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Rural Health Webinar Series - Curious prescribing habits in palliative care

Chantelle Vonarx: Welcome to the latest instalment of our Rural Health Webinar Series. So this webinar is Curious Prescribing Habits in Palliative Care and it will be presented by Dr Arron Veltre who is a Palliative Care Specialist working in Manning Base Hospital in Taree, and he is also the Clinical Dean at the Manning Campus for the University of Newcastle Department of Rural Health. And his research interests include emotional well-being and advanced care planning and he also has a special interest in the alleviation of suffering and the improvement of death literacy in the community. So we are very pleased that he could join us this evening.
 
We would just like to start with an Acknowledge of Country. RACGP would like to acknowledge the traditional custodians of the lands on which this event is being broadcast and we pay respect to their Elders past, present and emerging. We would also like to thank our sponsor Ochre Health and Recruitment. Established and still owned by two procedural GPs, they operate a network of medical centres around Australia, as well as operating a medical recruitment agency that works with hospitals and medical practices throughout Australia and New Zealand, to source and place locum and permanent doctors across a wide range of specialties. We greatly appreciate their support of this webinar series.
 
Finally, before we start, just a few housekeeping things to cover. All participants are set on mute just to ensure that the webinar is not disrupted by background noise, but we do encourage you to use the chat or the Q&A function to ask questions. And finally, the webinar has been accredited for two CPD points and in order to gain these points, you must be present for the duration of the webinar. We do also ask that you complete the evaluation activity that will pop up at the conclusion of the webinar. But now I will hand over to our facilitator for this evening, Dr Arron Veltre.
 
Dr Arron Veltre: Thank you. I will just share my screen and we can get started. Welcome everybody on a Thursday night that feels like a Friday because it is pre long weekend, so I hope everybody has got some time off over the Easter break. Today I was going to talk about prescribing in palliative care and some of the nuances and different ways that we utilise medication (so using medications for multiple purposes), and then also identify ways to use adjuvant analgesia when opioids are ineffective, and then also talk about ways to engage in treatment discussions between health professionals. So that is the kind of learning outcomes I am hoping that you can take away. But I am also trying to make this as reasonably interactive as possible, because on a Thursday night that would not be the best way to end the week.
 
So let’s talk first about prescribing and why we are doing it. So in terms of route of administration it is always good to understand what we are doing in terms of the route of administration and whether we are trying to get that context right and make sure that we are using subcutaneous or oral or potentially transdermal, or why we are doing it, and what we are trying to achieve. So understanding also the use of breakthrough and short acting medication, as well as understanding anticipatory prescribing is very helpful. And then hopefully thinking about reducing end-organ harm. So particularly in terms of reducing the effects on kidney and liver when we are prescribing, and then obviously reviewing and de-prescribing when we can is helpful, and when we are prescribing making sure that we are understanding the goals of care and goals of treatment. So that is always very useful to do as well.
 
So I thought we would look at one of the studies that David Currow did and David Currow is pretty prolific in this space and is very good at making sure that we are understanding differences between why we are doing things and, especially in the palliative care context, making sure that people are utilising the best possible evidence for why we are doing things. So he talks about the difference between malignancy and non-malignancy in terms of their approach to end of life care. And fatigue actually in terms of malignancy settings is the most prevalent system at around about 75%, and then nausea is actually 25% of cases, and more than half those people in the study that they looked at, which was a very large study and cohort looking at a number of people in the end stages of their conditions, pain and shortness of breath was often in the moderate to severe range. Interestingly for non-malignant conditions, they were about 34% more likely to experience shortness of breath, and that was really shortness of breath in terms of them being in a dying process, and that is pretty interesting because a lot of people do not necessarily think about that, and it is useful to keep remembering that at end of life shortness of breath, for a non-malignancy condition, is a pretty significant thing.
 
So I thought we would run through two case scenarios tonight. GPs can juggle lots of information at once, so I am sure you will all be very comfortable doing this. And interestingly, the literature that I have reviewed really indicates that GPs are very comfortable prescribing opiates. I don’t know, I used to be a GP and I do not really remember being that comfortable prescribing opiates, but I am sure there are lots of people who are very comfortable doing it. And I think it is very helpful to have a think about the rural context of this and how we can best support GPs in meeting end of life care needs. So a recent survey and study looked at Australian GPs and found that especially in a rural setting about 30% had lower confidence in providing palliative care because of inadequate training despite many of them saying that they want to learn more. So I guess that is one of the reasons that I am motivated to try and do these sessions, because I think it can be really helpful. And that is that is really the aim and if you can get something out of this and hopefully take something away then that is really useful. And also interestingly, they found that rural exposure to palliative care, to palliative care patients, and palliative care settings was often higher in these regions, but sometimes in a GP registrar situation they can be not as commonly seen. So the GP registrars were not necessarily getting as much exposure because perhaps they were getting seen by the practice principal or the more senior doctors in that practice and so sometimes despite having higher rates of GP palliative care presentations in rural areas, that was not necessarily translating to GP registrars seeing people. So yes I think it is good to keep that in mind as well and make sure we can expose people as much as possible.
 
