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Palliative Care

Palliative care is the term used for symptom relief in a terminal illness, from which recovery is not expected. Pain relief is part of this, although pain may not be the main symptom, and other symptoms may be treated as well. Psychological, social and spiritual problems may also need to be addressed, in order to achieve the best possible quality of life. The principles of palliative care have been developed through the hospice movement, and applied particularly to the care of cancer patients. More recently, these principles have been applied to other types of terminal illness, such as heart failure or the last stage of chronic bronchitis, and also to chronic painful conditions that are not life threatening. Advice and support for doctors and patients is often available from local hospices. With treatment, symptoms can be reduced or controlled so that they do not cause unnecessary distress.

Pain relief in palliative care
The initial treatment of pain in palliative care is the same as for other chronic pain. The most important thing is that painkillers are taken regularly, ‘round the clock’, instead of only being taken when the pain is troublesome. Painkillers used are of various types:

Non-opioid painkillers, including paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), for example ibuprofen, naproxen or diclofenac
Opioid drugs, such as morphine. These are generally divided into ‘weak’ opioids, such as codeine or dihydrocodeine, and ‘strong’ opioids such as morphine or fentanyl.

For mild to moderate pain, paracetamol taken regularly four times a day may be enough. A maximum of two 500 mg tablets four times a day can be taken. It may be combined with a weak opioid, for example paracetamol and codeine. If this is not controlling the pain, strong opioids will usually be used and this should be discussed with your doctor.

Morphine is most commonly used, and is available as tablets or liquid. First, the effective dose to get control of the pain needs to be decided. For this, short-acting morphine is used every 4 hours. While this is most effective if taken regularly, having to get up in the middle of the night to take a dose of morphine will disturb your sleep, so you may be told to take a double dose at bedtime. A typical starting dose would be 10 milligrams (mg) four-hourly. This will be gradually increased every two or three days until the dose that controls the pain is reached. There is no upper limit to the dose that can be used, as long as it is effective in controlling the pain.

Once the effective dose has been reached, this dose can be given in a long-acting format, taken every 12 hours, which is much more convenient. The short-acting morphine can be used if any ‘breakthrough’ pain occurs. Because pain will vary through the day, some breakthrough pain may continue while on regular long-acting treatment; this does not mean that the regular treatment is not working, and it should not be stopped. If extra doses of the short-acting morphine are needed often, the dose of the long-acting morphine may need to be increased.

Both weak and strong opioids can cause side effects:

Constipation: this is very common and persists while the opioid drug is being used. It is usual to anticipate this and give a laxative medication when regular opioid treatment is started, and continue it during the treatment.
Sedation may occur when opioid treatment is started, but lessens with continued treatment.
Nausea, and sometimes vomiting, may occur during the first few days of opioid treatment, and may need some medication to relieve it. However, this also decreases after a few days of treatment.
Less common side effects may include a dry mouth, itching, sweating, hallucinations and twitching movements in the muscles.
Both patients and their doctors may worry about the possibility of becoming addicted to the morphine, or of becoming tolerant to it so that larger doses are needed for the same effect. When using opioids in palliative care, however, if the pain is later treated in some other way, such as surgery or radiotherapy, the medication can usually be reduced or stopped without difficulty. It is important to take pain-relieving medication in palliative care regularly to get the most benefit from it. Increasing doses may be needed as the disease progresses, but this is an appropriate response to increasing symptoms, not an increasing dose for the same symptoms. If the disease causing the pain is stable, it is not usually necessary to rapidly increase the dose to obtain the same effect. The same dose can often be maintained for a long time if the pain is stable. The dose of opioids used should be adjusted in each individual to give the best effect.
Another worry doctors and patients may have is of an ‘overdose’ of morphine causing respiratory depression, which is a medical term used to describe a decreased breathing rate. This can be a serious side effect, but if the medication is used appropriately for the level of pain, and increased gradually, very high doses of morphine can be given without respiratory depression occurring.

SSome people may not be able to take medication by mouth for various reasons. Other common routes of administration are:

Transdermal (through the skin), using a patch, which is stuck onto the skin. Buprenorphine or fentanyl, strong opioid drugs, can be given in this way. They are absorbed slowly so are used as an alternative to long-acting morphine.
By injection. Commonly the opioid is injected very slowly under the skin (subcutaneously) by a machine called a syringe driver. Other medications may be given in the same way, for example drugs to treat nausea.
Morphine can also be given as a suppository into the rectum, but this is not commonly used.

Other drugs may be used instead of, or in addition to, an opioid in palliative care. These may include the following:

Non-steroidal anti-inflammatory drugs (NSAIDs) are often useful for pain from spread of cancer in the bones, or pain caused by inflammation, such as joint pain.
Pain from cramps in the bowel may be treated with a drug to relax the bowel muscle such as mebeverine.
Steroids, usually dexamethasone, are used for a variety of symptoms. They have anti-inflammatory effects and are not the same as anabolic steroids, which build muscle. Dexamethasone reduces swelling and can help pain caused by swelling inside the brain or in the spinal cord, or pressure on the gut, nerves or large blood vessels. They may help bone pain, and may also help other symptoms such as breathlessness, nausea or poor appetite.
Pain from damaged nerves (neuropathic pain) may respond better to medications also used to treat depression or epilepsy (such as amitriptyline and sodium valproate) than to opiates.

Non-drug treatment for pain in palliative care
Depending on the cause of the pain, other treatments may be used. Surgery may be used, for example, to bypass blocked areas of bowel, or to reduce the size of tumours that are causing pain by pressing on other organs. Radiotherapy can help to reduce the size of tumours, and is often helpful in bone pain.

Other symptoms in palliative care
This article is particularly concerned with pain relief, but of course other symptoms may also need treatment, which can be added to the pain relief. Some medications will help a variety of symptoms; for example, dexamethasone may help some types of pain and also may help nausea, and morphine may help pain, cough and breathlessness. The best combination of medication for maximum symptom relief with the least possible side effects will need to be individually decided for each patient. Local hospices can be very valuable sources of advice and support.