International Association for Hospice and Palliative Care
Subject: IAHPC Newsroom
Dear Members and Colleagues:
Until next month,
2. Article of the Month: Dr. Ripamonti
Intravenous morphine for rapid control of severe cancer pain
Author(s): Harris JT, Kumar KS, Rajagopal, MR
Abstract: Palliative Medicine 2003; 17: 248-256
This is a randomized controlled trial to compare the intravenous (IV) with the oral route for initial dose titration of morphine in 62 end-stage cancer patients. All were strong opioid naïve and had severe opioid responsive pain, having scored 5 or more on a 0-10 Numerical Rating Scale (NRS).
The setting of care is the Pain and Palliative Care Clinic in the city of Calicut, state of Kerala (India) where 2000 new patients are seen every year and about 80% of them present with severe pain. The routine clinical practice of the Authors of the paper is to administer bolus doses of IV morphine for immediate relief of severe pain followed by an appropriate dose of immediate release oral morphine every 4 hours. The Authors had previously published their experience with IV morphine for fast titration in 1478 cancer patients (Palliative Medicine 2000; 14: 183-88).
Thirty-one patients were randomly allocated to the Intravenous Group (IV) and were administered:
a) metoclopramide 10 mg IV as an antiemetic; b) 1.5 mg of morphine administered slowly as an IV bolus every 10 minutes. Pain relief and adverse effects (in particular drowsiness and respiratory depression) were assessed before each bolus. The end of the trial was considered when complete pain relief or drowsiness was achieved. The total dosage of IV morphine required was converted to an oral morphine dose to be administered every four hours (example 9 mg of IV morphine to achieve pain relief = 10 mg of oral morphine every 4 hours) plus the same dosage was used for rescue doses at a minimum interval of 1 hour.
Thirty-one opioid naïve patients were allocated to the Oral Group and titrated with 5 or 10 mg of oral morphine every 4 hours plus the same dosage for rescue doses at a minimum interval of 1 hour.
In both groups, the patients were monitored every hour for 12 hours, then every day for two days and then every week with regard to: 1. pain relief after each dose, 2. Number of rescue medications, 3. adverse effects.
After 1 hour of morphine administration, the number of patients in IV group with total or satisfactory pain relief was 26 and only 8 in the oral group (p< 0.001). However, after one day, the number of patients with satisfactory pain relief was similar in the two groups (p< 0.55).
Thirty, of the 31, patients in the IV group reached a satisfactory pain relief after 3 hours with dosages of morphine varying from 1.5 mg to 34.5 mg (median 4.5 mg) whereas in the oral group only 76% of the patients had satisfactory pain relief after 12 hours (p<0.001) with a mean dose of 7.2 mg of oral morphine every 4 hours (range 2.5-15 mg).
After stabilization and satisfactory pain relief using IV morphine, the mean dose of oral morphine required was 8.3 mg (range 2.5-30 mg) every 4 hours. The ratio of total IV requirement to control the pain to the stable oral morphine dose after 2-3 days varied between 1:0.5 and 1:3.3 (median 1:1).
Immediate side effects were drowsiness at the end of the IV trial in 11 patients and severe vomiting in 1 patient in the oral group. Delayed side effects were mainly constipation, drowsiness and vomiting. Patients were treated with metoclopramide tablets 10 mg t.i.d and laxatives.
Why I chose this article
Even if the titration with strong opioids is commonly performed using immediate release oral morphine every four hours, there are some clinical situations such as severe pain where pain relief has to be achieved as quickly as possible. This is the only prospective randomized study comparing titration with IV morphine compared to oral morphine. The results of fast IV titration compared to oral titration with morphine are very encouraging in terms of efficacy and tolerability of the IV route.
