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Palliative Care for Patients Living

with HIV/AIDSHAIVN

Harvard Medical School AIDS Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Explain what palliative care is and why it is important

Describe how to evaluate pain Explain how to treat nociceptive and

neuropathic pain Describe what end of life care is and

why it is important

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What is Palliative Care? (1)

“Palliative care is a combination of measures to relieve suffering and improve the quality of life of patients through the prevention, early detection, and treatment of pain and other physical and psychosocial problems that the patient and family are encountering.”

Source: Vietnam MOH: Guidelines on Palliative Care for Cancer and AIDS patients

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What is Palliative Care? (2)

The two major goals of palliative care are:

1) To relieve suffering, and

2) To improve the quality of life of the patient

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PAIN

Over 50% of AIDS patients in Vietnam suffer from pain – the majority of which is

undiagnosed and untreated.

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Pain: Definition

“the feeling of discomfort of a patient because of current or potential tissue damage or, it is an actual injury that

the patient is suffering from”

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Etiologies of Pain in HIV/AIDS

Category Type of Pain/Cause

Opportunistic infections

• Headache• Cryptococcal

meninigitis• TB meningitis

• Odynophagia• Esophagitis due

to Candida, HSV• Abdominal pain

• MAC/TB

Malignancies • HBV, HCV• Lymphoma

HIV virus • Distal symmetric polyneuropathy

Medications • d4T (peripheral neuropathy)

• AZT (headache)

Pain is exacerbated by psychological and social stress

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Pain Assessments

Based on patient’s own report Always use same pain assessment

scale to best monitor and compare the progress of pain control

Most common pain assessments include:• Pain Intensity Scale• Wong-Baker Faces Pain Rating Scale

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What are Some Things to Look for When Assessing Pain?

Location Type or quality of

pain: sharp, dull, constant, intermittent

Grade of pain • Pain Scale

Ability to sleep• Good indicator of

comfort level

Effect on functioning:• Ability to eat, swallow • Can walk with or

without assistance Response to

treatment• Pain medications• Non-pharmacological

treatment Heat, cold Acupuncture Massage

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Role Play: Assessing Pain

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Treating Pain

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Principles to Follow in Pain Treatment

Deliver pain relief interventions in a timely, coordinated and logical manner

After pain has been treated, assess if intervention worked• If not, may need to increase dose or try

another therapy Pain assessments and interventions

should be documented in patient’s chart so other doctors know what does and does not work

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Categories of Therapeutics

Nociceptive pain Responds well to

opioids and non-opioids

Neuropathic pain Responds better to

adjuvant medications (antidepressants, anticonvulsants) than opioids or non-opioids

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Easing Pain (1)

Mild Pain (1-3 on 0-10 scale)

Non-opioid analgesics +/- adjuvants

• Non-opioid analgesics• Ibuprofen• Aspirin• Paracetamol

• Adjuvants• Amitriptyline• Gabapentin• Carbamazepine

Moderate Pain (4-6 on 0-10 scale)

Weak opioids +/- adjuvants

• Weak opioid• Codeine

Severe Pain (7-10 on 0-10 scale)

Strong opioids with or without adjuvants

• Strong opioids• Morphine• Oxycodone

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Easing Pain (2)WHO three-step “analgesic ladder”

Pain persisting

or increasingPain

persisting or increasing

Pain Relief

3 SEVERE

PAIN

Strong Opioid +/- Non-opioid +/- Adjuvant

2 MODERATE

PAIN

Weak Opioid +/- Non-opioid +/- Adjuvant

Non-opioid

+/- Adjuvant

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MILD PAINAdapted from World Health Organization. Cancer Pain Relief. Geneva: WHO, 1990.

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Dosing Analgesics

Analgesics like all other drugs have side effects, dose carefully to attain useful effect

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Difference Between Oral and Intravenous Opioids

Oral, immediate release opioids have a 30 minute onset of action

Immediate release opioids last 3-7 hours in the blood

IV opioids have a 5 – 10 minute onset of action

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What’s Wrong with the Way this Analgesic is Being Given?

Pain

• Doses are not being given frequently enough • Analgesic wears off, and patient feels pain

until next dose is given

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Most short-acting opioids are given every 3-4 hours to maintain pain relief effect

Give Opioids at Right Frequency to Prevent Breakthrough Pain

What if Correct Interval but Patient Still Has Pain?

