BASIC SKILLS

pressure sores
constipation.

Palliative care for surgical

patients

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

WHO analgesic ladder

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

Strong opioid
non-opioid
adjuvants
ree

o
Step tw
Non-opioid
adjuvants

Margred M Capel is a Specialist Registrar in Palliative Medicine on the

All Wales Higher Training Programme, Wales, UK.

Step on

Ilora G Finlay is a Professor of Palliative Medicine at Cardiff University,

and Consultant in Palliative Medicine at Velindre NHS Cancer Centre,
Cardiff, UK.

SURGERY 23:2

Step th

Weak opioid
non-opioid
adjuvants

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2005 The Medicine Publishing Company Ltd

BASIC SKILLS

capsules, codanthramer suspension) may aid compliance and

reduce pill burden; codanthramer is licensed for use only in the
terminally ill.
Analgesia can be safely tailored to the individual using the basic
principles outlined below.
Metabolites of opioids (e.g. morphine-3-glucuronide, morphine-6glucuronide) accumulate in patients with impaired renal function.
Evidence of myoclonus, irritability, agitation or opioid toxicity
(depressed respiratory rate, pinpoint pupils, sedation or confusion)
should prompt an immediate check of renal function (including
calcium).
Opioids (e.g. fentanyl, alfentanil) which are mainly metabolized
to inactive compounds in the liver can be used in patients with
pre-existing renal impairment.

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.

Reviewing the drug regimen

Rapidly escalating requirements of analgesics should prompt a
review of the cause of the pain and exclusion of new developments.
Surgical signs (e.g. rebound, guarding) will not be masked by use
of analgesia.4 The efficacy of the analgesic regimen can be managed
using a pain chart with a simple visual analogue scale (e.g. 110).
Re-evaluate every 24 hours until pain control is achieved.
Most pains are sensitive to opioids; bone pain and neuropathic
pain are often only partially responsive to opioids. Adjuvant analgesics and referrals to palliative care should be considered if
pain persists despite reassessment and routine interventions.

Raised intracranial pressure: headache caused by primary or

secondary tumours of the brain should be managed with corticosteroids and analgesia according to the WHO analgesic ladder. The
long half-life of dexamethasone enables the corticosteroid dose to
be given in two divided doses early in the day (avoids provoking
agitation and poor sleep caused by administration of evening
doses); cyclizine is the antiemetic of choice in these patients.

Specific types of pain

Bone pain: underlying metastatic disease can be identified on plain
radiographs or isotope bone scans. Pain from isolated metastases
responds to radiotherapy in up to 80% of cases. More widespread
pain may respond to a combination of opioids and NSAIDs (with
appropriate gastric protection). Bisphosphonates (i.v.) can:
help control of pain
prevent skeletal morbidity in myeloma and metastatic breast
cancer.
Radioactive strontium can provide relief from pain caused by metastatic prostate cancer. Orthopaedic intervention may be needed to
stabilize a pathological fracture or a site of osteolysis if fracture
seems inevitable.

Visceral pain may be poorly localized and results from:

growth within an organ (e.g. liver metastases)
obstruction (or direct invasion) of visceral parietal surfaces.
The pain is sensitive to anti-inflammatory agents or corticosteroids
(e.g. dexamethasone 48 mg o.d.) in addition to opioids.
Bladder pain: urinary tract infection and an obstructed catheter
are common treatable causes of bladder pain. Anticholinergic
drugs (e.g. oxybutinin hydrochloride 5 mg t.d.s. or amitriptyline
1025 mg nocte) reduce bladder spasm and intravesical local anaesthetic (e.g. bupivicaine via indwelling catheters) can help.
Rectal pain may be caused by:
local disease
pelvic radiotherapy
lumbar sacral nerve involvement.
Pain presents as a combination of poorly localized visceral pain,
tenesmus and neuropathic pain, and consequently requires a
combination of the treatment interventions discussed.

Compression of the spinal cord: thoracic back pain may be the

presenting symptom of occult compression of the spinal cord.
Neurological examination may reveal:
leg weakness
sensory deficit
decreased anal tone.
MRI is the key to diagnosis. Neurosurgery will stabilize the spine
and decrease pain. If surgery is excluded, radiotherapy and
corticosteroids must be started immediately.

Muscle spasm may present a challenge, particularly in patients

with bone (e.g. vertebral) metastases. The long half-life of
diazepam enables it to be used on a once-daily basis (e.g. 510 mg
nocte). Alternatives include baclofen 510 mg t.d.s., but sedative
side-effects limit the use of diazepam and baclofen.

Neuropathic pain should be suspected in sites of pain where

the sensation is altered. The sensation is typically described as
stabbing, shooting, burning, stinging or pins and needles. After
mastectomy, some patients experience severe neuropathic pain in
the axilla or chest wall. Tricyclic antidepressants (e.g. amitriptyline
1025 mg nocte) or anticonvulsants (e.g. gabapentin 3002400 mg)
may be necessary to control pain, and should be started at the
lowest dose and titrated upwards according to response.

SURGERY 23:2

Colic: pain resulting from distension responds to antispasmodic

agents (e.g. hyoscine butylbromide) for the fluctuating colic and
an opioid (e.g. diamorphine) for the constant abdominal ache.
The subcutaneous route is preferred to ensure adequate drug
absorption.

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2005 The Medicine Publishing Company Ltd