So I thought we would kick off with a case, and this is the case of a patient TK, a 68-year-old man with metastatic non-small cell lung cancer. And he was diagnosed in January 2021 and he had mets to his, metastatic disease to lymph nodes. He had a past history of osteoarthritis. He was obese and a current smoker and very prolific smoker at 60 pack years. He lives alone at home with his dog. He has had no recent family contact, but has a few children, which he has not seen for quite a number of years. And he was a retired truck driver, and as often is used with truck drivers unfortunately, they tend to require lots of medication to ensure that they do that safely. So he was an interstate truck driver and utilised amphetamines in order to get through that safely, quote unquote, was what I was told. And then functionally he was independent and had some assistance from a neighbour for shopping. And for those of you who have used PCOC language before, PCOC is the Palliative Care Outcomes Collaborative and that is really just a framework to talk about palliative care, describing palliative care patients. So if you wanted to, you can have a look at some of my other talks where we talked about PCOC scoring and I do not urge you to do that, but really for simplicity’s sake, he was pretty stable and he had a reasonably high level of function at the time.
 
So you are the new GP at the practice and you have not met TK previously. And TK is concerned that you don’t know anything about him because you are new. And I guess my questions are, and if you can answer this in the chat section and just put to panellists and attendees or to everybody, and I would like you to perhaps suggest what you would like to know about him and what you can offer at this stage. So who have we got online that I can see? Um, so yes anyone, please have a go and type a message for me and see what we can come up with. So what do you want to know about this guy? You have not met him, he has got non-small cell lung cancer. Yes great, Emma said pain levels, yes fantastic agree. And someone else said, how is he feeling and what are his concerns? Absolutely. There is lots of really good contributions here, so people want to know what his regular medications are, people want to know whether his symptoms are concerning him. Also, about his end-organ functions, so renal and liver function, which is great. And people are also interested in some of his symptoms like appetite, weight, sleep, mood, some of his mobility. Absolutely it is useful to know allergies. Yes, fantastic. So really, really good answers. And someone said goals of care. So I think it is always was very nice and thank you for that so far. So I think in terms of structuring how we ask those questions I am going to offer what we try and do in palliative care, but please obviously everyone has got their own system and framework in terms of how to do that, but I like to structure my notes that I am looking at, what are the physical symptoms, what are some of his psychological and emotional needs, and what are some of his social situations and his understanding, and then also what are his spiritual concerns or looking at aspects of what his whole person care looks like. And again if you are interested in having a look at that, I have done a previous webinar on that as well, so I do urge you to have a look at that if needed. So thank you for those responses. I cannot see the Q&A chat for some reason but I can see the other chat so yes, please keep typing in the chat not in the Q&A if that is okay.
 
And so you asked him and he says he feels reasonably well physically on his self-report. He does get some shortness of breath on short sentences. He seems to be worse after mobilising, and that is his shortness of breath, but he can mobilise around the house without assistance. He denies pain, but he does describe discomfort and as I am sure many of you are aware, lots of people do not like to use the word pain, they like to say I’ve got discomfort. So whatever language people use, I always try and run with that language. So if he is saying he has got discomfort then let us call that pain unless he can come up with a better way to articulate that. And I would assume that that is his way of describing his pain and then he says that that discomfort is in his left upper chest region and he has commenced first line chemo.
 
And that is his CT PET. So I am not a radiologist but for those of you who like scans, I kind of like looking at them because they have got nice pretty colours. So the yellow indicates that that is the area of his malignancy and you can see that that also encompasses a fairly close line with his, almost abuts, the pleura there, so he has got a reasonably good going amount of disease in his left upper lobe there. And so you would also note that he is got a lymph node involved there.
 
So, in terms of, again I am going to ask for some audience participation, what would you, which symptoms in particular would you like to treat? Which route of administration and type of medications you want to choose and why? And is there a role for any long acting medication? So yes, absolutely I think the symptoms I am getting answers as shortness of breath and discomfort or pain. Fantastic. So yes I agree, and I agree also that one of the suggestions was that he wants, that we should look at what he wants managed, and I think that is a very good suggestion as well. I think in terms of his route of administration and medication, how would we think about doing that? Is there any kind of ways that we can package that up that make it easier? And which would we be looking at? So I am getting a couple of different suggestions. Someone wrote Ordine, which is great. Someone is writing subcutaneous morphine, either oral or subcutaneous. Other people are writing kind of oral, topical, subcut. Lots of different ways. Patches. Look I think in terms of which is the most effective medication for him at this point in time, I think it would be really, really useful to go back to what is our context? So he is still very much eating and drinking. He is still very much able to swallow, so I think as someone has indicated in here, lots of people have already said this, but I think oral medication is probably the best point of call to start with. And oral medication in particular I would be looking at for both shortness of breath and for his discomfort or pain, we would be looking at Ordine. So thank you for the suggestions and well done. And I think in terms of there being a role for long acting medication, lots of people have already suggested looking at immediate release versus slow release or short acting versus long acting, whichever way you want to say it, it is the same deal, potato-potato, so I think the reality is that there is very good evidence to suggest that long acting medication can even play a role in this.
 
So when we are looking at treating that the answers I would have kind of offered were definitely pain and his dyspnoea or discomfort and dyspnoea. They are both responsive to opioids. Morphine oral liquid is probably the most reasonable starting point at this stage, and then looking at long acting morphine and its benefits even in you know, in small doses is very, very effective and I will run through that in a second. So just reminding yourself of the checklist as well. Make sure you are thinking about, and all of you have already mentioned this, but thinking about allergies, think about his renal function as obviously morphine accumulates. In poor renal function you have got to look at something else. Whether a person is opioid naïve, which route of administration you are going for. And then a treatment goal. So, again looking at what is the evidence for the use of morphine. There is level one A evidence to support the use of opioids for both breathlessness as well as obviously good evidence for use in pain, but particularly in breathlessness. There was a study by David Currow again and Johnson looking at morphine doses between 10 and 30 milligrams, even for opioid naive patients, which showed that the serious adverse effects are no more common than placebo. So I think you can be really, really safe thinking about using those even when people are opioid naïve. And I know that sounds challenging for some people, but there is, you know, these are large studies that people are looking at, so I think be comfortable using low dose opioids. And look, for this guy there is no reason why you could not start MS Contin 5 milligrams twice daily or whichever brand of short acting morphine 5 milligrams twice daily, or even looking at 10. But I think there is reasonably good evidence to suggest that that could be helpful. There is also good evidence to suggest that exertion related breathlessness responds to opioids as well.
 
