Whats new in palliative care

Whats new in ...

Palliative care
Nikki Pease and Saskie Dorman

2007 is a landmark year for palliative care: 40 years since the first hospice, St Christopher's, opened in the
UK, and 20 years since palliative medicine was first recognized as a medical specialty. In that time, palliative
care has developed a firm foundation based largely on the care of patients with cancer. More recently, the
specialty has broadened to encompass the care of adults and children with non-malignant life-limiting
illnesses. Patient-centred care, which attempts to optimize quality-of-life, remains at the core of palliative
medicine. A holistic approach to the assessment of physical, psychological, social and spiritual domains
remains central [Saunders C. The symptomatic treatment of incurable malignant disease. Prescr J 1964e;
4: 6873]. Carers' needs are also important. Advances have been made in therapeutic interventions for
symptom control and models of the way palliative care can be delivered. This article highlights some
examples. It also highlights legislative changes that will impact on health care for this population.
Keywords analgesia; delivery of healthcare; mental competency; opioid; palliative care; terminal care

Pain management
Pain is a subjective phenomenon experienced in up to 6570% of patients with
advanced disease (both cancer and noncancer diagnoses). It is acknowledged
that pain is multi-factorial, with physical,
psychological, social and spiritual elements. The mainstay of pharmacological pain control remains the 3-step WHO
analgesic ladder. Its simple stepwise use
can control pain in approximately 80% of
patients.1
Although morphine is currently recog
nized as the strong opioid of choice
(European Association for Pallitive Care
guidelines), alternatives are readily available within the UK. There is increasing
flexibility, both with respect to the choice
of opioid and the route of administration.

Recent additions to the opioid medications available to prescribe include:

fentanyl transdermal patch, now available in 12 g/hour patch
oral transmucosal fentanyl citrate (OTFC,
also known as fentanyl lozenges)
buprenorphine transdermal preparations (Transtec and BuTrans)
oxycodone for parenteral use.
There has also been a reduction in the
availability of:
diamorphine (parenteral) this is
more soluble than morphine and was,
until recently, widely used in the UK
as a first-line parenteral opioid because
of its increased solubility compared to
morphine
co-proxamol, a weak opioid, which the
Committee on Safety of Medicines has
advised is no longer prescribed because

Nikki Pease MRCGP MSc is Consultant in Palliative Medicine at Velindre Cancer Centre and
Honorary Senior Lecturer for the Diploma and Post Graduate Certificate in Palliative Medicine,
Cardiff. Her special interests are education and quality of life. Competing interests: none
declared.
Saskie Dorman MRCP MA MSc is a Consultant in Palliative Medicine at Poole Hospital NHS Trust,
Poole, Dorset, UK. She qualified from Cambridge University and King's College, London, and
trained in Palliative Medicine on the All Wales Higher Training Programme. Her research
interests include breathlessness and quality of life. Competing interests: none declared.

MEDICINE 35:5

292

of the incidence of 300 to 400 deaths

per year associated with its use.2
Transdermal fentanyl
The availability of the fentanyl 12 patch
(releasing approximately 12 g/hour for
72 hours) in 2006 complements the
25, 50, 75 and 100 fentanyl patch
strengths which are already available. The
12 g/hr patch is equivalent to 3045 mg
of oral morphine in 24 hours.
It is important to note that:
transdermal fentanyl is not appropriate
for patients experiencing acute pain
transdermal fentanyl will not relieve a
pain unresponsive to morphine
evaluation of the analgesic effect
should not be made before the patch
has been worn for 24 hours
more than one patch may be used at a
time for doses greater than 100 g/hour
on removal of the patch, it may take 22
hours or longer for the plasma fentanyl
concentration to decrease by 50%.3
Oral transmucosal fentanyl citrate
Oral transmucosal fentanyl citrate (OTFC,
also known as fentanyl lozenges) are available in 200 g, 400 g, 800 g, 1.2 mg and
1.6 mg lozenges. The drug is incorporated
into a hard sweet matrix attached to a
short plastic handle. OTFC is intended for