To treat break through pain give 10% of daily dose of opioids:• every 1 – 2 hours for immediate release oral opioids OR • every 30 – 60 minutes for subcutaneous or intravenous

opioids• Should NOT be substituted for opioid already being given every 3 – 4 hours

Breakthrough pain

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Example: Calculating Breakthrough Pain Dosages

A patient is receiving oral morphine 10mg, every 4 hours

What is her total daily dose? Total daily dose is 10 mg x 6 = 60

mg What is her breakthrough dose? Breakthrough dose: 10% x 60mg =

6 mg every 2 – 4 hours as needed

Tolerance to Opioids Tolerance develops with time in most

patients requiring dosage increases Unlike NSAIDS and most adjuvants, there

is no maximum dosage for opioids.

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Equianalgesic Dosing of Opioids

Sometimes side effects, lack of effectiveness or tolerance requires a change from one opioid to another

When changing to a different opioid one must refer to an opioid table to determine the appropriate dose to start with

This is called the “equianalgesic dose”

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Non-Pharmacologic Pain Treatments

Acupuncture Heat or cold packs Massage Deep breathing exercises

Gets patients and families involved in helping with pain control

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Case Study: Thuy (1)

Your patient, a 37 year-old female named Thuy, is HIV positive and has been on ART for the last 6 months with nearly perfect adherence

She presents with aching right hip pain which worsens at night• no history of trauma or accident

Examination revealed tenderness over the right proximal femur

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Case Study: Thuy (2)

What kind of pain is Thuy having? She is having nociceptive pain as she

describes it as aching pain What steps would you take to further

evaluate and treat her? Treatment would be a nonsteroidal

anti-inflammatory drug (i.e. ibuprofen, diclofenac)

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Case Study: Thuy (3)

6 months later, Thuy returns with burning and shooting pain in both legs• Pain is intermittent, examination of

lower extremities was not remarkable She takes D4T 40 mg plus 3TC/EFV She is also on the continuation phase

of TB treatment Her weight is 55kg

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Case Study: Thuy (3)

What do you think could be going on with Thuy?

What kind of pain is she having? What are the possible causes of her

pain? What steps would you take to further

evaluate her? Do you think paracetamol would help?

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HIV-Related Symptoms Other than Pain

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Prevalence of Symptoms in Patients with AIDS*

Fatigue

Weight loss/anorexia

Pain

Anxiety

Insomnia

Cough

Nausea/ vomiting

Depression/ sadness

Dyspnea/ respiratory symptoms

Diarrhea

Constipation

48-77%

31-91%

29-76%

25-40%

21-50%

19-36%

17-43%

15-40%

15-48%

11-32%

10-29%* Based on several published descriptive studies of patients with AIDS, predominantly in patients with late-stage disease, Europe and North America, 1990-2002.

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Addressing HIV-Related Symptoms

Treatments can be: • disease-specific

(e.g. ARV) and/or• symptom-specific

(e.g. anti-emetics, anti-histamines)

Effective treatment of these symptoms:• Reduces suffering• Improves quality of

life• Improves ARV

adherence• Improves clinical

outcomes

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Symptoms Addressed in 2006 Palliative Care Guidelines

Nausea / vomiting Diarrhea Constipation Odynophagia Dyspnea Cough Weakness / fatigue

Fever Insomnia Agitation / delirium Depression Anxiety Pruritus Bed sores

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End of Life Care

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Overview of End of Life Care

What is End of Life Care? Provision of care during the final

days and hours of life How is it Different from Palliative Care? End of life care is only given at the

very end of a patient’s life with the goal of helping the patient reach death with dignity and with as little pain as possible

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Ways to Provide Support at the End of a Patient’s Life

Provide emotional and spiritual support• Encourage patients to discuss feelings• Listen attentively, be empathetic• Respect patients’ decisions

Provide grief and bereavement support• Once patient dies, family will need support

Provide bereavement counseling

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Key Points

The two major goals of palliative care are to relieve suffering and to improve patient quality of life

Assess pain based on patient’s own report and standard pain assessment

Important to understand pain in order to know how to treat effectively

Emotional and spiritual support are important parts of palliative care

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Thank you!

Questions?