Other studies that confirmed the fast pain relief with IV morphine titration:
1. Radbruch L et al. Intravenous titration with morphine for severe cancer pain: report of 28 cases. Clinical Journal of Pain 1999; 15/3 September : 173-8
3. Ethics Article of the Month: Dr Paulina Taboada
ETHICAL ANALYSIS OF SELECTED CLINICAL CASES (No. I):
PAULINA TABOADA & RODRIGO LÓPEZ
A 26 years old male patient with a HIV (+) test refuses to believe his diagnosis and does not accept to undertake any complementary studies (e.g. CD4+ T cell count, levels of HIV RNA in serum plasma, etc.) and treatment. Five years later, the patient had to be admitted to the Intensive Care Unit for the treatment of respiratory failure secondary to Pneumocystis Carini pneumonia. He had CD4+ T cell count <50, a severe nutritional compromise and skin lesions compatible with Kaposi’s sarcoma. The patient refused antiretroviral therapy. Nevertheless, his mother insistently requested the attending physician to begin the therapy even against the patient’s wishes. The physician refused to do so. One week later, because of his family’s persistence, the patient changed his mind and accepted treatment. The opportunistic pathologies evolved favorably, so that the patient could be discharged from the hospital one month later. He now accepts regular control of the antiretroviral therapy and is progressively improving his general and nutritional conditions.
1. Define the specific ethical dilemma/s.
Seemingly, the referred case does not raise major ethical problems: an adult patient assumes the risks derived from his refusal to medical treatment and abandons control. Nevertheless, a more accurate reflection reveals some profound ethical dilemmas related to this situation, such as – for instance – the questions whether it is legitimate for a patient to refuse any kind of treatment even when its benefits have been proven; whether the patient was fully competent when he rejected the treatment (specially if one takes into account that his emotional reaction pointed towards a negation of his health condition); whether it is appropriate to treat complications when a patient refuses to receive the treatment for the underlying condition; whether the family has a right to ask for treatment against the patient’s wishes; etc.
2. Refer to the ethical principles involved
Focusing our attention on the patient’s refusal to receive a useful treatment, the ethical principles involved are primarily beneficence and respect for patient’s autonomy.
3. Collect and analyze ethically relevant clinical information
The fact that antiretroviral therapy is highly effective in the treatment of HIV infection is doubtless ethically relevant in this case. If our patient would have had a different type of disease (e.g. metastatic cancer) the analysis of the case would have followed a quite different path. We would have probably concentrated on the analysis of the proportionality of the proposed therapy. But since there is no doubt that antiretroviral therapy is actually very effective in the treatment of HIV infection, the ethical questions refer to the reasons why this patient refused the treatment. Thus, the question about his competence rises.
It is evident that the duty to respect a patient’s autonomous decision presupposes that this decision has been made by a free and competent person. This means that health care professionals have to check the patient’s competence. This becomes even more important when a patient refuses an intervention that is known to have beneficial effects. To determine a patient’s competence is not always an easy task. Summarizing a delicate evaluation-process, we may say that the abilities that need to be tested for in order to establish a patient’s competence are at least:
- The intellectual capacity to understand the provided information.
In our present case, the patient’s denial of his clinical condition at the moment of his diagnosis suggests that he was emotionally compromised in a way that might have prevented him from making truly free decisions. Unspoken reasons might underlie this emotional reaction, such as for instance, the patient’s sexual behavior, drug abuse, social or family pressures, etc. Whether health care professionals should follow a patient's decision under these circumstances deserves further discussion.
4. Review alternative courses of action
Taking into account both the duty to benefit the patient and the duty to respect his autonomy, health care professionals may suggest two opposing courses of action: accept the patient’s denial or disregard the patient’s wishes arguing that his emotional state renders him unable to make free decisions. This last solution would be difficult to implement because the cooperation of the patient is absolutely needed for the kind of treatment required. Thus, a “third way” could be suggested, namely to offer the patient psychological assistance in order to find out which are the unspoken reasons is underlying his denial.
5. Suggest an ethical solution
The above described "third way" seems to respect both the ethical principle of beneficence and autonomy. By simply accepting the patient’s denial (as the attending team did in this case), health care professionals would neglect their duty to act in the best interest of the patient. On the other hand, it is certainly not correct to treat an adult, competent patient against his explicit will.
