The changing face of palliative care

The face of palliative care has changed considerably in the past four decades. The increased consumption of opioids did not fulfil the promise of freedom from pain. The reason for this may be that cancer patients live longer and suffer from different types of pain than before. Increasingly, patients suffer because of treatment-induced pain and pain due to degeneration and deterioration. Different strategies for coping with pain are now needed in comparison with four decades ago.The face of palliative care has changed considerably in the past four decades. The increased consumption of opioids did not fulfil the promise of freedom from pain. The reason for this may be that cancer patients live longer and suffer from different types of pain than before. Increasingly, patients suffer because of treatment-induced pain and pain due to degeneration and deterioration. Different strategies for coping with pain are now needed in comparison with four decades ago

Management of diabetes mellitus in terminally ill cancer patients

Many patients not only with cancer cared for by palliative care services suffer of diabetes. Treatment of diabetes in palliative care differs markedly from general medicine. Patients in palliative care usually have short prognosis and treatment targets are related more to the possible symptoms of hyper- or hypo-glycaemia and less to prevention of long term complications. Therefore monitoring of plasma blood glucose can be done less often. In this article we discuss all aspects of plasma glucose control in terminally ill. We also discuss problem of hyperglycaemia induced by steroids. The use of oral hypoglycaemic agents and insulin, together or separately, is discussed in detail. For patients near the end of life and on insulin, we propose a scheme with once daily plasma glucose monitoring and once daily administration of long acting insulin. Adv. Pall. Med. 2010; 9, 3: 99–102Many patients not only with cancer cared for by palliative care services suffer of diabetes. Treatment of diabetes in palliative care differs markedly from general medicine. Patients in palliative care usually have short prognosis and treatment targets are related more to the possible symptoms of hyper- or hypo-glycaemia and less to prevention of long term complications. Therefore monitoring of plasma blood glucose can be done less often. In this article we discuss all aspects of plasma glucose control in terminally ill. We also discuss problem of hyperglycaemia induced by steroids. The use of oral hypoglycaemic agents and insulin, together or separately, is discussed in detail. For patients near the end of life and on insulin, we propose a scheme with once daily plasma glucose monitoring and once daily administration of long acting insulin. Adv. Pall. Med. 2010; 9, 3: 99–10

The systemic effects of local infiltrations with corticosteroids. Implications for palliative care?

Corticosteroids are used in approximately 50% of palliative care patients. Increasingly corticosteroids are used as local infiltrations together with local anaesthetics. This treatment may be adjuvant to other measures to control pain. Depo preparations, although their main activity is topical, may also exercise systemic toxicity. This may include transient suppression of adrenal activity which may be exacerbated by the use of morphine. Some women in reproductive age may experience vaginal blood loss between the periods. Other toxicities are rare.Corticosteroids are used in approximately 50% of palliative care patients. Increasingly corticosteroids are used as local infiltrations together with local anaesthetics. This treatment may be adjuvant to other measures to control pain. Depo preparations, although their main activity is topical, may also exercise systemic toxicity. This may include transient suppression of adrenal activity which may be exacerbated by the use of morphine. Some women in reproductive age may experience vaginal blood loss between the periods. Other toxicities are rare

Anatomy of clinical consultation. Pain in a patient with metastasized prostate cancer. I can help when you ask me the right questions

We are all asked for consultations to see a complex patient or to answer the telephone call and think about the patient without seeing him and without touching him. Although this type of consultation is much cheaper, faster and sometimes effective. There is a danger that we hear only a part of the story, or a story coloured in such a way that it will push the decision in one direction, intended by a doctor or nurse who requested it. In this article I describe a consultation “by a telephone”. I go in de depths of the request and discuss with the doctor who asked me in consultation all pros and cons. I come to conclusion that we should teach young doctors how to request consultation, which questions to ask without suggesting the answers. Adv. Pall. Med. 2011; 10, 2: 79–82We are all asked for consultations to see a complex patient or to answer the telephone call and think about the patient without seeing him and without touching him. Although this type of consultation is much cheaper, faster and sometimes effective. There is a danger that we hear only a part of the story, or a story coloured in such a way that it will push the decision in one direction, intended by a doctor or nurse who requested it. In this article I describe a consultation “by a telephone”. I go in de depths of the request and discuss with the doctor who asked me in consultation all pros and cons. I come to conclusion that we should teach young doctors how to request consultation, which questions to ask without suggesting the answers. Adv. Pall. Med. 2011; 10, 2: 79–8

Opioid-induced hypogonadism: the role of androgens in the well-being and pain thresholds in men and women with advanced disease

Hypogonadism is probably very common among patients with advanced disease. It may result from the disease itself but might also be caused or exacerbated by the drugs used to treat these patients and their symptoms. Opioids are notorious for their ability to depress the production of androgens by both adrenals and gonads. The corticosteroids used in more than 30% of patients with advanced disease may also contribute to hypogonadism. The symptoms of hypogonadism may involve not only fatigue, lack of energy and loss of libido, but also most probably increased sensitivity to pain. In many cases this may lead to increased doses of opioids and increased inhibition of androgen production. Opioid-induced hypogonadism may thus contribute to the development of opioid tolerance. Treatment with androgens for these indications is still controversial and not widely accepted. Androgens may have different adverse effects and their effect on pain has not yet been confirmed in clinical trials. Many patients (with breast and prostate cancers) may have hypogonadism induced pharmacologically in order to inhibit tumour growth. Treatment with androgens in these cases may be contraindicated. Conversely, patients with iatrogenic hypogonadism may suffer more pain and other symptoms which may negatively influence their quality of life.Hypogonadism is probably very common among patients with advanced disease. It may result from the disease itself but might also be caused or exacerbated by the drugs used to treat these patients and their symptoms. Opioids are notorious for their ability to depress the production of androgens by both adrenals and gonads. The corticosteroids used in more than 30% of patients with advanced disease may also contribute to hypogonadism. The symptoms of hypogonadism may involve not only fatigue, lack of energy and loss of libido, but also most probably increased sensitivity to pain. In many cases this may lead to increased doses of opioids and increased inhibition of androgen production. Opioid-induced hypogonadism may thus contribute to the development of opioid tolerance. Treatment with androgens for these indications is still controversial and not widely accepted. Androgens may have different adverse effects and their effect on pain has not yet been confirmed in clinical trials. Many patients (with breast and prostate cancers) may have hypogonadism induced pharmacologically in order to inhibit tumour growth. Treatment with androgens in these cases may be contraindicated. Conversely, patients with iatrogenic hypogonadism may suffer more pain and other symptoms which may negatively influence their quality of life