So do not forget aperients in using opioids which someone very, very diligently wrote, thank you for that suggestion and I was going to say that as well. So do not forget opioids as a class effect cause constipation and they cause nausea. So we know they are going to cause these things. So make sure you are thinking about co-prescribing aperients. I do not really mind which one you do, but again, think about the most ease of use if you can for that patient population. And so I always try and think about people using small volume things and easy to use, so Dulcolax Drops is my go to because I think it is very effective and also very helpful because it is small amounts, whereas a lot of people like to use Movicol or big kind of sachet liquid things and I tend to find that people do not really like using that as much because there is so much volume. And then Coloxyl and Senna is pretty easy, so you can use both or single agents, depending on how you go. And then in terms of anti-emetics please think about using haloperidol. I always go to haloperidol as a first line. I think a lot of people again would probably use metoclopramide first line, but I would suggest definitely using haloperidol as first line. There is lots and lots of good evidence for ondansetron, particularly in the context of chemotherapy induced nausea, however I would not necessarily suggest it as first line, despite lots of people in the hospital using it as first line, and that is something that I think we all need to remind ourselves of, ondansetron is very, very good for specifically chemotherapy induced nausea but not so great for you know, every other kind of nausea and does have the complicating factor that it can cause some constipation. So I try and avoid it first line and think about using haloperidol if you can.
 
So in terms of his social situation, he feels supported enough by his neighbour. He is currently able to self-care and does not have any services in place. He is not registered with ACAT even though he is over 65. He could do that. And again, I think people mentioned this in the chat before, thinking about discussing his future planning and his goals of care, so well done for the people that mentioned that. I think talking about his advanced care planning is also really, really important and something that is hard to do in a general practice setting, but again it is about those themes of saying okay well, what can I do in my, you know, my five minutes of potentially having some effect on motivating people to change? And that motivation to change thing is really helpful in the advanced care planning phase or in the advanced care planning space anyway. So yes please, please do consider some of that if you do.
 
So someone has asked just quickly which dose of haloperidol would I normally use to treat for nausea? And I generally treat nausea with haloperidol 0.5 milligrams to begin with, and 0.5 milligrams to 1 milligram q. four hourly. So just for this guy for instance very, very quickly I would run with just 0.5 milligrams and do that and suggest that he can have that q. four hourly.
 
So you now get to see him and it is three months later. He is three months down the track and as you know, with this stuff people tend to not always visit their GPs as much when they are being heavily seen by the oncology teams, depending on where you are. But that is you know something that can happen. So he has not been seeing you for the last three months, but he is seeing his oncology team predominantly. Unfortunately, during this time he has got some disease progression despite chemotherapy, and he is now being on third line palliative intense chemo and he had his last dose five days ago, but has now decided to cease his chemo treatment and he is now kind of looking at really just telling his oncologist that and he is seeing them so that is fine. He comes today and he has got more pain and nausea. And his AKPS or his functional status is around about 40 to 50. So he is still out of bed and around about, you know, more than 50% of the time, and he is still a little bit reliant on using his neighbour for some assistance. So in terms of the pain, he is describing the pain as burning, shooting and around his left chest wall and for those of you that remember the CT PET scan, he has got a fair bit of disease in that area, so that is not particularly unexpected. The unexpected thing is though, that he is now been up-titrated to using about 5 milligrams of Ordine every four hours and he is using that you know, mostly kind of four to six hourly, and he is up to 60 milligrams twice daily of long acting morphine. And in terms of his nausea, he has had chemo five days ago as we said, but he has been on multiple regimens for his nausea and he has not managed to really kind of effect much change. And so in terms of what he does for that nausea, he has had Ondansetron, he has had Maxolon, he has had haloperidol, he has had Cyclizine and he has even had dexamethasone so he does not seem to be able to really get the nausea under control. So what can we do and what are I guess the suggestions? Can we call our local specialist pharmacist, because you know pharmacists know stuff and they are always a useful resource? Can we call the local palliative care community teams, because they are always very knowledgeable and can provide some suggestions as well. Can we call the local hospital, speaks to the palliative care C and S or C and C, or a specialist team? And I am getting some suggestions that maybe we could, absolutely use some neuropathic agents, which is a great suggestion. And then look at whether or not we should be thinking about NSAIDs. And someone has even offered the suggestion of methadone which I would agree is a very good NMDA receptor and has some nerve involvement, but specifically I would be looking at trying to start a non-opioid kind of adjuvant at this stage. And then someone else has suggested adding some neuropathics and thinking about the role of chest wall pain and radiotherapy in that case, and I think that is a fantastic suggestion as well. And then again, someone said, adding some neuropathics. So yes, really good suggestions people.
 