6. Consider the best way of implementing the suggested solution
To declare a patient as “incompetent” (i.e. unable to exercise his autonomy) on the grounds of a neurological condition (e.g. viral encephalitis) is usually not very difficult for health care professionals. But in the case of emotional factors compromising a patient’s autonomous decisions, they might consider it more difficult. It is indeed not always easy to help the patient realize what his state actually is. An experienced and attentive professional assistance is needed here, and this course of action would probably take time.
Dr Paulina Taboada
Jo Armes, Meinir K. Krishnasamy and Irene Higginson (Eds).
In the foreword to this book, Simon Wessely observes why we as a profession are wary of fatigue. It is non-specific, difficult to measure and difficult to treat, but it is also a major source of morbidity to our patients. When lay people and doctors were asked to rate symptoms in order of importance, the professionals placed fatigue at the bottom of the list, while the public ranked it at the top.
The book is divided into three sections. The first covers definitions, epidemiology, models, and clinical associations of fatigue. The second is about the experience of fatigue and includes chapters on fatigue in people caring for patients with cancer and in children with cancer and their families. The last section covers the assessment and management of fatigue and includes an in-depth discussion of all the physical, emotional, psychiatric and social associations of fatigue.
This book opens with the statement that cancer-related fatigue is the most frequent, distressing, persistent, important, under diagnosed, and under treated symptom in cancer medicine. How true.
The book is divided into four large chapters. The first covers definitions and factors that influence the recognition and treatment of fatigue. The second covers the relationship between cancer-related fatigue and other cancer-related symptoms. The next is a discussion of the possible causative, predisposing and perpetuating factors in cancer-related fatigue. The last covers the treatment and includes discussion of exercise, energy management, sleep therapy, cognitive behavioral therapy, nutritional, pharmacological, complementary and immunological therapies.
Patarca-Montero or Armes?
This year sees the publication of two books devoted to cancer-related fatigue. Similar size and similar cost. The full Tables of Contents are available in the IAHPC’s Bookshop. Patarca-Montero has the advantage of being a single author text, but I think the multi-authored and multidisciplinary approach in Armes brings a greater depth and breadth to the discussion of what is a very complex clinical problem. In Patarca, key points are usefully highlighted in little boxes in the text. In Armes, there is a thought-provoking list of future areas for research at the end of each chapter. Patarca provides a little more detail about available therapies, particularly the complementary and alternative treatments. The Oxford book is better presented with the use of tables, dot-point lists and diagrams of concepts; whole pages of references in parentheses, four and a half consecutive pages in one case, within the text in the Haworth book are an annoyance and a strong recommendation for an alternative referencing system.
Both are worthy, scientifically-founded books that will do a lot to reinvigorate clinicians who have tired of fatigue and help get this complex symptom out of the too-hard basket.
Sara Booth and Eduardo Bruera (Eds).
This is the latest addition to Oxford’s Palliative Care Consultations series. The first two chapters provide concise descriptions of the oncological management of primary and metastatic brain tumours; in contrast to some oncology texts, the discussion does not stop when the patient’s disease relapses. There is a useful chapter on the pitfalls of anticonvulsant therapy in patients with intracranial malignancy.
Three chapters in the middle of the book, which deal with the non-oncological management, are particularly good. The first deals with the neuropsychological complications of the disease and therapies, including behavioural changes. The next discusses all aspects of family care. The third describes the management of the communication and swallowing problems suffered by these patients.
I was troubled by the discussions of how and when corticosteroids should be withdrawn from patients who become unconscious and cannot swallow. In one chapter, the ethical issues are briefly discussed; in another it is stated that corticosteroids can be stopped without weaning the dose; and in a third, the acute withdrawal of steroids is described as ‘a therapeutic strategy’ with an expected outcome of rapid deterioration that is, of course, undertaken only with the full understanding of the family. Is this not another opportunity for advance care planning with the patient and family? Recent Papal edicts aside, I thought this clinical problem probably deserved its own small chapter.
This is a useful and an up to date synopsis of the interface between neuro-oncology and palliative care. It will be a useful addition to the library shelf of any palliative care service.
