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pressure sores
constipation.
Analgesia
Analgesia should be prescribed according to the WHO analgesic
ladder (Figure 1). Move up the analgesic ladder (rather than change
to a similar drug at the same level) if pain control is not achieved.
For example, continuous pain in the immediate postoperative
period requires continuous pain relief which can be achieved by
regular prescription of analgesic. Availability of p.r.n analgesia
at the appropriate breakthrough dose (e.g. one-sixth of the total
dose of opioid prescribed in a 24-hour period) should always be
available to the patient. Monitoring of the use of p.r.n. medication indicates the incremental increase of the regular analgesia.
Using opioids for pain in these circumstances does not result in
dependence or tolerance in the long term.3
Margred M Capel
Ilora G Finlay
Definition
Palliative care is the active total care of patients and their families
whose disease is not responsive to cure. The focus is symptom
control, with appropriate support (psychological, spiritual, social)
to achieve the best quality of life for the patient and his/her family.
Patients can receive advice on symptom control and palliative care
while surgical management continues.
Drug delivery
The appropriate route for drug delivery should be selected.
Individuals unable to tolerate oral medication (e.g. because of
dysphagia, vomiting, altered conscious level) can be given equivalent analgesia parenterally. The need for repeated intramuscular
injections can be obviated by the use of the subcutaneous route.
Diamorphine is preferred to morphine for the subcutaneous route
due to its greater lipophilicity and solubility in water, and is the
opioid of choice for use in a syringe driver.
Communication
Communication problems frequently underlie complaints. People
react to receiving bad news in many different ways.1 Some of the
subsequent hostility between patients, their families and doctors
can be avoided if attention is given to the delivery of bad news.
Open and sensitive delivery of information using unambiguous
language (that lay people can comprehend) is crucial. Explanations for further investigations (including the potential finding of
malignancy) should be explained from the outset, and act as a
warning shot before confirmation of bad news.
If possible, give patients the choice of receiving information or
results in the presence of carers/family (particularly when dealing
with an unexpected finding). The doctor detailing bad news should
do so without interruption from hospital bleeps or members of
staff. Patients should be encouraged to inform their children about
treatment intentions.2 Having had a little time to think, patients
must be given an opportunity to ask questions and describe their
feelings.
Side-effects
Nausea, sedation, vivid dreams (CNS effects) and constipation are
common side-effects of opioids. Patients should be reassured that
the CNS effects will resolve within days, although about one-third
will need an antiemetic that acts centrally (e.g. haloperidol 1.5 mg
nocte; cyclizine 50 mg p.o. t.d.s.) for the first few weeks.
However, the effect on gut motility is ubiquitous and enduring,
so laxatives containing a stimulant (e.g senna) and softener (e.g
magnesium hydroxide) should be prescribed to counteract druginduced constipation. Combination agents (e.g. codanthrusate
Pain
Causes
Pain is subjective and is modified by emotions (e.g. fear, anxiety). The site, onset, duration, radiation, precipitating or relieving
factors and temporal relations of the pain will guide appropriate
prescribing of analgesia. Other factors causing pain require different treatment, for example:
comorbidity (e.g. arthritis)
treatment complications
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BASIC SKILLS
After head and neck surgery, patients may experience neuropathic pain that responds to the addition of neuropathic agents
to opioid analgesia, but the route of delivery can pose problems.
Adjuvant analgesics in liquid form (e.g. sodium valproate) can be
delivered via a gastrostomy. Postoperative pain after amputation
is classically neuropathic.
Early referral for specialist advice is recommended if recalcitrant or neuropathic pain is identified. Corticosteroids can reduce
oedema surrounding the nerve or even decrease tumour bulk.
Ketamine and methadone should be prescribed only under
specialist supervision. Methadone has an unpredictable half-life;
ketamine should be given with benzodiazepine or haloperidol
to counteract psychomimetic effects. Ketamine (s.c., p.o.) can
be effective against neuropathic pain resulting from ischaemic
limbs.
Neuroanaesthetic interventions ameliorate:
pancreatic cancer pain by coeliac axis blockade
tenesmoid and sciatic nerve pain, which may respond to epidural intervention.
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