So, in terms of what dosing of the short acting morphine we can use, that is probably something that we should be thinking about, especially now, because he is on 60 milligrams of morphine twice daily. What can we do for the neuropathic pain? We have already kind of offered some suggestions for that, and someone has just recently offered a lignocaine patch, I am assuming that is what you meant by, or is LA patch long acting patch?  I am not sure, but you can offer, potentially lignocaine useful as well, but a long acting patch, yes lignocaine that is fine. So then I guess the other thing is, what can we use for his now what we would call refractory nausea? Because we have used lots of different things for his nausea and not really kind of getting much value out of the stuff we are using. So looking at the literature again, some of the things that have been suggested that can be really helpful in first line situations are things like SNRIs and so duloxetine really is probably my go to in terms of the neuropathic stuff. Tricyclics are reasonably good but, as you know, can cause some side effects so nortriptyline is actually better in terms of evidence than say amitriptyline. And then pregabalin is obviously something that lots of people use but is getting a little bit controversial in terms of its side effect profile and whether or not it is the best option first line. This was a 2015 systematic review as well, which included gabapentin as first line and even, I mean the second line agents I would not necessarily use very often at all, I hardly ever use tramadol and I would really not use capsaicin patches at all, but I would use lignocaine patches. I think they are reasonable.
 
And then there was another study in, a systematic review in 2020 which looked at specifically French populations, but I think it is a reasonably good systematic review as well, and they said predominantly that SNRIs should be considered first line, and also that interestingly, that pregabalin is now recommended second line from their systematic review. And psychotherapy is also recommended second line as another addition to therapies which can be useful for neuropathics. So look, I think that we can safely say that one of the SNRIs is probably quite useful. The tricyclics have been long standing and very good evidence base, but I would probably say that the things that are changing in this space and probably thinking about using less pregabalin as a first line option. So that is probably the takeaway for that. Someone has offered, Emma has offered, that perhaps we could discuss evidence for cannabis, but look that probably, this is not the forum to do that and the evidence is very, very limited. But yes I would urge you to keep asking those questions and maybe someone else will do a webinar on looking at cannabis in that setting.
 
So what I would suggest we do is look at his pain management and then think about using at least a sixth to a tenth of his 24 hour dose as the short acting dose, and then I would also look at changing therefore that 5 milligrams to at least 15 milligrams because that would be more in line with his 60 milligrams twice daily, which is obviously 120 milligrams of morphine in 24 hours and then using a sixth to a tenth of that. I mean a tenth is 12 milligrams, so really using something in that pocket will be more reflective of his opioid requirements and more likely to potentially utilise that more effectively. And so I would probably start him on duloxetine and the evidence in terms of duloxetine is that it starts its pain management effects within the first three to five days, potentially, whereas the mood effects obviously take a lot longer. So I would be saying that duloxetine is a reasonable thing to start although you know potentially, we could be looking at starting one of the TCAs as well, like nortriptyline or amitriptyline, depending on what you are more comfortable doing. And again it is about what you are more comfortable doing and what you are used to in terms of medication. And then interestingly, I thought this was a point that some people might already know because it is been around for a while, since a 2014 systematic review looked at olanzapine for chemotherapy induced nausea and we use olanzapine a lot off label. When I say a lot it is more something that I would use after I have tried one or two other medications for nausea and I would use it probably third line or even fourth line, but I think it is very good to keep in the back of your mind. It can be very, very useful for refractory nausea and particularly chemotherapy induced nausea and was used a lot as breakthrough nausea, so even when someone is on another anti-emetic you can add in some olanzapine. Obviously there is some sedation potentially at higher doses, and also the effects on blood glucose and weight gain and so, so you know you have got to use it in context, but I think it is also very useful to think about as one of those things that you can use off label. And not very expensive anymore. It used to be expensive, but not very expensive at all.
 
So now, you see him two weeks later, and this is I guess where the crossover with palliative care and potentially kind of looking at the start of life and the end of life, where you start to see people you know kind of monthly or three monthly, and then you start to see them second weekly and weekly, and then in the same way, this is kind of what happens in the end of life as well. So you see him two weeks later for review. He has been linked to the palliative care community nursing support team, which is great. He is now brought to the clinic by an ex-partner who has moved into his house to help look after him, which is very, very common as everyone probably knows. He has noticed significant pain improvement since you started him on his neuropathic agent whichever one you ended up choosing. And his nausea is now subsequently resolved as well. He now presents with increased shortness of breath and anxiety, and he has also had some difficulty sleeping. So I guess the question becomes which single medication can you use and can be useful for all three of those things combined, some shortness of breath, anxiety and sleep, and I think someone already mentioned that back earlier and I think someone said yes, so one of the suggestions I have got coming through is lorazepam and I think lorazepam is a great option. And someone else has suggested clonazepam. Look, I think using one of the benzos is probably again a really good option. My go to in this situation would probably be lorazepam only because, in terms of its route of administration it is a sublingual tablet. It does come in a tablet but it is a sublingual kind of tablet so you can just put it in the bottom of someone’s mouth and it will dissolve, which is very helpful. Clonazepam I find difficult to titrate effectively for people in terms of the drops. So I would probably urge people to be cautious about using clonazepam because you give people the drops, and then they go home and they try and use it and they are not really sure about how many drops and how much is each drop, and so I think that can be a little bit tricky. So I usually start with 0.5 to 1 milligram of lorazepam twice daily, and then if this person has some kind of tolerance having a past history of some amphetamine use, you often get some cross tolerance anyway, so I find it generally safe to start people on if you just wanted to be very cautious, you could say just use it at night and then go to up-titrate to b.d. a couple of days later, and then start to use it t.d.s. as needed so p.r.n. And I think that can be really helpful. It addresses his anxiety, it will address some of his sleep issues. And yes obviously it is titratable as well, so that can be helpful.
 
