Katri Elina Clemens

Is There a Higher Risk of Respiratory Depression in Opioid-Naïve Palliative Care Patients during Symptomatic Therapy of Dyspnea with Strong Opioids?

OBJECTIVE Dyspnea is a highly prevalent symptom in palliative care patients. Opioids are the first-line therapy for symptomatic relief of dyspnea. However, respiratory depression is still a feared side effect of therapy with WHO III opioids. The risk of respiratory depression in opioid-naïve patients and in patients pretreated with strong opioids during symptomatic therapy of dyspnea was investigated in palliative care patients. PATIENTS AND METHODS Twenty-seven patients were included in a prospective, nonrandomized study. All patients suffered from moderate to severe dyspnea. Transcutaneous measurement (earlobe sensor) of carbon dioxide partial pressure (tcpaCO(2)), pulse oximetry oxygen saturation (SaO(2)), and pulse frequency (PF) were monitored with SenTec Digital Monitor (SenTec AG, Therwill, CH). The following monitoring data were compared: baseline recording for 15 minutes, and 30, 60, 90, and 120 minutes after opioid application. RESULTS The data obtained with transcutaneous measurement showed that there were no significant differences between the groups of opioid-naïve patients and those pretreated with strong opioids with regard to tcpaCO(2) increase or SaO(2) decrease after the first opioid application. Neither SaO(2) decreased significantly nor tcpaCO(2) increased significantly after the initial opioid application, which means there was no opioid-induced respiratory depression. The first opioid application, however, resulted in a significant decrease in the intensity of dyspnea and respiratory rate. CONCLUSIONS No higher risk of respiratory depression and increase in tcpaCO2 in opioid-naïve palliative care patients, compared to patients pretreated with strong opioids, during symptomatic therapy of dyspnea with strong opioids could be found.

Management of constipation in palliative care patients.

Purpose of reviewConstipation is a common symptom in palliative care patients that can generate considerable suffering due to both unpleasant physical symptoms and psychological preoccupations that may arise. There is uncertainty about the choice from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review is to evaluate the current recommendations of therapy guidelines and to determine the effectiveness of laxative administration for the management of constipation in palliative care patients. Recent findingsRecent findings in the literature include an updated version of the Rome criteria and related information on the functional gastrointestinal disorders, as well as information on opioid antagonists. Knowledge of the role of definitions, causes of constipation and the pathophysiology of opioid-induced constipation must be given a high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. SummaryThe treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient randomized controlled trial data. Recommendations for laxative use can be related to efficacy. Particularly in patients with advanced-stage tumor disease this must be undertaken with careful consideration of their physical activity and dietary needs.

Bowel function during pain therapy with oxycodone/naloxone prolonged-release tablets in patients with advanced cancer

Background:  The World Health Organization (WHO) step‐III opioids are often required right from the start of pain therapy in order to achieve sufficient symptom control. Bowel dysfunction, particularly constipation, is one of the most frequent and persistent side effects of opioid therapy, and it is known to cause considerable distress in many patients. The aim of the study was to evaluate whether patients with advanced cancer and moderate to severe cancer pain will benefit from treatment with oxycodone/naloxone prolonged‐release tablets (OXN), with particular regard to constipation.

Evaluation of the Clinical Effectiveness of Physiotherapeutic Management of Lymphoedema in Palliative Care Patients

OBJECTIVE Lymphoedema is a common sequela of cancer or its treatment that affects lymph node drainage. The physiotherapist, as member of the multiprofessional team in palliative care, is one of the keys to successful rehabilitation and management of patients with cancer and non-malignant motoneuron disease such as amyotrophic lateral sclerosis and palliative care needs. The aim of the study was to evaluate the frequency and effect of manual lymphatic drainage in palliative care patients with lymphoedema in a far advanced stage of their disease. METHODS Retrospective study (reflexive control design) of data of the 208 patients admitted to our palliative care unit from January 2007 to December 2007. Demographic and disease-related data (diagnosis, symptoms, Karnofsky performance status and effect of manual lymphatic drainage interventions) were documented and compared. STATISTICS mean ± SD, median; Wilcoxons test. RESULTS Of the 208 patients, 90 who reported symptom load due to lymphoedema were included; 67 (74.4%) had pain, 23 (25.6%) dyspnoea due to progredient trunk oedema. Mean age 65.5 ± 13.0 years; 33 (36.7%) male; Karnofsky index 50% (30-80%), mean length of stay 15.6 ± 8.0 days. The mean number of physiotherapeutic treatment interventions was 7.0 ± 5.8. Manual lymphatic drainage was well tolerated in 83 (92.2%) patients; 63 of 67 (94.0%) patients showed a clinically relevant improvement in pain, and 17 of 23 (73.9%) in dyspnoea. CONCLUSIONS The majority of the patients showed a clinical improvement in the intensity of symptoms after manual lymphatic drainage.

