THE ASSESSMENT AND MANAGEMENT OF A PATIENT’S PAIN IN THE PALLIATIVE CARE SETTING.DR GREG PARKER MBBCH FRACGP FACHPM

DIRECTOR METRO SOUTH PALLIATIVE CARE SERVICE, BRISBANE

SCOPE OF TALK

•

SCOPE OF TALK

• The individual nature of pain

• Principles of pain assessment and management

• Individualising pain management plans

• Initiating opioids in opioid naïve patients

• Managing refractory pain

THE INDIVIDUAL NATURE OF PAIN

• The concept of total pain and its influences

• The perception of pain is unique to the individual

• https://www.youtube.com/watch?v=o__2hrc2gVY

• https://www.youtube.com/watch?v=nOgMtClL1xU

Pain

Physical symptoms

Psychological

Social

CulturalSpiritual

Suffering

Woodruff, 1999

THE ASSESSMENT-LONG CONSULT

TOOLS AVAILABLE FOR YOUR TOOLBOX

• Brief Pain inventory

• PAINADD

• Abbey Pain Score

• DNR4

• GP pain help

• Palliaged GP

• Spotonhealth health Pathways

INITIAL MANAGEMENT

• Non Pharmacological

• Pharmacological

ONGOING REVIEW-LONG CONSULT

• What else is going on for this patient and family?

• Are there other issues to address?

• Are there concerns?

• Is what we are doing-working?

• JK 30 YEARS OLD

• BUSINESS WOMAN

• SINGLE MUM

• 2 CHILDREN: 10 years & One month old (breast feeding)

• Lives in her own low set house

• Previous smoker

• No known allergies

CASE:

HISTORY

• Sx: Ante Partum

initial lower back pain in late pregnancy with some “sciatica”

pedal oedema

NVD at term-healthy baby girl

Post Partum

worsening back pain, flank pain and right sided buttock and thigh pain-Panadol

1g QID is hardly helping

haematuria

Occasional Breathlessness on exertion and lying flat

Also complaining of bony pain all over and fatigue++

No fevers

Nausea is prominent

CLINICAL ASSESSMENT

• Clearly uncomfortable when getting on to the examination bed

• Cardiac examination is normal

• Respiratory examination indicates a tachypnea and rt basal effusion

• Fullness in the right flank but no associated tenderness

• Tenderness over L3 area

• Pain on right straight leg raising

• Urine dipstix positive for blood and protein

ASSESSMENT

• DDx is considered and Ix to be ordered.

INITIAL MANAGEMENT

• Clear discussions?

• Arrange a series of defining investigations?

• Address nausea?

• Address pain?

• Arrange follow up!!!!

HOW DO WE ADDRESS HER PAIN?

• How do you individualise JK’s pain management plan?

• What considerations do you need to take into account?

• What are you going to prescribe?

• What are you going to counsel her about based on what you prescribe?

• What follow up do you provide?

• Ix

• Urine MCS negative

• normocytic anaemia

• Moderate hypercalcaemia

• Normal renal function

• Baseline imaging confirms an effusion and suspicious lytic area over

lumbar vertebrae

• CT- pulmonary nodules/rt moderate pleural effusion/right sided

complex renal mass/para-aortic nodal disease/left ischial

metastasis/impression of right L3,4,5, nerve root entrapment-MRI and

biopsy recommended.

CASE CONTINUED

• Multimodal management

Follow up and counselling

Review of current symptoms and management

Referral

CASE:

NON-PHARMACOTHERAPEUTIC MANAGEMENT OF JK’S PAIN

PHARMACOTHERAPEUTIC MANAGEMENT OF JK’S PAIN

HOW DO I INITIATE OPIOIDS AND WHAT DO I NEED TO TAKE INTO CONSIDERATION?

• Is the patient opioid naïve?

• What are their sensitivities?

• Do I need to address any myths?

• Do I start with an immediate release or controlled release formulation.

• What is the most appropriate mode/route of delivery?

OPIOID INITIATION CONTINUED

• What do I have to take into consideration in opioid choice?

• What do I have to take into consideration when writing the script?

• What educational information/material do I provide to the patient

• What sort of follow up is needed.

• JK received targeted therapy and radiotherapy with an initial partial

response

• Further progression dictated instigating 2nd line targeted therapy with some

disease stability

CASE CONT

REFRACTORY PAIN MANAGEMENT

• Important considerations?

• What is occurring- re-evaluate everything

MANAGING REFRACTORY PAIN IN JK’S CASE

• Ongoing pain issues –opioid escalation-s/e affecting function and ability to

deliver cares to infant- opioid rotation to methadone with success but short

lived as further disease progression on treatment.

• Interventional pain specialist consult-lumbar plexus block done-good effect,

reduction in baseline opioid and B/T. Improved functionality and QOL.

• 3.5 months later analgesic requirements increasing. Further RT ceiling reached,

repeat block short lived 1 month.

• Continued deterioration.

• Needing increased home support , GP and Specialist Palliative Care support

ongoing

• Converted from orals to a syringe driver, family able to deliver s/c

breakthroughs at home on palliative care program.

CASE CONTINUED

THE ROLE OF A SYRINGE DRIVER IN PALLIATIVE CARE PAIN AND OTHER SYMPTOM MANAGEMENT AND THE CARING SAFELY AT HOME PROGRAM.

CASE CONCLUDED

• Manages to reach some milestones-daughter’s 1st birthday, makes memory

boxes and records messages for future.

• Dies at home peacefully surround by family.

SUMMARY• Impeccable palliative symptom including pain assessment and management in the

palliative care setting is complex, but is absolutely within the remit of General

Practitioners supported by Palliative Care Specialist services as appropriate.

• Know your patient cohort

• Develop your toolbox

• Ensure impeccable assessments

• Know your baseline drugs and understand prescribing requirements

• Know when to call for help and who to call-consider a shared care model

• Ensure appropriate close follow up

• If the management plan is not working re-evaluate

SOME FOOD FOR THOUGHT

• https://www.youtube.com/watch?v=KREufd4t0vo

• https://www.youtube.com/watch?v=2FtyXc1QycQ

• https://www.youtube.com/watch?v=01_ISKV2eF0

• https://www.youtube.com/watch?v=iETY3z559jU