You now see him six weeks later. He has been at home and he is almost completely in his bed or his chair and so his AKPS or his Karnofsky score has now dropped to about 30, so he is almost completely bed bound or chair bound. His palliative care community team have given you a call and they suggested that he is now phase three, meaning that he is deteriorating. He has presented with new onset confusion, headaches and visual changes and his ex-partner is describing vacant episodes and you have got lots of bells going off in your head thinking what the hell is going on here and yes, he got sent to ED. He was seen in ED and he actually ends up having multiple brain mets which someone has already suggested, so well done. I am sure everyone was thinking that anyway and that is the thing that you really need to try and exclude, especially in a non-small cell lung cancer, it is very common for that to happen, to get brain mets. He, of course, has decided that he wants to go home immediately and does not want anyone to do anything and wants to have his end of life care at home. So you discuss that with his ex-partner and his neighbour and they are agreeable to take care of that. So I guess in terms of you being the GP in this scenario and a GP VMO perhaps in a rural setting, what are the key kind of messages that you are trying to relate to the family and the carers, the ex-partner and the neighbour? What are some of the things that you will anticipate will be required for end of life care medication? And what do you really need to and who would you be communicating with?
 
I have already got some suggestions in terms of medication as dexamethasone and Stemetil. Look Stemetil is not probably my favourite drug. I probably would not necessarily use this in this situation. But if people can offer I guess what you think would be pretty useful in terms of end of life care medication at this point, that could be good. And then also I guess the key messaging, I have got some suggestions here that we need to talk to the family about spirituality in addition to medications, and absolutely I would agree with that. I think that is the mainstay of kind of what we do in palliative care, although I am really trying to focus this talk specifically on prescribing habits and why we do things but absolutely I think that is the most important point, so thank you for saying that. Talking about a plan for death is really helpful, as well as a suggestion someone has given. And making sure that they have contact details for the GP after hours service someone offered, and that is fantastic. Also, thinking about, someone else has said, the role of palliative care versus GP, what to expect. Not to call an ambulance and the reasons why, and an advanced care directive that is documented and accurate is all very, very good ideas. An ambulance plan someone suggested, which is again something that can be useful. And then thinking about end of life care medications people have offered things like morphine, midazolam, haloperidol. Talking about subcutaneous medications and talking to community palliative care. So yes all very good and all very helpful suggestions. So well done.
 
I think, look at the moment I would be saying and trying to get the message that yes, plan A is go home. But plan A is fantastic but plan B is you really should be doing whatever is the safest place of care. So if plan B is see plan A, then that is fantastic as long as it remains safe. But they really need to be safe and that is both for the family and carers as well as for the patient. So absolutely as someone suggested, Louise I think that said, if they get scared and they need to come back to a hospital if needed, and yes I think that is that is really where it is at. So interestingly, when people are surveyed at end of life, as opposed to being well, their common response is they want to be in a safe place of care, not necessarily at a location, and I think that is very reflective of this space as well.
 
So consider clonazepam I think in seizure prophylaxis is always very helpful because we are worried if he is just got new brain mets and he has been having these vacant episodes. I would be worried about whether or not he is having some seizures. And you can use subcutaneous clonazepam 0.5 milligrams twice daily as a seizure prophylaxis, or you can put in a pump or you can send them home with drops, depending on again context and trying to work out what is most useful. And then, considering anticipatory end of life medications for prescribing. So something for pain, something for nausea, confusion, delirium, something for agitation, distress, and something for secretions. And again communicating that with the palliative care team to assist in the community, and then considering even a discussion with your friendly pharmacist is probably a good idea.
 
So what is the big four? I always like to talk about the big four in end of life and they are obviously something for pain and usually in this case we would be looking at morphine because he is already on it, it seems to be working so we definitely use some morphine. So we would be looking at using all those subcutaneously now, given that we are worried about whether or not he can swallow. If he has got brain mets and he is just you know, potentially having seizures, I think making things as simple as possible and trying to use one route of administration to simplify things can be very helpful, especially towards the end of life. So subcutaneously I would be going for that, as well as looking at something for nausea, confusion and delirium.  And so haloperidol becomes that drug that is very useful for both nausea at lower doses, and then for delirium and confusion at higher doses. So you can utilise both of them in different dose ranges and use that four hourly which I think is also very helpful. And then, using something for agitation, distress, whether that is midazolam. I would avoid using the longer acting clonazepam as agitation, distress, whereas midazolam is shorter acting and therefore you can give it one to two hourly. And I think that is a safer option. Otherwise, if you start utilising clonazepam in that way, more frequently, it just accumulates and then you are really sedating people and that is probably not the intent of treatment here at the moment. And then something for secretions like Buscopan, which can be very helpful. So that is your big four. Obviously people know that already, just remind yourselves of that.
 
So just in terms of his update. You are called by the community palliative care nurse to start a syringe driver. And then the nursing team described that they can also hear some audible secretions, so again we are converting everything oral to subcutaneous. You add the benzo for the seizure prophylaxis as we talked about, we add an anti-emetic and an anti-secretory. So all four of those can go into a subcutaneous infusion pump, as people have already kind of indicated. Yes, syringe driver is fantastic, so yes you guys are all over this, well done. And absolutely I think someone has talked about how we are going to make sure that we are looking after the carers, and I think that is incumbent upon us to make sure that we are caring for the carers as well, and looking after their needs and referring them back to plan B, as the safest place of care if that is not going so well. So that is the vital role that the community pall care team can play in this, and they do a fantastic job of that, and I am sure that for a lot of GPs out there, GPs play that role as well. So well done and keep doing that.
 
