیر ضروری –کاهش آزمایشات پر هزینه –توجیه کردن

بیمار وخانواده او که بهتر است در منزل بستری باشد .بردن تخت بیمارستانی در منزل بیمار وآموزش همراهان بیمار واستفاده از آنها به

طب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم - عنوان پرستار ودستیار پزشک طب تسکینی 1392عبدالرحیم حزینی - دیماه

Palliative careطب تسکینی

یا

مدیریت بیمار و بیماری او

1

حمایت و هدایت بیمار و

بستگان او

Palliative care

طب تسکینییا

2

رعایت حقوق اولیه بیمار


یا 3

باال بردن کیفیت ( Quality of life)زندگی

بیمار


یا 4

ساعته 24سرویس دهی از طریق مشاوره تلفنی و ویزیت به بیمار

در منزل


یا 5

End Stageکاهش بستری بیماران ICU در بخش ها ی ویژه و اورژانس


یا 6

کاهش فرسودگی شغلی Burn Outپزشک،پرستار و

پرسنل بیمارستانی


یا 7

Palliative careطب تسکینی یا 8

کاهش هزینه های بیمار* *کاهش هزینه های دولتی و بیمه

ها*کاهش سردرگمی بیمار

*کاهش بستری های غیرضروری *کاهش آزمایشات تخصصی

بیهوده*کاهش فرسودگی شغلی پرسنل

آموزش به بیمار و خانواده جهت رفع نیازهای اولیه توسط او

خود بیمار (Home & Self Care)


یا 9

انتقال تخت بیمارUستانی انجام کلیه به خانه بیمارو

درمان های غیراورژانسی در منزل خود


یا 10


* مشاوره تخصصی روانشناس*مشاوره روحانی و معنوی

*مشاوره تغذیه*مشاوره مددکاری

*مشاوره فیزیوتراپی

Palliative careطب تسکینی یا

12

سرویس دهی دائمی و تمام Continuously: وقت

در روز ساعت24 در هفته روز7 در ماه روز30

در سال روز 365


*مشاوره تخصصی جهت انکولوژیست تیم

پاسخگویی به سواالت ، ابهامات و دغدغUه های بیمار و بستگان او.

و به عنوان نیروی کمکی * پزشک اولیه بیمار.

Symptom Therapy in Advanced Pancreatic Cancer

PainConstipation

Nausea / VomitingAnorexia / CachexiaDepression/ Anxiety

Others…


What’s so Great about Opioids?• They relieve most types of pain• No analgesic ceiling• No risk of damage to liver, kidneys or stomach• No increased risk of bleeding.


Treating Pain with Opioids

WHO 3-step Analgesic Ladder


Opioid Effectiveness

• Most common reason an opioid is ineffective is reluctance to titrate up till pain is relieved

• No upper limit to amounts of opioid• Increase dose until

– pain is relieved or– there are dose limiting side effects


Pain Poorly Responsive to Opioids

If dose escalation adverse side effects– Alternative

• route of administration• opioid (“opioid rotation”)

– Nonpharmacologic approach or coanalgesic– Therapy to counteract adverse effect


Other Routes for Pain Relief

• IV PCA (The Button)• Nerve Blocks

– Celiac Plexus Block• Spinal Opioids

– Intrathecal or epidural


Six Opioids for Chronic Pain• Morphine: Most Commonly Used• Oxycodone: Oral only• Oxymorphone: Opana Oral Only• Hydromorphone: Dilaudid

– Short-acting & long-acting pills• Fentanyl: Patch for long-acting pain relief.100x stronger

than morphine• Actiq/ Fentora/ Abstral/ Onsolis/ Lazanda• Methadone: inexpensive, long acting

– Bad reputation


Opioid Side Effects

Common UncommonConstipation Bad dreams / hallucinationsDry mouth Dysphoria / deliriumNausea / vomiting Myoclonus / seizuresSedation Pruritus / urticariaSweats Respiratory depression Urinary retention


Adjuvant Pain Medications

Medications that work with opioids to help treat pain

– may themselves be normally used for pain and so used alone


Adjuvant (Non-opioid)

• Pain Medications• Acetaminophen• Non-steroidal anti-inflammatory drugs• Corticosteroids• Antispasmodics• Tricyclic antidepressants• Anticonvulsants (anti-seizure)• NMDA antagonists (ketamine)• Anesthetics


Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Motrin, Advil, ibuprofen, Aleve etc.– All have analgesic ceiling

Effective for bone, inflammatory painHighest incidence of adverse events

– Stomach problems– Kidney problems– Bleeding problems


SteroidsMany Uses but Many Side Effects

• Bone & Inflammatory pain• Improved appetite• Improved energy• Feeling of well-being• High Blood Sugars• Swelling• Confusion• Weakened muscles• Weakened bones


Constant Neuropathic Pain

Usually Burning and/or TinglingAntidepressants

– Amitriptyline: lots of side effects– Desipramine: tricyclic of choice in seriously ill– Duloxetine (Cymbalta)