2007 Elsevier Ltd. All rights reserved.

Whats new in palliative care

PRN (pro re nata: as the occasion arises)

use in patients receiving opioid therapy
for chronic cancer pain and has been used
for incident pain. There is no correlation between the fentanyl patch strength
needed for background analgesia and the
strength of the lozenge needed for episodes of breakthrough pain.4 OTFC is very
expensive compared to other opioids.
Buprenorphine
Buprenorphine is a partial agonist at
opioid receptors and therefore may antagonize the effect of other opioids.3
Transdermal buprenorphine systems
were launched in 2006.
5, 10 and 20 patch systems
(BuTrans) deliver 5, 10 and 20 g
buprenorphine/hour respectively and
should be changed every 7 days. The
analgesic effect should not be evaluated until the system has been worn
for 72 hours.
35, 52.5 and 70 patches (Transtec)
deliver 35, 52.5 and 70 g buprenorphine/hour respectively and should be
changed at least every 96 hours. The
analgesic effect should not be evaluated until the system has been worn
for at least 24 hours.
These complement the sublingual tablets
and parenteral preparations of buprenorphine. Both patch systems are indicated for
moderate-to-severe pain unresponsive to
non-opioid analgesics. No adjustment dose
is needed for the elderly or for those with
renal impairment, but severe liver impairment may result in its accumulation.
Oxycodone
Some patients have difficulty tolerating
morphine or diamorphine (for example
increasing the dose may cause drowsiness,
confusion or hallucinations). Switching
the opioid can be useful.5 Oxycodone is
one option, and for people who become
unable to manage oral medication,
parenteral oxycodone is now available.
However, a recent meta-analysis reported
similar efficacy and tolerability of oxycodone compared to morphine.6 There was
no difference in quality of life scores or
patient preference.7 Therefore morphine
remains the strong opioid of choice.
Novel routes of administration
A pain pen for patients to selfadminister subcutaneous analgesia has

MEDICINE 35:5

been developed. Strong opioids such as

hydromorphone, morphine or sufentanil
were used subcutaneously, for a median
of 6 weeks. Early reports of its use in the
Netherlands and Sweden suggest good
overall efficacy in 84% patients (n=58).8

Adjuvant analgesics
Neuropathic pain
Neuropathic pain is caused by damage
to the peripheral or central nervous system, and is often burning or stabbing in
quality. Such pain is frequently associated
with a sense of distortion or numbness of
the body part.9 Examples of frequently
prescribed adjuvant analgesics for neuro
pathic pain include tricyclic antidepressants, anticonvulsants and less commonly
selective serotonin re-uptake inhibitors
(SSRIs) and serotoninnoradrenaline reuptake inhibitors (SNRIs). All these work
on spinal and supraspinal pain pathways.
Evidence of effectiveness for SSRIs and
SNRIs in the treatment of neuropathic
pain is less good compared to tricyclic
antidepressants and anticonvulsants
(Table 1).10,11
Pregabalin (Lyrica), designed as
amore potent successor to gabapentin,
was approved in the UK in 2004. Its side
effect profile is similar to that of gabapentin. A recent review stated that there

was no evidence to use pregabalin in

preference to the now much cheaper
generic gabapentin.12

Legislative changes
The Mental Capacity Act
The Mental Capacity Act (2005) comes
into force in April 2007 and will have
an impact on all healthcare teams caring
for patients with diminished capacity
(Table2). It will apply to patients aged
18 years and over in England and Wales.
Introduction of the Act provides a statutory framework to clarify decision making for those patients who are no longer
able to take decisions for themselves.
This applies to decisions regarding treatment options, place of care or finances.13
The Act allows a person to appoint their
advocate for health decisions and aims
to clarify the current law on:
capacity
best interests
advanced decision making.
The act is underpinned by 5 key principles.
Every adult should be presumed to
have capacity.
Patients should be afforded all appropriate help to make decisions.
Patients with capacity retain the right
to make what might seem an unwise
decision.

Comparison of efficacy and adverse events for anticonvulsants

and antidepressants in the treatment of neuropathic pain
Drug

Tricyclic antidepressants
Amitriptyline
Anticonvulsants
Gabapentin
Pregabalin
Carbamazepine
Selective serotonin
reuptake inhibitors10
Serotonin-noradrenaline
reuptake inhibitors10

NNT*

NNH** (minor
adverse events)

Side effects

2.7

Sedation, dry mouth, confusion

4.3
2.3
2.5
7

2.5
(not yet analyzed)
3.7

Sedation, tremor, confusion

Sedation, tremor, confusion
Sedation, nausea and vomiting
Nausea and vomiting, tremor,
dizziness
GI upset, sedation, confusion

*Number needed to treat (NNT): the number of patients that need to receive a treatment for one of
them to benefit.
**Number needed to harm (NNH): the number of patients who would need to receive a treatment for one
of them to experience an adverse event.11
(Table adapted from that previously produced in BJCM 2006, issue 3.2.)