Attitudes toward active euthanasia among medical students at two German universities

AimThere has been an ongoing debate about a legalisation of active euthanasia (AE) in Germany. Palliative care education in German medical schools seeks to foster and cultivate a negative attitude toward AE, but little is known about its effectiveness in this respect. The aim of this study was to assess attitudes toward AE among students with and without palliative medicine tuition (PMT).MethodsThe link to an anonymised online questionnaire was sent out to 1,092 third, fifth and sixth year medical students (YMS) in August–November 2006 at two German universities: university one (U1) with compulsory and additional optional PMT and university two (U2) without any PMT. Thirteen questions addressed active, passive or indirect euthanasia and physician-assisted suicide (statistic: mean ± SD (range), Wilcoxon, Whitney U Test, significance p < 0.05).ResultsResponse rate was 17.5%; 59.2% of the questionnaires were returned from U1 and 40.8% from U2; 28.3% of the students were male. Whereas 50% of third YMS at U1 and 36.7% at U2 favoured a legalisation of AE, this was true for 22.4% sixth YMS at U1 and 35.7% at U2. At U1, the number of students who would want to make use of AE for themselves decreased considerably (70%-44.9%) but less at U2; main reasons were ‘unbearable suffering’ and ‘circumstances that lack dignity’. Of all students, 21.1% at U1 and 37.2% at U2 could imagine to perform AE in patients, even though 72.6% at U1 and 78.2% at U2 think its legalisation would promote misuse.ConclusionsThe high proportion of pro-AE attitudes gives reason to reconsider both ‘standard’ and palliative medicine tuition for medical students.

Managing opioid-induced constipation in advanced illness: focus on methylnaltrexone bromide

Constipation is a common symptom in palliative care patients which can generate considerable suffering. There is uncertainty about the choice of treatment options from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines for the management of opioid-induced constipation in palliative care patients with a focus on methylnaltrexone bromide. Recent findings in the literature and related information on the opioid-induced gastrointestinal disorders in patients with advanced illness, as well as information on the opioid-antagonist methylnaltrexone, are discussed. Knowledge of the role of definitions, the causes of constipation and the pathophysiology of opioid-induced constipation must be given high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. Opioid-induced constipation and its adequate treatment is an important issue for patients with advanced illness and also poses therapeutic challenge for clinicians in daily routine. Methylnaltrexone bromide may represent an important therapeutic option for palliative care patients who are suffering from opioid-induced constipation with failure of conventional prophylactic oral laxative treatment.

Palliative care in developing countries: what are the important issues?

