12. Palliative care

Palliative care refers to an approach that attempts to improve the quality of life of patients and their close ones and to relieve their suffering. It's most frequently used in life-threatening diseases, most commonly cancer. Palliative care is a symptomatic approach, aiming to relieve symptoms; it does not involve disease-specific treatment. Treatment of pain, distress, anxiety, and nausea/vomiting are the cornerstones.

Palliative care is often confused with end-of-life care. There's also the misconception that employing palliative care means that the patient is end-of-life, but this is not true. Also false is the commonly held idea that palliative care is not indicated as long as curative treatment or disease-specific treatment is administered. In reality, palliative care should be practiced at every step along the way in case of life-threatening disease or other disease with significant decreased quality of life.

Cancer pain

Many patients with cancer experiences severe pain, usually due to tumours compressing and putting pressure on nearby structures or due to the inflammation triggered. Bone metastases are especially painful. Cancer pain may also be neuropathic. Most patients with cancer pain are inadequately treated.

Paracetamol and NSAIDs are cornerstones of cancer pain therapy, but they're rarely enough alone. They must usually be combined with opioids like morphine or oxycodone. The most common approach is to give a slow-release formulation of the opioid twice daily and have immediate-release formulations available in case of so-called "breakthrough" pain. Opioids may be administered orally, subcutaneously, or transdermally. The correct dose of opioid is the one that relieves the patient's pain to an acceptable level. Pregabalin and gabapentin may be used for neuropathic cancer pain as an adjuvant. Corticosteroids may also be used as adjuvant cancer pain therapy.

To prevent opioid-induced constipation, laxatives should be administered routinely in those taking opioids, and they should be titrated up until the stool is normal. Some opioids exist in enteric formulations where naloxone is included; this reduces opioid-induced constipation by blocking the opioid from binding to opioid receptors in the GI tract and causing constipation. The naloxone does not reduce the analgesic effect.

Nausea and vomiting

Nausea and vomiting are also common in case of cancer, either due to the disease itself or due to treatment of it, most commonly chemotherapy.

Serotonin 5-HT3 receptor antagonists like ondansetron or granisetron are most commonly used. Dopamine D2 receptor antagonists like metoclopramide may also be used. They may be administered IV or sublingually, which is especially useful in nausea and vomiting. Corticosteroids also improve cancer-related nausea and may be used for this purpose.

Constipation

Constipation may be secondary to the cancer or to the opioids used to treat cancer pain. This can be treated with laxatives.