Intractable Pain & Palliative Sedation in Children John J. Collins MB BS, PhD, FRACP Head of Department Pain Medicine and Palliative Care The Children’s Hospital at Westmead, Sydney Australia [email protected] INTRACTABLE PAIN and PALLIATIVE SEDATION IN CHILDREN Objectives: Definition Epidemiology of Intractable Pain in Children Review of practice Review of literature Ethical issues INTRACTABLE PAIN IN CHILDREN AT THE END OF LIFE: DEFINITIONS Pain that cannot be alleviated using conventional treatment is intractable Intractable pain that does not respond to therapies beyond conventional practice is refractory The relief of refractory pain may require a therapy that reduces conscious awareness Intractable pain in childhood is unusual and is mostly seen in the setting of cancer pain and at the end of life Intractable childhood cancer pain is usually disease related INTRACTABLE PAIN IN CHILDREN AT THE END OF LIFE: 1995 A retrospective study published in 1995 examined the opioid requirements of children with terminal malignancy* Twelve (6%) of the patients required therapies beyond conventional opioid dosing Eleven patients had spinal cord compression, solid tumour metastatic to the spinal nerve roots, nerve plexus, or large peripheral nerve Fifty per cent of the patients had adequate analgesia with either regional anaesthesia or with high dose opioid infusion alone Remaining patients required sedation to control refractory pain *Collins JJ, Grier HE, Kinney HC, Berde CB. Control of severe pain in terminal pediatric malignancy. Journal of Pediatrics 1995; 126(4):653-657 THE MANAGEMENT OF INTRACTABLE PAIN IN CHILDREN AT THE END OF LIFE: 1995 → Practice has become more sophisticated, greater understanding of: 1. Management of the paediatric pain crisis 2. Calculation of opioid “rescue” dosing and dose escalation 3. Opioid switching 4. Management of opioid side-effects 5. NMDA antagonists as new therapeutic options 6. Invasive approaches to pain management in children Fewer children may need to be sedated to reduce conscious awareness of intractable symptoms NMDA RECEPTOR ANTAGONISTS NMDA- receptor antagonists depress central sensitisation in animal experiment and in humans* Dextromethorphan, dextrorphan, ketamine, memantine and amantadine, among others have been shown to have NMDA-receptor antagonist activities** The clinical usefulness of some of these medications is compromised by an adverse effect to side effect ratio There are no data of their utility in paediatrics, other than procedural pain management Clinical usage is increasing, particularly in the setting of severe neuropathic pain and rapid opioid dose escalation and perceived tolerance *Eide PK, Jorum E, Stubhaug A, et a. Relief of post-herpetic neuralgia with the N-methyl-D-aspartic acid receptor antagonist ketamine: a double-blind cross-over comparison with morphine and placebo. Pain 1994; 58:347-354 **Persson J, Axelsson G, Hallin RG, et a. Beneficial effects of ketamine in a chronic pain state with allodynia. Pain 1995; 60:217-222 **Nelson KA, Park KM, Robinovitz E, et al. High dose dextromethorphan versus placebo in painful diabetic neuropathy and postherpetic neuralgia. Neurology 1997; 48:1212-1218 **Eisenberg E, Pud D. Can patients with chronic neuropathic pain be cured by acute administration of the NMDA-receptor antagonist amantadine? Pain 1994; 74:37-39 INVASIVE APPROACHES TO INTRACTABLE PAEDIATRIC CANCER PAIN Anaesthetic approaches Experience of using regional anaesthesia for children with intractable pain is limited. A retrospective study of children with terminal cancer showed that regional anaesthesia may be appropriate in a highly select subset of children* The indications for regional anaesthesia mostly related to either dose-limiting side-effects of opioids or opioid unresponsiveness in patients where pain was confined to one region of the body Rapid intravenous opioid dose reduction was required in some cases *Collins JJ, Grier HE, Sethna NF, Berde CB. Regional anesthesia for pain associated with terminal malignancy. Pain 1996; 65:63-69 EAPC DEFINITION OF PALLIATIVE SEDATION * • ‘Therapeutic (or palliative) sedation... Is the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers.’ * Cherny N, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliative Medicine. 