Table 1

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Whats new in palliative care

The Mental Capacity Act 2005

The test for capacity is whether a person can:
understand the relevant information
retain this information
use or weigh the information as part of the decision making process
communicate their decision14
For more information, visit: http://www.dca.gov.uk/legal-policy/mental-capacity/
mca-summary.pdf
For easy-to-read booklets, appropriate to provide patients with information on the Mental
Capacity act (available to download in different languages), visit: http://www.dca.gov.uk/
menincap/mca-act-easyread.pdf
Table 2

If a patient is deemed not to have

capacity to make a decision then the
decision taken for them should be in
the patient's best interests
The decision made for patients who do
not have capacity should be the least
restrictive to their basic rights and
freedoms.
House of Lords Palliative Care Bill
The Palliative Care Bill seeks to make provision for Palliative care for persons who
are suffering from terminal illness; and for
connected purposes. If enacted, the appropriate authorities in England and Wales
will have a duty to ensure palliative care is
available to all terminally ill patients. The
bill underwent its second reading within the
House of Lords on 23rd February 2007.

Co-ordination of services
The NHS End-of-Life Care strategy was
launched in 2006. Its aims are to promote choice, quality, equity and value for
money in the provision of palliative care.
The strategy builds on the expertise developed in hospices and specialist palliative
care services and seeks to make this more
widely available. It applies to patients
dying of any condition and in any location
(home, hospital, care home or hospice).
This work builds on the End-of-Life Care
Programme (2004), which aimed for:
greater choice for all patients in their
place of care and place of death
decreased numbers of emergency
admissions for patients whose preference is a home death
decreased numbers of patients transferred from a care home to district
general hospital in last week of life

MEDICINE 35:5

generalists skilled in the use of care

models to improve end-of-life care.15
Three suggested models to achieve these
aims are the Gold Standards Framework,
the Liverpool Care Pathway and Preferred
Place of Care.
Gold Standards Framework
The Gold Standards Framework (GSF)
seeks to improve the care of patients in
their last six to nine months of life.15 It is
being implemented in many areas throughout the UK. It is summarized in Table 3.

Liverpool integrated care pathway

The Liverpool Care Pathway (LCP) uses a
model of care for the dying which has been
developed within a hospice environment.
It seeks to make this model of care available to people dying in other locations
hospital, home or care home, and
has been implemented widely across
the UK.16
In essence it is simple: the care pathway encourages clinicians to identify when
a patient is dying, and to make appropriate adjustments to the care process. This
includes:
assessment for symptoms seen in the
terminal phase
prescribing appropriately (subcuta
neous analgesia, antiemetic, anxiolytic,
anticholinergic for respiratory secretions to use as needed)
ensuring the family are prepared for
death
ensuring unnecessary interventions
are stopped (for example, routine
blood pressure measurement).
Preferred place of care
Although half of people with a terminal
illness say they want to die at home,
only about a quarter do so. One network

The Gold Standards Framework

The Gold Standards Framework can be summarized by:
Three processes
Identify patients in need of palliative/supportive care towards the end of life
Assess their needs, symptoms, preferences and any issues important to them
Plan care around patient's needs and preferences, and enable these to be fulfilled and,
in particular, to allow patients to live and die where they choose
Five goals
Patients are as symptom controlled as possible
Patients live and die where they choose
Better advanced care planning, information, less fear, fewer crises/admissions
Carers well supported, enabled, empowered and satisfied
Staff confidence, team-working, satisfaction, communication better
Seven key tasks or standards: the 7 Cs
Communication
Co-ordination
Control of symptoms
Continuity including out of hours
Continued learning
Carer support
Care in the dying phase
For more information, go to http://www.goldstandardsframework.nhs.uk/
Table 3

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Whats new in palliative care

( Lancashire and South Cumbria Cancer

Network) chose to address this by institu
ting a preferred place of care patientheld document. This allows the patient to
record their thoughts and preferences for
end of life care, as well as documentation
about the family and the needs of both
patient and carers.17

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2007 Elsevier Ltd. All rights reserved.