This is a narrative-driven, longitudinal study of a small group of patients dying with cancer. It is divided into four main sections – Departure (Diagnosis), Exploration (Tests and Treatment), Anticipation (Remission and Recurrence), and Destination (the Deaths). There is a dearth of valid, truthful, experiential accounts of dying and the author’s extensive use of quotations allows us a glimpse of some of the most personal and sensitive issues while the respondents describe the effects of the disease and treatment on their own practical, emotional and social worlds. We see what it means, from the patients’ perspective, to live as fully as possible for what remained of their lives; physically restricted but psychologically invigorated.
The author correctly notes that the observations in this book are not generalizable, but there are important messages for those who work in medical oncology and
palliative care. We don’t treat a case of breast cancer, we treat a person with breast cancer; and every person is a unique individual with differing practical, emotional and social needs, which
we must recognize. Health care professionals need to understand how easily their actions and poor communication can compound a patient’s suffering. Hats off to the woman who had out-lived so many
life expectancies given by her consultant that when she saw him next, she ordered ten more years!
Now is the time just before the launching of the Council of Europe recommendations on palliative care. The common date is set to be October 11 and up till now recommendations have been translated into 17 different languages: Croatian, Dutch, English, French, Georgian, German, Greek, Latvian, Lithuanian, Hungarian, Polish, Romanian, Russian, Serbian, Swedish, Turkish, Ukrainian. Some of the languages will be used in several countries. We expect and hope there will be lot of discussions about palliative care in all of Europe in October.
We hope this occasion will be a good opportunity to inform widely about palliative care in different kinds of settings and surroundings in both East and Western part of Europe. Let's hope the recommendations will turn out to be a useful tool to help development in a positive direction.
The International Psycho-Oncology Society:
The International Psycho-Oncology Society (IPOS), founded in 1984, is the only international body devoted solely to the "human" aspects of cancer care and research – the psychological, social, behavioral spiritual domains, which contribute materially to quality of life. These issues are especially important in resource-limited countries where the treatment of cancer is largely palliative. IPOS recognizes that it is through collaboration with other international bodies that more attention, concern, education and training can be achieved to improve the aspects of care. A close working relationship with the International Association for Hospice and Palliative Care is important to meld a close tie to the global palliative care efforts.
IPOS is presently petitioning the World Health Organization to become a WHO non-governmental organization, to harness the expertise of its multidisciplinary members to contribute in critical areas of WHO global cancer control national programs, which have been developed for resource-rich and resource-poor countries. These programs target cancer prevention, early diagnosis, treatment, pain and palliative care. Psychosocial issues cut across all of these areas and, as such, can potentially contribute to each of these efforts. For example, cancer prevention and screening critically depends on understanding the cultural background, attitudes, language fears of outsiders, and concerns of a community. In cancer treatment, the control of pain, fatigue and distress is often central to tolerating radiation and chemotherapy. When treatment is palliative, as it is in most developing countries, the major effort has been pain control, especially obtaining narcotic analgesics. What has not received adequate attention is the need for better understanding of the emotional care of patients at home, and the need to support and educate families and to combat the stigma and negative attitudes of some communities, especially where fear of cancer is high. IPOS is proposing to work closely with WHO in its global cancer control programs, to add this cross-cutting issue of psychosocial care to its overall efforts in prevention, early diagnosis and screening, and treatment and palliative care.
Several other steps being taken are:
In conjunction with the European School of Oncology, a core curriculum of lectures on basic topics in psychosocial oncology is being translated into 5 languages, having been developed in English, through the American Psychosocial Oncology Society. The curriculum will be available to anyone at no charge online at www.ipos-society.org in 2005. At the 7th World Congress in Copenhagen in August 2004, plans began to add translation of these lectures into Polish, Russian and Lithuanian. We hope to work with the network of centers of excellence in palliative care in Eastern Europe to support the mental health workers and expand psychosocial care.