So yes just quickly clonazepam and some of those dose equivalents are useful to kind of snapshot in your head. My conversion ratios for subcutaneous midazolam, so 2.5 to 5, roughly 5 milligrams I use of midazolam as 0.5 milligrams of clonazepam. So just in terms of understanding, making sure that you are using those kind of equivalents and lorazepam 1 milligram is around about 5 milligrams of midazolam, so just understanding that so that you are using those doses appropriately.
 
So I might move on to case two because you have not got all night to talk with me, even though yes, I am sure I could talk for ages. So a 77-year-old woman with ovarian cancer diagnosed in February 2021. She has a past history of hypertension and elevated cholesterol. She lives at a residential aged care facility and has done so for several years. She has multiple family members interstate who are her default decision makers. And she is documented that, and that is all in place. She is a retired family court scribe so that is why she is very organised and she managed to get all these in place already. And she is mostly really kind of independent, but is, yes needing some kind of care. So she is in the lower kind of care level of the of the residential aged care facility. But you know her PCOCs was pretty good and she is really not doing so badly you think. And you are asked to take a phone call from the residential aged care facility about her and the nursing staff advised that she has been really, really fatigued. It is not like her, and she is in bed, and she does not have any appetite. But the residential aged care facility is saying that the family is requesting a GP review. And you have not really met her before but what would you like to know?
 
So can I get some chat suggestions before people fall asleep in terms of what you think would be useful to know at this point? So someone is offered a dietitian input. Yes, absolutely I think that has a role, potentially, as to why she is not eating and has decreased appetite. Yes, has she had any weight loss? Yes, I think that is a good suggestion. People are offering potentially basic obs and a temperature. Yes, I think that is also good. Physical examination stuff is always helpful. Other people are asking maybe whether it is a mood related thing, is she depressed? How long has symptoms been going on is another suggestion. So yes all very good stuff. I think someone also has said that we should be thinking about her advanced care directive which is fantastic and end of life care plan.  And in some detail well, so thank you for that suggestion. Oral versus IV antibiotics, which I think is also yes good to know. Transfer to hospital, and whether or not that is something that they have talked about. So yes, people have also talked about constipation which is fantastic. Yes so excellent, very good suggestions and thanks for still staying awake. And, well done, that is very good.
 
So she has had no surgical intervention whatsoever to date for her ovarian CA. She does not want chemo and does not want any radio, and she has decided that she does not want to go to hospital. And she actually has had a capacity assessment and someone has just offered, does she have dementia? So thank you, but yes, she did have a capacity assessment very recently by her very friendly geriatrician and the geriatrician has decided that she definitely has capacity and her default decision makers are there, but they are documented, but you know obviously, given her capacity she is okay. The ovarian cancer looks like there is some peritoneal involvement and a lymph node involvement as well, and so I think, trying to understand how that can play out is also going to be helpful. So you have a chat to her and she has had increasing fatigue over the last two weeks, she describes constant nausea and small infrequent vomiting. Her bowels have not opened for five to seven days and now some alarm bells are starting to go off in your head. And her abdomen is distended. She is got absent bowel sounds and she has got some intermittent pain that she described as kind of cramping and, given that she had this kind of pain, one of your colleagues has decided to prescribe some Norspan, a patch about two weeks ago. So she has also been on that.
 
So, suggestions from the floor. I have got Deb suggesting that we might have a bowel obstruction. I like your thinking, Deb. Any other suggestions or thoughts from the floor as to what we think could be going on? What do you think is happening and given that she insists on not going to hospital, if we are assuming that this is either a progressive metastatic process, which was the other option or offering, thank you, from the floor, and or it is a bowel obstruction, what could we do to manage this potentially in the facility? And then, what can we kind of communicate to the family? So I have had a couple of suggestions, thank you. Just looking, some people have offered Coloxyl drops, severe constipation as a possibility, she could be getting ascites. Yes, they are all very good suggestions. And then is she willing to have any investigations is the question. And I guess, and then the next thing was does she want a nasogastric tube and could we look at changing some of the medication? So I think they are all very, very good suggestions. I think, knowing that she is insistent on not going to hospital and she still has capacity, I think we need to keep that in mind in terms of investigations and explaining to her that this is what we think it is, but unless we get a clear indication of that then we are going to have to run with the best case scenario. And so my offering would be that I think she has a likely bowel obstruction and usually that would be a functional rather than a mechanical obstruction secondary to an ovarian cancer, which is very, very common. And I think in terms of how we messaging this for her and discussing this, we would be talking about a reversible versus a non-reversible bowel obstruction. Now, you might be thinking what is he talking about because we cannot really reverse a bowel obstruction unless we chop you know some bits out of it, if there surgical intervention or something. But realistically, we can still offer some conservative management that may or may not partially resolve the bowel obstruction. Yes, she is a very good candidate for repeated bowel obstructions, but there is some medical management that we can offer, even in a residential aged care facility to potentially alleviate all that, well potentially reverse that. We can revisit her goals of care with her family, because she has got lots of them, and we can also talk to her. And we can liaise with the community palliative care team who may or may not go out to visit the residential aged care facility, as well as in our area, we are fortunate enough to have very clever nurse practitioners to go out to the residential aged care facilities as well, so talking to those people and getting them involved, I think is also a very useful resource and things to do.
 