Whereas the number of palliative care services and clinical and educational programmes is increasing rapidly in Western industrialised countries,1 the extent of establishment of urgently needed clinical and educational palliative care programmes in the developing world remains at a dramatically low level.2 The great majority of the world population, however, lives in developing countries. Despite great geographic, ethnic, and socioeconomic diversity health care issues in these regions of the world reflect a number of common features.2–4 Natural disasters and war frequently cause famine leading to relocation and/or death of large numbers of individuals. In addition, low-income populations frequently suffer from chronic malnutrition with consequent long-term health implications. Reasons for limited treatment and care include excessive costs for health care,5,6 insufficient availability, lack of health care professionals, lack of infrastructure, limited research into specific needs, limited academic links and education among health care professionals and structural exclusion of rural areas, mismanagement of resources, misunderstandings, wrong assumptions and false beliefs regarding health issues. Palliative care can be provided using limited resources with minimal infrastructure support. One of the most notable examples is the Neighbourhood Network in Palliative Care (NNPC) in Kerala, India, a grass root level movement in palliative care. It relies on the local community to identify patients in need of help, plan strategies and help them with active support from health care professionals. The service covers a population of more than 15 million. In some districts coverage for patients in need of palliative care has reached to more than 60% of the population compared to a national average of around 1%.7 Unfortunately, some administrative, clinical, and educational leaders in the developing world believe that palliative care is a luxury that cannot be afforded by countries that do not have the means to provide many of the needed basic curative interventions for their population. Nevertheless, in most of the places where NNPC is active, the movement has also been able to convince the local governments to take an active role in the care of the incurable, chronically and terminally ill. Many local governments in the Kerala region are now taking a lead role in NNPC programmes.8–10 It has been observed that the most significant barrier in the development of such programmes is an inflexible, hierarchical, organisational structure with limited input from the grass root levels.11 The socioeconomic realities of low-income regions make it essential that palliative care programmes are able to deliver education, medications and food free of cost to patients and families. It is impossible to expect the great majority of the population to pay or even to be able to travel to areas where care is delivered. Difficult terrain and lack of facilities and resources for transportation make the need for home care services greater in the developing than in the developed world. In Namibia, for example, highly successful programmes for the control of tuberculosis were achieved by tying together directly observed tuberculosis drug therapy with the administration of food to the patient and family which dramatically increased compliance. It also reduced the gastrointestinal side effects of these drugs by allowing patients to take them together with their meals.12 Patients were also encouraged to participate in light work by keeping vegetable gardens that were used for nutrition. This mild exercise had beneficial metabolic effects and major psychological benefits for patients and families. Returning to their communities, patients introduced this method to their neighbours. Programmes like this have a sustainable impact on the quality of life of whole communities. A needs-based holistic approach can be achieved without increasing the necessary expenses of the general, usually curative-oriented health care system. Taking into account the different socioeconomic and social conditions and in order to be successful, palliative care programmes in developing countries will have to be Palliative care in developing countries: what are the important issues?

Pharmacological treatment of constipation in palliative care.

Purpose of reviewThe prevalence of constipation in palliative care patients varies. There is uncertainty about the choice from varying recommendations for pharmacological management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines and to determine the effectiveness and safety of laxative administration for the management of constipation in palliative care patients. Recent findingsDespite the clinical importance, there are limited data on the efficacy and safety of laxatives in palliative care patients. The social acceptability varies from country to country, but overall, oral laxatives should, where possible, be used in preference. Systemic opioid antagonists, such as naloxone and methylnaltrexone have been studied in few clinical trials. There is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from constipation and treated with pharmacological methods. SummaryThere are limited data available on the conventional pharmacological treatment of constipation in palliative care patients due to insufficient randomized controlled trials. However, subcutaneously administered methylnaltrexone was found to be effective in aiding of laxation and well tolerated with limited or transient side effects in palliative care patients.

Update on combined modalities for the management of breathlessness.

Purpose of reviewBreathlessness is a symptom which is felt as shortness of breath or tightness in the chest. The symptom of breathlessness is essentially an awareness of difficult respiration; in other words, respiration becomes an effort. The increase due to pathological change supplements the effect of exercise. In this article, the combined modalities of palliative management of breathlessness are discussed on the basis of current literature (published and indexed in PubMed from January 2009 to week 1 in January 2012). The findings were used to derive a treatment algorithm for the management of dyspnoea. Recent findingsThe findings in the recently published literature with treatment recommendations for the management of breathlessness were scarce. Although there are multiple clinical trials regarding treatment of breathlessness, there is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from breathlessness and treated with combined pharmacological and nonpharmacological methods. SummaryAs yet, there is no clinical trial that can accurately reflect the far-reaching effects of combined treatment modalities of breathlessness. Therefore, at present, we would recommend combining a treatment with opioids, anxiolytics and corticosteroids accompanied by oxygen and physiotherapeutic treatment options.

Palliativmedizin in den Entwicklungsländern

Die Entwicklung der modernen Palliativmedizin begann in den spaten 1960er Jahren in Grosbritannien und wurde bald weltumfassend [2, 3]. Inzwischen sind in den meisten europaischen Landern, in Nordamerika und in einigen Entwicklungslandern nationale Gesellschaften fur Palliativmedizin gegrundet worden. Zusatzlich sind einige internationale Gesellschaften wie die International Association of Hospice and Palliative Care (IAHPC), die European Association of Palliative Care (EAPC), die Pan American Health Organization (PAHO), die African Palliative Care Association (APCA) und die Latin American Palliative Care Association (ALCP/Asociacion Latinoamericana de Cuidados Paliativos) ins Leben gerufen worden.