Anticonvulsants (anti-seizure)– Pregabalin (Lyrica)– Gabapentin (Neurontin)

minimal adverse effectsdrowsiness, tolerance develops within days


Shooting, Stabbing, Neuropathic Pain

Anticonvulsants (anti-seizure)– Pregabalin– Gabapentin– monitor plasma levels for risk of toxicity

OxcarbazepineCarbamazepineValproic Acid


Barriers to Pain Management

• Barriers exist within and among three• different groups:• Health care systems• Health care professionals• Patients and families/caregivers


Barriers to Good Pain Management:Patients/Families/Caregivers

Fears of:Looking weakDistracting physiciansMeans disease is worseBeing seen as a bad patientToleranceAddictionSide effects of opioidsطب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم -


ConstipationMedications

– opioids– calcium-channel blockers– anticholinergic

Decreased motility IleusMechanical obstructionMetabolic abnormalitiesSpinal cord compressionDehydrationAutonomic dysfunctionMalignancy


Constipation

• Common to all opioids• Opioid effects on CNS, spinal cord, gut• Physiologic tolerance usually does not develop• Much easier to prevent than treat


ConstipationDiet usually insufficientOTC bulk forming agents not recommendedStool softeners

– Sodium docusate– Phosphosoda enema if needed

Stimulant laxative– senna, bisacodyl, casanthranol– Combine with a stool softener

senna + docusate sodiumcasanthranol + docusate sodium


ConstipationOsmotic laxative

– Lactulose or Sorbitol– Bisacodyl– Polyethylene glycol (MiraLax, GlycoLax)

Prokinetic agent– Metoclopramide

Other measures– Mineral oil, magnesium hydroxide,

magnesium citrate, suppositories, enemas– Methylnaltrexone (Relistor)


Nausea / Vomiting

Nausea– subjective sensation– stimulation

gastrointestinal lining, CTZ, vestibular apparatus,cerebral cortexVomiting

– neuromuscular reflex


Causes of Nausea / Vomiting• Metastases• Meningeal irritation• Movement• Mental anxiety• Medications• Mucosal irritation• Mechanical• obstruction• Motility• Metabolic• Microbes• Myocardial


Managementof Nausea / Vomiting

• Dopamine• antagonists• Antihistamines• Anticholinergics• Serotonin antagonists


Dopamine Antagonists

Prochlorperazine– (Compazine, Stemetil)Promethazine– (Phenergan, Phenadoz)Trimethobenzamide– (Tigan)Metoclopramide– (Reglan)Haloperidol– (Haldol)


Treatment of Nausea/ Vomiting

Seratonin antagonists– Ondansetron, granisetron, dolasetron

Antihistamines– Diphenhydramine, Meclizine, Hydroxyzine

Anticholinergics– Scopolamine

H2 receptor blockers– Cimetidine, famotidine, ranitidine, etc.

Proton Pump Inhibitors– Omeprazole, lansoprazole


Other Medications

Dexamethasone (and other steroids)– (Decadron)

Dronabinol– (Marinol)

Lorazepam– (Ativan)

Misoprostol– (Cytotec)

Octreotide– (Sandostatin)


Dyspnea (Breathlessness)

May be described as– shortness of breath– a smothering feeling– inability to get enough air– suffocation


Dyspnea (Breathlessness)

The only reliable measure is patient selfreportRespiratory rate, pO2, blood gas determinations

DO NOT correlate with the feeling of breathlessness

Prevalence in the life-threateningly ill: 12 –74%


Causes of Dyspnea• Anxiety• Airway obstruction• Bronchospasm• Hypoxemia• Pleural effusion• Pneumonia• Pulmonary edema• Pulmonary embolism• Thick secretions• Anemia• Metabolic• Family / financial /legal / spiritual /practical issues


Management of Dyspnea

Treat the underlying causeSymptomatic management

– Oxygen: potent symbol of medical carePulse oximetry not helpful

– Opioids– Anxiolytics– Nonpharmacologic interventions

Fanطب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم -


Anorexia / Cachexia

• Loss of appetite• Loss of weight and energy, fatigue


Management of Anorexia/ Cachexia

• Assess, manage comorbid conditions• Educate, support• Favorite foods / nutritional supplements


Management of Anorexia /Cachexia

• Corticosteroids (short term)• Progestational agents (megestrol acetate)• Dronabinol• All have side effects• Trials of many other medications


Management of Fatigue /Weakness

• Education, support• Clarify role of underlying illness• Promote energy conservation• Permission to rest• Evaluate medications• Optimize fluid, electrolyte intake


Management of Fatigue /Weakness

• Dexamethasone– feeling of well-being, increased energy– effect may wane after 4-6 weeks– continue until death

• Methylphenidate (Ritalin)


Depression Anxiety

• Highly prevalent, under-diagnosed• May prevent quality dying• Effective management is possible


Depression

• 25%–77% of patients• Intense suffering• Not inevitable• Treatable in most cases• Early treatment is better• Monitor for suicidal ideation