IPOS has an active tie to the African Organization for Research and Training in Cancer (AORTIC), and the Pan African Psycho-Oncology Society (PAPOS). AORTIC, through a Psychosocial/Quality of Life Committee, is committed to working with PAPOS, IPOS and International Cancer Training and Research (INCTR) pursuing these issues aggressively to assure that they are a fully integrated part of palliative care in Africa, utilizing the nurses, palliative care doctors, workers and volunteers to enhance their basic knowledge of the psychological issues and to give them the support of a network of people who are available to organize regional conferences and to organize traveling fellowships. There is a need to make these aspects of care more visible and more compelling to policy makers in all countries, especially in Africa and India where scant resources are available and stigma is high.
For more information, please go to the IPOS website: www.ipos-society.org. We welcome your participation
and membership in IPOS, and we welcome ideas for new collaborations.
Hospice Connection in the Himalayas
In the Himalayan Kingdom of Nepal, where families take care of their own, there is a growing Hospice work to assist them in caring for their dying loved ones. Hospice Nepal was started about five years ago, by Drs. Gongal and Vaidya and others, first as a hospital ward, then branching out to their own eight bed inpatient facility and to home visitation teams.
Our family lived in Nepal during the early 80’s and during our last visit this past January, we were anxious to visit the growing work of Hospice Nepal. We were excited to wind our way through the narrow streets of Kathmandu to find their clean and attractive compound. The peaceful atmosphere there seemed like a sanctuary amid the bustling capital city of approximately 2 million people. Dr. Gongal welcomed us and took us on rounds, introducing us to patients and nurses. I brought them greetings from our chapter of Hospice in North Idaho where I have worked as a nurse for the past 5 years, and presented them with a picture of our staff and a financial gift. He seemed delighted with the gifts and told us that Hospice Nepal works on a donation basis and patients are not charged for their care.
Dr. Gongal, Dr. Vaidya, the Hospice nurses and I met and exchanged questions and ideas. I presented them with some written material that we use and have found helpful in our Hospice. Dr. Gongal encouraged the nurses to “get more into the patients” by listening to them share who they are and what they are feeling. Dr. Vaidya mentioned that it is good to hear what other Hospices are doing and to use the things that are helpful and will work in their culture. He teaches medical and nursing students in the Kathmandu valley, which includes hospice and palliative care.
After returning from our trip, I shared my experience with Hospice of North Idaho and they wanted to continue a relationship with the work in Nepal. We ordered the American Journal of Hospice and Palliative Care to be sent to them. We decided we would like to send a financial gift to Hospice Nepal so our staff signed up to have a small amount ($1-3) withheld from each bimonthly check. Our Administration matched what the staff gave and as a result we can send $366 dollars quarterly to our Sister Hospice Nepal.
In the months since our trip, Drs. Gongal and Vaidya, as well as one of the nurses Anusha Sharma, have kept us informed of the progress of Hospice Nepal. The inpatient unit is staying full; one of the local hospitals is starting a Hospice wing and has sent some of their nurses to be trained by the Hospice Nepal staff. They are in the process of training volunteer nurses to give hospice and palliative care to patients who live in their areas. The Hospice nurses will visit the patients close to the inpatient facility by bike and motorbike. They also have a plan to expand community service CohoN (Community Hospice Nepal) as they are able to train more staff and acquire a jeep for transport. Anusha Sharma, one of the Hospice nurses, writes “I too go for home visits these days. I enjoy home visits because we can give more advice to the family members and we can learn more from their (patient’s) life time experiences.”
Dr. Vaidya reports “We are also sending two of our staff nurses to Callicut, India for six weeks of palliative care training.”
Dr. Gongal wrote “We believe this (support and encouragement) to be a blessing from you all that will encourage us to continue to work hard to help the unfortunate people here. Your generosity touches us and our patients in a very special way …your effort to help us not only helps us in our finances, but just as importantly, keeps our morale high and helps us in our perseverance to establish Hospice on the ground and in peoples’ minds and hearts”
We are not sure where this” Sistering” between Hospice of North Idaho and Hospice Nepal will lead, but we are excited to have the connection? We have been thrilled to hear how they have expanded in these last months and our hope is that soon we can take some of our staff on a trip to Nepal where they can have a Himalayan adventure and a cross-cultural Hospice experience.
Welcome to the Webmaster's Corner!