2009;23(7);581-593. PALLIATIVE SEDATION A medical intervention utilised to control symptoms when all other interventions have failed. A medical therapy for imminently dying patients. It involves administration of pharmacological agents with the express intention of: • relieving pain • other symptoms other than pain • other causes of intolerable suffering Reduced level of consciousness is anticipated and accepted as an effect of therapy SYMPTOM MANAGEMENT Symptom Intervention Burden Intervention Intervention REFRACTORY Symptom Progression towards end of life QUESTIONS TO CONSIDER FOR PAIN AS A SYMPTOM FOR PALLIATIVE SEDATION Are primary therapies (chemotherapy, radiation therapy etc) feasible, and, if so, likely to improve patient outcome? Has the opioid dose been titrated up to maximum tolerated doses? Have side-effects been addressed with treatment of alternative opioids? Have anaesthetic options been considered? PROPOSED GRADATIONS OF PALLIATIVE SEDATION 1. Degree: mild to deep 2. Duration: intermittent to continuous From: Morita, T. Proposed definitions for terminal sedation. Lancet, 358, 335-336, 2001 MILD SEDATION To maintain consciousness so that patients can communicate with care-givers DEEP SEDATION Almost or complete unconsciousness From: Morita, T. Proposed definitions for terminal sedation. Lancet, 358, 335-336, 2001 INTERMITTENT SEDATION Some periods when patients are alert CONTINUOUS SEDATION To alter a patient’s consciousness until they die From: Morita, T. Proposed definitions for terminal sedation. Lancet, 358, 335-336, 2001 PALLIATIVE SEDATION IN CHILDREN Few data Mainly case reports Clinical experience in paediatrics limited Rarely required clinically: optimal palliative care can effectively manage most symptoms Ethical issues CHW review of practice • • • • Retrospective chart review January 2008- December 2013 Patients known to Palliative Care Team Sedation for management of refractory symptoms • 1.4% of total cases (3 children) • Ethical approval by CGU at CHW RESULTS Study number 1 2 3 Age 17mo 12yo 16yo Gender Male Female Male Diagnosis AML Rhabdomyosarcoma Osteosarcoma with pulmonary metastases Comorbidities Nil Nil Nil Time known to pall care prior to death 2months 3months 8.5months Location of care when sedation commenced Hospital Hospital Hospital Location of death Hospital Hospital Hospital Indication for sedation Pain and respiratory distress Pain, anxiety, respiratory distress Hallucinations, respiratory distress RESULTS Study number 1 2 3 Type of sedation (cont/intermittent) Time between starting sedation and death Intermittent Deep Sedation Continuous Continuous 23 days 48 hours 70 hours Drugs used- opioid Morphine Methadone Morphine Drugs usedbenzodiazepine Midazolam Midazolam Midazolam infusion Drugs used- other Levomepromazine Ketamine 1x Haloperidol S/C Route of administration IV IV IV Consent for sedation Verbal consent. Multiple discussions documented Discussions that sedation likely to occur with increased medication Discussions that sedation likely to occur with increased medication Known goals of care at time of sedation Yes. Comfort. Yes. Comfort Yes. Comfort. Adverse events Nil Nil Nil Clarification of important points: • Sedation vs Sedative medication for EOL care • Increased fatigue and sleepiness, and reduced consciousness can be part of the natural dying process • Primary vs Secondary sedation* * Morita T, Tsuneto S, Shia Y. Proposed definitions for terminal sedation. The Lancet. 2001 July 28; 358: 335-336. AN ALGORITHM FOR THE IDENTIFICATION OF SYMPTOM REFRACTORINESS Any further interventions capable of providing adequate relief? Yes No Is the anticipated acute or chronic morbidity of the intervention tolerable to the patient? Yes No Are the interventions likely to provide relief within a tolerable time frame? Yes No “Difficult” symptom amenable to further trials of standard therapies C O N S I D E R S E D A T I O N REQUIRED DOCUMENTATION 1. Goals of care clearly stated: the relief of suffering must predominate over other considerations 2. Patient, family and treating clinicians are in agreement 3. Are refractory symptoms identified? 