Paediatrics: Palliative care

Palliative care

Around 30% of children with cancer will die, mostly from progressive di-sease. Death from complications of treatment is more likely to be swift, with limited opportunity for preparation. Palliative care is the active total care of patients whose disease is no longer curable. It needs to embrace physical, emotional, social, and spiritual needs of children and their fami-lies. Chemotherapy, radiotherapy, and surgery may still be used for pallia-tion and control of symptoms.

Breaking bad news

It is extremely important to be honest with an open approach, avoiding false hope. What to tell the child is always difficult; many families tend to be over-protective. This risks loss of their child’s trust when the truth can no longer be hidden.

Organization of care

There are few paediatricians specializing in palliative care:

·  Location: most children die at home, through family preference; some prefer a hospice and a minority the acute hospital ward.

·  A multiprofessional approach is required and will vary according to needs and organization of local healthcare.

·  The Association for Children with Life threatening or Terminal Conditions (ACT; www.act.org.uk) has played a central role in the development of paediatric palliative care as a specialty in the UK.

·  Bereavement support should be considered part of the role of the palliative care team and may be provided by various disciplines within the team, depending on local arrangements.

Symptom control

Anticipated symptoms will depend on the diagnosis. Symptom control measures may be pharmacological or non-pharmacological. Aim to cor-rect the underlying cause, e.g. constipation, infection. Good communica-tion and consideration of psychosocial and spiritual factors will contribute to good control.

Pain

·  Oral route is effective for most, until the terminal phase, when SC infusion, often in combination with anti-emetics, sedatives, and anticonvulsants may be preferred. The transdermal route is used for

some agents.

Different agents suit different types of pain, e.g. inflammatory and neuropathic pain, muscle spasm, and raised ICP. Combining different agents is more effective than escalating dose of one

·World Health Organization (WHO) three step analgesic ladder.

·  Step 1: non-opioid +/– adjuvants (e.g. paracetamol, NSAID);

·  Step 2: weak opioid (e.g. codeine) + non-opioid +/– adjuvants;

·  Step 3: strong opioid (e.g. morphine, fentanyl) + non-opioid +/– adjuvants.

·Adjuvants are additional drugs used in pain management. They include:

·  analgesics that relieve pain in specific circumstances, such as gabapentin for neuropathic pain, anti-spasmodics (hyoscine, glycopyrronium), muscle relaxants (diazepam), corticosteroids, bisphosphonates;

·  drugs to control adverse analgesic effects, e.g. laxatives, antiemetics.

Other symptoms

·Nausea, vomiting: domperidone, cyclizine (particularly for raised intracranial pressure), methotrimeprazine, haloperidol, ondansetron, metaclopramide.

·Convulsions, cerebral irritation: diazepam, midazolam.

·Spinal cord compression: dexamethasone, radiotherapy, bladder and bowel management.

·Terminal restlessness: midazolam.

·Dyspnoea: non-pharmacological measures (position, play therapy, fan), opioids, benzodiazepines, oxygen, steroids.

·Excess secretions: hyoscine, glycopyrronium.

·Anxiety, depression: diazepam, methotrimeprazine, amitriptyline.

·Constipation: anticipate by prescribing laxatives when starting opioids; select least constipating opioids (e.g. fentanyl); may need high enemas.

·Bowel obstruction: antispasmodics, stool softeners, rectal preparations to reduce impaction, octreotide to reduce secretions and vomiting.

·Sweating, from advanced disease fever or drugs: cimetidine, NSAIDs.

·Pruritus: cimetidine if due to disease, antihistamine if opiate induced

·Haematological (anaemia, haemorrhage, bruising): transfuse (blood +/– platelets) only for symptomatic improvement and for quality of life; topical tranexamic acid or adrenaline for troublesome mucosal bleeding.