This month we have allot of great things to tell you about and a few upcoming sneak peaks.
The IAHPC Hospice & Palliative Care Manual Second edition is coming soon. Watch the What's New page for its avalability.
Hospice & Palliative Care Educational Resources - Here is a list of educational resources available for clinicians working in pain and palliative care settings.
Professionals Available to Spend Time Abroad - View professionals who are willing to spend time abroad. You can submit yourself to be added to the list to spend time abroad. We had 6 new listings this month! More Info Here
Purchase items with the IAHPC Logo on them using the link below to donate to the IAHPC while shopping for cool items at no extra cost to you!.
The IAHPC Fact Sheets are now available in Portuguese and to download in MS.Word Format in Portuguese.
Our Book & Video Shop has has a few changes in the navigation to help you find your way around better. You can now view by author or category. Last month we added 4 more new titles with reviews.
The International Directory has had 38 new listings this month, a great resource for all.
Have a hospice and/or palliative care related question? Or just want to discuss hospice & palliative care issues? Join in at our Forum. No registration required. It's Free
Coming Events! Do you have a Hospice & Palliative Care event you wish to promote?
Sneak Peeks What's Coming!
Until next month!
Journal of Palliative Medicine
"The American Academy of Hospice and Palliative Medicine, the specialty association representing physicians and other health care professionals in the field,
and Mary Ann Liebert, Inc. publishers are pleased to announce that Charles F. von Gunten, MD, PhD, FAAHPM is the new Editor-in-Chief of Journal of Palliative Medicine... Dr. von Gunten currently serves
as Medical Director, Center for Palliative Studies, San Diego Hospice & Palliative Care, one of the nation’s oldest and largest hospice programs, and a teaching and research affiliate of the
University of California, San Diego School of Medicine. He directs one of the largest fellowship programs in palliative medicine in the US. In addition, he serves as Chairman of the American Board of
Hospice and Palliative Medicine…
The Academy of Hospice and Palliative Medicine
"The American Academy of Hospice and Palliative Medicine (AAHPM) announces the appointment of C. Porter Storey, Jr., MD, FACP as its first Executive Vice President. The position was created to strengthen the Academy's infrastructure and advance the practice of palliative medicine. Storey will assume the position in October.
Most recently, Storey served as Medical Director of Palliative Care Services at St Luke's Episcopal Hospital at the Texas Medical Center in Houston, Texas. He was also Associate Professor of Medicine at Baylor College of Medicine and Adjunct Assistant Professor in Symptom Control and Palliative Care at the University of Texas M.D. Anderson Cancer Center…." Reprinted in part from a press release issued by The American Academy of Hospice and Palliative Medicine.
9th World Congress of the European Association for Palliative Care
Date of Event: 06-10 April 2005
Languages (English, translation into French & German)
World Hospice and Palliative Care Day
Date of Event: 8 October 2005
A group of organisations including IAHPC, Help the Hospices and Voices for Hospices are planning events for the first World Hospice and Palliative Care Day next
year - if you want to plan some events please let us know.
Pain and Palliative Care Society
Taking Place: Calicut
The 6th Asia Pacific Hospice Conference
Event taking place in: Sheraton Grande Walkerhill, Seoul, Korea
III Advance Symposium on Palliative Care (In Spanish)
Event taking place in: Rosario, Argentina
Directed by: Profesor Eduardo Bruera (The University of Texas MD Anderson Cancer Center).
Texas Partnership in End of Life Care
Announcing the TxPEC High Flight of Champions Gala, to honor champions in End of Life Care. Mark your calendars and order your tickets early.
Date of Event: November 12, 2004
Paediatric Pain and Palliative Care Fellowship (Australia)
The Children’s Hospital at Westmead http://www.chw.edu.au is the largest and busiest paediatric hospital in Sydney/Australia (240 beds, > 25,000 admissions/year).
Applications are invited for the post of a Paediatric Pain & Palliative Care Fellow
Please consider joining the IAHPC's effort to improve palliative care in developing countries. We recently developed a new
sliding fee schedule.
****Thanks to all contributors to this issue.****
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