Risk Factors

• Pancreatic Cancer• Progressive physical impairment• Pain, other symptoms• – Spiritual pain• Preexisting risk factors• – priorHx, Family Hx, social stress• – suicide attempts, substance use• Medications• – Steroids, benzodiazepines


Diagnosing Depression inAdvanced Illness

• Somatic symptoms always present– Poor appetite, poor sleep, low energy

• Look for psychological, cognitive• symptoms

– pain not responding as expected– sad mood / flat affect, anxious, irritable– worthlessness, hopelessness, guilt, despair– Lack of enjoyment, lost self-esteemطب تسکینی در سرطان پانکراس - مرکز تحقیقات پورسینای حکیم -


Management of Depression

• Psychotherapeutic interventions– cognitive approaches– behavioral interventions

• Medications• Combination of psychotherapy, medication


Pharmacologic Management• Psychostimulants

– Rapid effect– Methylphenidate, 5 or 10 mg q am,

• Also Modafinil or dextroamphetamine– Alone or with antidepressent– May continue indefinitely

• SSRIs & atypical antidepressants– Latency 2–4 weeks– Highly effective (70%)– Well tolerated


Anxiety

• Fear, uncertainty about future• Physical, psychological, social, spiritual,• practical issues• Presentation

– agitation, insomnia, restlessness,– sweating, tachycardia, hyperventilation,– panic disorder, worry, tension


Management of Anxiety

• Counseling, supportive therapy• Atypical antidepressants• Benzodiazepines

– short vs. long half-life• diazepam• Clonazepam• lorazepam• alprazolam, oxazepam


Summary

• Many symptoms can make patients miserable• Treat them

– Maximize effects of disease-specific treatments– Care for patients after disease-specific treatments stopped

• Palliative care teams can be effective in treating difficult symptoms at all stages of disease


تماس با ما :•بیمارستان حضرت سیدالشهداء اصفهان-درمانگاه طب تسکینی

اصفهان- پل شیری- خیابان خیام- جنب نهر فرشادی- بیمارستان آدرس: حضرت سیدالشهداء اصفهان- کلینیک فوق تخصصی امام رضا )ع(- درمانگاه

طب تسکینی2207 داخلی 2350210تلفن:

مرکز مراقبتهای تسکینی انتخاب )خیریه آالء(اصفهان- پل شیری- خیابان خیام- کوچه شهید باغی – بن بست امین آدرس:

الدوله – جنب مدرسه راهنمایی دخترانه قائم مقام فراهانی2363352 و 2331051تلفن:

14 الی 8از ساعت ساعات اداری و روزهای غیر تعطیل: 09133151200 دکتر حزینیساعات غیر اداری و روزهای تعطیل:

دکتر صادقپور 09136886837

Website: www.palliativeiran.ir www.palliativeiran.com

Email: [email protected] [email protected]

http://www.palliativeiran.ir/

http://www.palliativeiran.ir/

mailto:[email protected]

mailto:[email protected]

خسته نباشیدبا تشکر از توجه شما

Palliative Care

3 clinical problems in advanced pancreatic CA:1. Pain2. Jaundice3. Duodenal obstruction

** cachexia, malabsorption

Palliative Care: PAIN• Oral narcotics – mainstay

– SR preparations of morphine sulfate

• Celiac plexus neurolysis – i.e. chemical splanchnicectomy of the celiac plexus with

alcohol. – injecting 50% alcohol directly into the tissues along the

sides of the aorta just cephalad and posterior to the origin of the celiac trunk.

– intraoperatively, percutaneously, or endoscopic ultrasonography.• effective • minimal risk of the potentially serious complications

Palliative Care: JAUNDICE

• Choledochojejunostomy – surgical formation of a communication between the

common bile duct and the jejunum• Cholecystojejunostomy– surgical formation of a communication between the

gallbladder and the jejunum.

** can be performed with gastrojejunostomy

Palliative Care: JAUNDICE

• Expandable wire stents: endoscopically– Lower risk vs. surgery– not as durable as a surgical bypass– Complications: bleeding, infection, and

pancreatitis; recurrent obstruction & cholangitis– effectively manage duodenal obstruction in 81% of

patients– Metal stents cost less and require a shorter

hospital stay than surgical treatment

Palliative Care: DUODENAL OBSTRUCTION

• Gastrojejunostomy– GI surgery procedure in which the duodenum is

excised or bypassed and the stomach is end-to-end anastomosed to the jejunum

– relieves gastric outlet or duodenal obstruction– sometimes associated with delayed gastric

emptying

Gastrojejunostomy

Palliative Care: CACHEXIA, MALABSORPTION

• Pancreatic enzyme replacement– Exocrine pancreatic insufficiency and subsequent

malabsorption– 30,000 IU of pancrelipase – before, during, and after a meal, with ↑ titration

as needed• Appetite stimulants, high-calorie diet or

nutritional supplements

Documents

Palliative and Supportive care in Pancreatic Cancer Patients