So someone has also offered lactulose as a possibility, so keep in mind people that, if we think someone has a bowel obstruction, trying to give them things to stimulate their bowel is probably not the best idea. So if she is still able to swallow then using a softener is the first port of call. So using something like docusate by itself without the Senna component is very, very helpful, but using things that can stimulate the bowel are not necessarily going to be the greatest idea at this stage.
 
So, suggestions I guess that we would be looking at are ceasing oral intake really because we want to make sure that we are giving her bowel a rest and then trying to convert everything to the subcutaneous route if that includes potentially giving her some fluids, then maybe that is something that we can look at, again depending on what is our goal of care. Are we trying to potentially alleviate this bowel obstruction and promote the longevity of her life, and in that case I would be thinking about communicating that with her family and potentially looking at a short period of some subcutaneous fluids in addition to making sure that we are giving her treatment for her vomiting and her distention with anti-emetics, anti-secretaries, some dexamethasone and analgesia. Now people might be scratching their heads going why is he doing this? Because we are giving fluids, and then we are giving anti-secretaries. But actually the point of the anti-secretories is to reduce the secretions within the gut lumen and within the bowel. And then, also the dexamethasone is to reduce the swelling or oedema around the bowel when we have some kind of obstruction.  So anti-emetics for the vomiting, the anti-secretories and dexamethasone for the distention and hoping that that can potentially medically manage or reduce the possibility of that bowel obstruction being a permanent thing and potentially resolving that. Now how often does it help? Look, it does actually. I can tell you that I have used subcutaneous infusions of Buscopan and haloperidol and it does work, in addition to giving dexamethasone as a once daily dose of 4 to 8 milligrams in the morning. Why do not we put dexamethasone in a subcutaneous infusion pump? Because it keeps people awake. So giving it in the morning is fantastic, but infusing it over long periods of time is not so great and yes it is not ideal in terms of making sure that people get some sleep.
 
The other things I think we can be doing here is adding some anticipatory end of life care subcutaneous medications just in case, so that the nurse practitioner or the nursing staff at the residential aged care facility have something for her on hand to treat if necessary. And obviously we do not need to use those if we do not need to use them, but it will be very helpful to have those just in case, so that the nursing staff do have an escalation plan to work with, and that means that they have the big four, right? As long as you have got a representation of the big four, then that is fantastic, because then the nursing staff can manage those situations and manage her symptoms more effectively.
 
A bit of controversy about the patch. I would leave it in place. I just would, yes, it is not worth the effort of trying to take it off and convert it and everything. Leave it there, know it is there, and then make sure that you are titrating things according to what she has already had, so I do not think that is a problem. In terms of, you might be wondering which opioid is the preference in terms of avoiding further constipation, because obviously this is a woman with bowel obstruction, we do not want to slow down her gut too much. But pain is an important thing to treat. So fentanyl is the best option in terms of avoiding constipation. It is the least constipating of the opioids, but also the least effective in terms of pain relief. So if her pain is not too bad, you could potentially get away with using some fentanyl. But if it is not so great, then I would probably be looking at using small amounts of hydromorphone which is much more effective, but yes, is equally kind of constipating in terms of morphine and hydromorphone. So yes, it is again, it is about whatever you are comfortable using. Remember the opioid App on from ANZCA, the opioid calculator, so that you are more comfortable using these. I will not go through that tonight, but it is something that you should all have in your phones. Everyone has phones and they are fantastic. But yes it is a very easy App to look at so please do that.
 
So you get an update from the nursing home about JL a couple of weeks later, and yes people can sometimes go for a while with a bowel obstruction. She has had progressive decline. She has been assisted by the very friendly nurse practitioner at the residential aged care facility and she is been having some subcutaneous medications. She has now got to the point where she is unconscious and very controversially, the family have decided that the nursing home is not safe and looking after and want her transferred to hospital for her end of life care. I am sure many of you have seen this happen. I certainly have seen it happen quite commonly and it is disappointing because I think one of the things about people wanting this ability to die at home is also recognising that a residential aged care facility are people's homes and if people want to die at home then the home becomes the residential care facility. So I think keeping that in mind and trying to communicate that with families is very challenging, believe me, I find it very challenging, but it is also I think, very good to keep in mind that we do mention that. And yes, this woman ended up dying in hospital unfortunately for her, but actually yes, that was you know, something that does happen, and sadly does continue to happen.
 
So in summary, I think consider that context of prescribing in palliative care. It is probably one of the most important things and context is always king for these situations, so please remember to do that, as you probably already do. Many medications have multiple uses. That sounds like a tautology but yes it is true in palliative care that we use multiple different medications for many different ways of getting symptom benefit and so please have a think about using those in the most efficient way and if you are unsure please give us a call, or please use one of the multiple kind of Apps I think people talked about before some of the different Apps that are available. So yes, please look at those as well. And then consider using an SNRI or TCA for neuropathic pain, again controversially I will note that I have not used pregabalin in that list, but yes, I think in moving away from that as your first port of call for neuropathic pain is probably something to think about. And for those of you who are more interested in this space, I think thinking about methadone is one of the things that I am really into, and I think that is something that we can chat about at another time. And communicate your thoughts with patients, families and carers, because it is amazing how effective that can be. Often I make a whole lot of assumptions about people's understanding of things and communicating that as effectively and as clearly as possible is really useful. And please, please, please ask for help from your many, many clever people in the community, such as community palliative care nurses who know a bunch of stuff that I did not know, and yes, and still kind of am learning from. So please use them as much as possible. Ask your friendly pharmacists and also contact us or your local palliative specialist, palliative care service, if you need to.
 
