Professional Documents
Culture Documents
pada Keganasan
dr Shahrul Rahman, Sp.PD
Tends to devalue
information that is
subjective,
immeasurable, or
unverifiable
Therapy is medically
indicated if it eradicates
or slows the progression
of disease
Cancer
Other
84%
47%
51%
51%
33%
38%
71%
47%
28%
37%
67%
49%
27%
36%
38%
36%
38%
32%
14%
33%
PALLIATIVE CARE:
World Health Organization Definition
Palliative care is an approach that improves the
quality of life of patients and their families facing the
problem associated with life-threatening illness,
through the prevention and relief of suffering by means
of early identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
4
Palliative Care
Google Images
General Principles
Pain, other symptoms, and side-effects are managed based upon the
best available evidence
Breathlessness
Insomnia
Anxiety
Depression
Constipation
Anorexia
Fatigue/weakness
Nausea
Confusion
Physical pain
Anger
Depression
Anxiety
All affect patients perception of pain.
Needs thorough assessment
90% can be controlled with self-administered oral
drugs
Depression
Anxiety
Anger
Delays in diagnosis
Unavailable physicians
Uncommunicative physicians
Failure of therapy
Friends who dont visit
Bureaucratic bungling
Treatment options
Analgesic drugs
Adjuvant drugs
Surgery
Radiotherapy
Chemotherapy
Spiritual and emotional support (total pain)
Analgesic drugs
Mainstay of managing cancer pain
Choice based on severity of pain, not stage
of disease
Standard doses, regular intervals, stepwise
fashion
Non-opiodweak opioidstrong opiod
+-adjuvant at any level (WHO analgesic
ladder)
Non-opioid drugs
Paracetamol
1g 4 hourly
NSAIDS
Ibuprofen 400mg 4 hourly
Aspirin 600mg 4 hourly
NB daily maximum doses
Weak opioids
Codeine
60mg 4 hourly
Dihydrocodeine
30-80mg tds max 240mg daily
Dextropropoxyphene
65mg four hourly
Tramadol 50-100mg 6 hourly
Prescribing more than the maximum daily dose will
increase s/e without producing further analgesia
Combinations
Convenient
Care with dosing
Some combinations e.g co-codamol contain
subtherapeutic doses of weak opioid
Co-proxamol only contains 325mg
paracetamol
Get dosing right before moving on to strong
opioids
Strong Opioids
Morphine
Hydromorphone
Fentanyl
Diamorphine
Buprenorphine
Bone pain
Paracetamol
Morphine
NSAIDS
Radiotherapy
Bisphosphonates
Neuropathic pain
Features which suggest neuropathic pain
Burning
Shooting/stabbing
Tingling/pins and needles
Allodynia
Dysaesthesia
Dermatomal distribution
Neuropathic pain
Antidepressant
Anticonvulsant
Antiarrhythmics
Steroids
Anaesthetics
Ketamine
Nerve blocks and spinal anaesthesia
Neuropathic pain
Complementary therapies
TENS
Acupuncture
Hypnosis
Aromatherapy
Counselling
Social support
1.ILLNESS
1.ILLNESS
MANAGEMENT
MANAGEMENT
8.8.LOSS,
LOSS,
BEREAVEMENT
BEREAVEMENT
7.7.CARE
CARE
AT
ATTHE
THEEND
ENDOF
OF
LIFE
LIFE/ /
DEATH
DEATH
MANEGEMENT
MANEGEMENT
2.2.PHYSICAL
PHYSICAL
PATIENT
PATIENT&
&
FAMILY
FAMILY
6.6.PRACTICAL
PRACTICAL
3.3.