4. Are parameters for sedative titration identified? PALLIATIVE SEDATION PHARMACOTHERAPY Literature anecdotal, guidelines empirical Opioids: morphine Benzodiazepines: midazolam, diazepam Phenothiazines: chlorpromazine Barbiturates: pentobarbital ETHICAL CONSIDERATIONS Ethical validity is derived form the “Principle of double effect” Distinguishes primary intent on relieving suffering to the potential unavoidable consequence of a hastened death CONDITIONS TO INVOKE THE “PRINCIPLE OF DOUBLE EFFECT” 1. The treatment is at least neutral (if not beneficial), but may have untoward as well as beneficial consequences 2. The clinician intends the beneficial outcome but the unforseen outcome may be unavoidable 3. The untoward outcome is not necessary to achieve the desired beneficial outcome 4. Adequate relief of unendurable symptoms is a compelling reason to place the patient at risk of the untoward outcome CONSIDERATION PAEDIATRIC ISSUE Discussion about symptom management & decision making process for palliative sedation Language must be clear, concise, & if the child is included, developmentally appropriate. Interpreters should be used for culturally and linguistically diverse communities. Indications for sedation Refractory symptoms when all therapeutic options have been implemented or explored The child is in the terminal phase of the illness Consent May include the consent/assent of the child Selection of sedation method To accommodate the principle of proportionality. In particular, consider short half-life medicines if sedation if to be reversed Dose titration, monitoring, care Consider the use of paediatric sedation measures Discussion about nutrition, hydration, and concomitant medications These considerations to be made in discussions with the family and in the light of benefits versus burdens Documentation Documentation to placed in an easily located part of the medical records Care and information need of family This should be on-going Care of clinicians This should be on-going CONCLUSIONS The relief of intolerable symptoms is a moral imperative Must distinguish between “difficult” and “refractory” symptoms Guidelines for the identification of refractory symptoms essential Very small numbers of children need palliative sedation Guidelines assist in the task of providing adequate relief whilst maintaining ethical equilibrium References • • • • • • • • Morita T, Tsuneto S, Shia Y. Proposed definitions for terminal sedation. The Lancet. 2001 July 28; 358: 335-336. Anquinet L, Rietjens JAC, van der Heide A, Bruinsma S, Janssens R, Deliens L, Addington-Hall J, Smithson WH, Seymour J. Physicians’ experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life. Psycho-Oncology. 2013 May: 23: 539-546. doi: 10.1002/pon.3450 Levine D, Lam CG, Cunningham MJ, Remke S, Chrastek J, Klick J, Macauley R, Baker JN. Best practices for paediatric palliative cancer care: a primer for clinical providers. The Journal of Supportive Oncology. 2013 September;11(3):114-125. Morita T, Tsuneto S, Shima Y. Definition of sedation for symptom relief: A systematic literature review and a proposal of operational criteria. Journal of pain and symptom management. 2002Oct: 24(4): 447453. Inghelhrecht E, Bilsen J, Mortier F, Deliens L. Continuous deep sedation until death in Belgium: A survey among nurses. Journal of Pain and Symptom Management. 2011May5;41(5):870-879. Anquinet L, Rietjens JAC, Seal C, Seymour J, Deliens L, van der Heide A. The practice of contiuous deep sedation until death in Flanders (Belgium), The Netherlands, and the U.K.: A comparative study. Journal of Pain and Symptom Management. 2011July20; 44(1). doi: 10.1016/j.jpainsymman.2011.07.007. Sinclair CT, Stephenson RC. Palliative Sedation: assessment, management, and ethics. Hospital Physician. 2006March; 42(3):43-46 Morrison W, Kang T. Judging the quality of mercy: drawing a line between palliation and euthanasia. Pediatrics.2014;133:S31-S36. doi:10.1542/peds.2013-3608F. • • • • • • • • • • • • • Cherny N, Portenoy R. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. Journal of palliative care. 1994, 10:2, 31-38. Claessens P, Menten J, Schotsmands P, Broeckaert B. Palliative sedation: a review of the research literature. 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Palliative care for children with cancer. Nature Review Clinical Oncology. 2011Jan; 10:100-107. Doi:10.1038/nrclinonc.2012.238. Drake R, frost J, Collins JJ. The symptoms of dying children. Journal of pain and symptom management. 2003 Jul; 26(1): 594-603. Kenny N, Frager G. Refractory symptoms and terminal sedation of children: Ethical issues and practical management. Journal of palliative care. 1996; 12(3):40-45. Collins JJ. Intractable Pain in Children with Terminal Cancer. Journal of Palliative Care 12 (6): 29-34, 1996. Mherekumombe and Collins, Patient-contolled analgesia for children at home. J Pain Symptom management. 2014 Dec DOI: http://dx.doi.org/10.1016/j.jpainsymman.2014.10.007 . Paediatric Pain and Palliative Care Fellowships at CHW PAIN x2 [email protected] [email protected] PALLIATIVE CARE x2 [email protected] [email protected]
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