I might open up the floor to questions in the chat if anybody has some burning questions that they were thinking of, or comments. But yes, please feel free to chuck a couple of questions in there, or even make suggestions for things that we could perhaps visit for the next talk if that is something that you would be interested in. So someone has offered, is there anything for appetite stimulation and suggestions? Yes, good question. I think dexamethasone is useful as an appetite stimulant. It is also obviously used as an anti-emetic and as we saw also used for reducing gut oedema in terms of a bowl obstruction. It is probably the go-to appetite stimulant that we tend to use in palliative care and again, we need to balance that with the risks of side effects, most predominantly the proximal weakness that you get in shoulders and hips, and I think that is you know, not so helpful, so making sure that we are doing that, but also reviewing that regularly. So if you put someone on dex, the short version is make sure that you review that a week later, and if they are not getting the same benefit that they were then dose reduce it and wean it. But most importantly, wean it, because yes, weaning is important.
 
The App that I mentioned is called the opioid calculator, which is the App that everybody should be using. I would encourage you to use it. If you go to your Play Store or iPhone stuff it is called the opioid calculator. It looks like that, on oh that is terrible you cannot see it. It is a green App done by ANZCA, so the Australian and New Zealand Anaesthetic College. So yes please, please use that. I think that should be the standard App that everybody uses and it is certainly the one that we use here in the hospital and the one that I recommend to use for everybody.
 
And Louise has asked if there is anything about nebuliser Lasix for shortness of breath. In the current context nebulisers are very much out of fashion Louise, but I yes I think that it has been used in the past. People have used nebuliser Lasix for shortness of breath. People have used nebuliser morphine for shortness of breath. The evidence is pretty small to be honest, and a lot of those studies really found it hard to get any appreciable benefit versus using liquid or tablet form of morphine. So not as effective. Sounds like a good idea, I agree, I actually had a colleague who tried to do a study on using nebulised morphine for a while, but did not really kind of get very far with that. So, yes it is pretty much long acting opioids and then yes, absolutely looking at the oral kind or subcutaneous forms of that as well.
 
So someone also asked is there any role for mixing many different opioids? I saw a palliative care patient on methadone, fentanyl, oxycodone. Look, Dave good question, and probably beyond the scope of this chat for my two second answer, but I think it is a really, really good question and I always try to tell people to think about simplifying opioids as much as possible. I think having three different opioids in the mix is probably a little bit unnecessary, and trying to keep it as simple as possible is my take on these things. I think methadone is probably in the not so much another opioid addition, whereas I think a methadone in particular should be seen separately to the other opioids because it is a separate class in terms of its neuropathic and NMDA receptor activity. So I think if anything, that is probably the only one I would say you can use multiple of, but certainly try and keep it as simple as possible.
 
And someone else has asked how do you convince oncologists to pull the pin on futile treatment? Wow is that not a good talk for the next time? So maybe we can talk about what we describe as futile treatment and then whether or not it is something that is controversial. Maybe we can get an oncologist to come and talk about futility and treatment as well. It is definitely a space that I am interested in and definitely something that we are looking at doing a collaborative study with the oncology team as well, but I think it is something that yes, is an ongoing space so yes, happy to chat about that at another time.
 
And someone has asked about de-prescribing, and my thoughts and method on that. Again, probably beyond the scope of my short answer today, because this is about to end. But thank you all for your attendance and yes, really look forward to perhaps having another chat sometime. So thank you very much.
 
Chantelle Vonarx: Excellent. Thank you so much, Arron. A very interesting talk there, I am sure everyone agrees. So yes, we will be ending this evening's talk. So just wanting to thank again our sponsor Ochre Health and Recruitment and also thank you to all of our attendees for joining us this evening. So just a reminder to complete the evaluation form that will pop up in a new window once the webinar session closes. It takes no more than a minute to complete. And certificates of attendance will become available on your CPD statements next week, but for any non-RACGP members who would like a certificate of attendance, please just email rural@racgp.org.au. But on that note I would like to thank everyone again and wish everyone a great long weekend.

Other RACGP online events

Originally recorded:

1 April 2021

This instalment of the Rural Health Webinar Series will explore prescribing habits that are particular to palliative care. GP participants will learn about effective prescribing and how certain medications can be utilised to improve symptoms in palliative care patients.

Learning outcomes

  1. Select appropriate medications for multiple purposes in a palliative care setting
  2. Identify options for adjuvant analgesia when opioids are ineffective
  3. Confidently engage in therapeutic treatment discussions between health professionals (including pharmacy, palliative care, and nurses)
This event attracts 2 CPD points

This event attracts 2 CPD points

This event is part of Rural Health Webinar Series. Events in this series are:

Presenter

Dr Arron Veltre
B.AppSci(Hons), MBBS, FRACGP, FAChPM

This webinar will be facilitated by Dr Arron Veltre (B.AppSci(Hons), MBBS, FRACGP, FAChPM). Arron is a Palliative Care Specialist working in Manning Base Hospital (Taree). He is also the Clinical Dean at the Manning Campus for the University of Newcastle Department of Rural Health (UONDRH). His research interests include emotional wellbeing and Advance Care Planning. He has a special interest in the alleviation of suffering and the improvement of death literacy in the community. He spends his *spare* time drinking coffee and riding bicycles... often while contemplating death.

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