What are the purposes of palliative medications?
Palliative medications are one component of a 'whole-person' approach to supporting people with life-limiting and terminal illnesses. Medications may be needed to treat and / or prevent symptoms associated with the palliative diagnosis. These include problems such as pain, nausea and vomiting, depression, shortness of breath, among other issues. Some specific disease modifying treatments aimed at controlling and slowing down the progress of a disease (rather than curing it), are also often called 'palliative treatments'. This may include chemotherapy, hormone treatments and radiotherapy. For more information about these go to the National Cancer Institute website, or the Cancer Council of Australia website.
What medications are we talking about?
The classes of medication most commonly used in palliative care are:
- analgesics (to treat pain)
- antiemetics (to treat and also to prevent nausea and vomiting)
- laxatives / aperients (to prevent and treat constipation)
- adjuvant medications (medications that work with analgesics to improve pain or symptom control)
- steroids (that may reduce a range of symptoms related to inflammation), and
- antidepressants (to treat depression, or sometimes pain) and other neuroleptic medications (to treat depression, anxiety, or pain delirium) and sedatives.
What is different about palliative medications?
Standard medications may be used differently in the palliative care setting, based on well established practices for which there are varying degrees of evidence. Examples include the use of antipsychotic medications to treat nausea, anticonvulsants to treat pain, and opioids to treat dyspnoea. Where these indications are unlisted in the product information (found in the package insert or the eMIMS®) this is termed 'off-license' prescribing. Sometimes it may be difficult to access these medications for patients in the community. There are also cost implications as they are unable to be subsidised through the Pharmaceutical Benefits Scheme (PBS).
In a palliative approach to treatment, giving medications should be as simple and non-traumatic as possible, with the potential for them to be given at home. The route of administration may differ from that usually used in a hospital based acute care situation.
A frequent issue is the need to continue medications for a person who can no longer swallow, and a common alternative route of administration is a subcutaneous injection or infusion. This is less traumatic and less difficult to maintain than intravenous medication, and it can often be managed at home with nursing support. Some medications are only available by the oral route. At the time a person can no longer take solid oral preparations, other options (including dissolving the tablet in water) may need to be substituted.
Stopping unnecessary medications
When people have a number of other medical conditions that are unrelated to their palliative care diagnosis, they may be on numerous medications, many of which have a role in maintaining health and preventing the long-term consequences of diseases including, but not limited to, diabetes and hypertension. The burden in terms of cost and discomfort of taking many drugs, as well as the escalating risk of drug interactions from polypharmacy, means that long-term medications should be frequently reviewed. Decisions about which medications to stop should be made by balancing the likely prognosis from the palliative care diagnosis, with short, medium, and long-term risks associated with stopping medications to manage co-morbidities.