PSYCHOLOGICAL
PSYCHOLOGICAL
4.4.SOCIAL
SOCIAL
5.SPIRITUAL
5.SPIRITUAL
1. ILLNESS MANAGEMENT
1. ILLNESS MANAGEMENT
Primary diagnosis, prognosis, tests
Primary diagnosis, prognosis, tests
Secondary
diagnosis (for example,
Secondary diagnosis (for example,
dementia, psychiatric diagnosis, use of
dementia,
psychiatric diagnosis, use of
drugs,
trauma)
drugs, trauma)
Co-morbid
(delirium, attacks, organs
Co-morbid (delirium, attacks, organs
failure)
failure) episodes (collateral effects,
Adverse
Adverse episodes (collateral effects,
toxicity)
toxicity)
8. LOSS, BEREAVEMENT
8. LOSS, BEREAVEMENT
Loss
Loss
Pain
(for example, chronic acute,
Pain (for example, chronic acute,
anticipatory)
anticipatory) planning
Bereavement
Bereavement planning
Mourning
Mourning
7. CARE AT THE END OF LIFE/DEATH
7. CARE AT THE END OF LIFE/DEATH
MANAGEMENT
MANAGEMENT
End
of life (businesses ending,
End of life (businesses ending,
relationships
closing, to say goodbye)
relationships
closing,
to say
goodbye)
Delivery of gifts
(objects,
money,
Delivery of gifts (objects, money,
organs, thoughts)
organs, thoughts)
Creation
of legacy
Creation
legacy
Preparationoffor
the awaited death
Preparation for the awaited death
Anticipation
changes in agony
Anticipation changes in agony
Rituals
Rituals
Certification
Certification
Care
of agony
Care
of agony
Funerals
Funerals
2. PHYSICAL
2. PHYSICAL
Pain
& other symptoms
Pain & other symptoms
Conscience
level, cognition
Conscience level, cognition
Function,
safety, materials:
Function, safety, materials:
Motor
(mobility, shallowness,
Motor (mobility, shallowness,
excretion)
excretion)
Senses
(hearing, sight, smell, taste,
Senses (hearing, sight, smell, taste,
touch)
touch)
Physiologic
(breathing, circulation)
Physiologic
(breathing, circulation)
Sexual
Sexual
Fluids,
nutrition, wounds
Fluids,
nutrition,
wounds
Habits (alcohol,
smoking)
Habits (alcohol, smoking)
PATIENT & FAMILY
PATIENT & FAMILY
Characteristics
Characteristics
Demographic
(age, sex, race,
Demographic
(age, sex, race,
contact
information)
contact
information)
Culture (ethnic, language, nurture)
Culture (ethnic,
language,
nurture)
Personal
values, beliefs,
practices,
Personal values, beliefs, practices,
strengths
strengths status, education,
Development
Development status, education,
alphabetization
alphabetization
Disabilities
Disabilities
6. PRACTICAL
6. PRACTICAL
Everyday
activities (personal care,
Everyday activities (personal care,
home
work)
home work) pets
Dependents,
Dependents, pets
Access
to telephone, transport
Access to telephone, transport
Care
Care
3. PSYCHOLOGICAL
3. PSYCHOLOGICAL
Personality,
strengths, behavior,
Personality, strengths, behavior,
motivation
motivation anxiety
Depression,
Depression, anxiety
Emotions
(anger, distress, hope,
Emotions (anger, distress, hope,
loneliness)
loneliness)
Fears
(abandonment, burdens, death)
Fears
burdens, death)
Control, (abandonment,
dignity, independence
Control, dignity, independence
Conflict,
guilt, stress, assuming answers
Conflict,
stress, assuming answers
Self-image,guilt,
self-esteem
Self-image, self-esteem
4. SOCIAL
4. SOCIAL
Values,
cultural, beliefs, practices
Values,
beliefs,
practices
Relations,cultural,
roles with
the family,
friends,
Relations, roles with the family, friends,
community
community
Isolation,
abandonment, reconciliation
Isolation, abandonment, reconciliation
Safe,
comforting environment
Safe, comforting environment
Privacy,
intimacy
Privacy,
Routines, intimacy
rituals, leisure, vocations
Routines, rituals, leisure, vocations
Financial
resources, expenses
Financial resources, expenses
Legal
(powers of attorney for
Legal (powers of attorney for
businesses,
health attention, advanced
businesses,
attention, advanced
directives, lasthealth
desire/testament
directives,
last
desire/testament
beneficiaries)
beneficiaries)
5.SPIRITUAL
5.SPIRITUALvalue
Significance,
Significance, value
Existential,
transcendental
Existential,
transcendental
Values, beliefs,
practices, affinities
Values,
beliefs,
Spiritual advisors,practices,
rituals affinities
Spiritual advisors, rituals
Symbols,
icons
Symbols, icons
NON-SPECIFIC INTERVENTIONS
FOR SUFFERING
1. Non-pharmacological
Talk about death and dying
Calm reassurance
Emotional and spiritual support
2. Pharmacological
Opioids, other analgesics and adjuvants (eg/
gabapentin)
Sedatives
Neuroleptics CPZ, methotrimeprazine
Possibly benzodiazepines
Corticosteroids reduce inflammation, edema
41
Palliative Care
Interdisciplinary Care
Aims to
relieve suffering
improve quality of life
Combined with ALL OTHER appropriate
medical treatment
Vigorous care of
Not in place of
pain and symptoms
curative or lifethroughout illness
prolonging care
decision-making
their families