Palliative care: How to help a patient in pain?

Yuri Vitalievich Voynovsky, an anesthesiologist and resuscitator, is a guest of the Medical Solution Tour. Marat Sarsenbekov, head of the Medical Solution Tour office in Almaty, talked to the doctor about palliative care and how to really help a patient with pain.

Also, Yuri Vitalievich talked about the peculiarities of using port systems, what kind of help is provided in dispensaries, and in what cases it is more profitable to be treated in Kazakhstan than to go to other countries.

What is palliative care?

Marat Sarsenbekov: Dear colleagues, dear friends, hello! Let me introduce myself, my name is Marat Sarsenbekov. I am the head of the Medical Solution Tour company – Medical Assistance Clinic. Our guest today is Yuri Vitalievich Voynovsky – a doctor of intensive care, and anesthesiologist. Yuri Vitalievich, hello! Please tell us what palliative care is.

Yuri Voynovsky: The French word “palliative” means temporarily. Palliative care is a set of measures aimed at maintaining the life activity of a patient with extremely serious diseases at the most comfortable level. Currently, in the Republic of Kazakhstan, all dispensaries have palliative care departments. Patients are hospitalized through a portal to palliative care units in specialized centers. Patients who do not undergo specific methods of oncology treatment can continue treatment in such centers. That is, when chemotherapy, immune therapy, radiation therapy, and surgery are no longer indicated.

How to help with pain syndrome and how to properly combine drugs in treatment

Marat Sarsenbekov: Often patients have pain syndrome. Please tell me how to help the patient?

Yuri Voynovsky: Treatment of pain syndrome in cancer patients is quite a complex problem. This problem is multidisciplinary. It depends not only on the attending physician and the district oncologist. It happens that patients first turn to a neurologist. The neurologist prescribes one drug. The attending physician recommends another drug. The district oncologist prescribes a third drug. And it often happens that these drugs are incompatible with each other. For example, using one of the antidepressants, which is often recommended, increases the action of analytes together with one of the antagonists of the support receptors. I will not mention its name, but it is included, so to speak, in the list of what is used in oncology. A seizure syndrome develops after the use of such a drug. You need to be very aware of drug interactions. We should not treat the disease that the patient has, but treat a specific patient.

Unfortunately, in our country, everything often goes to standardization. For example, all over the world clinical guidelines are called Guidelines. That is, literally translated as guidelines. But here they are standards, clinical protocols. I personally strongly disagree with this. It is not always possible to act according to a clinical protocol. You need to have, as they say, your own thinking, knowledge and clearly know how drugs interact with each other. Often patients ask far beyond the six stages of the process: “How am I going to live my life? Am I going to have everything hurt all the time now?”. This can be a very difficult question to answer. In many cases, a competent anesthesiologist-anesthesiologist-animatologist can help to choose the right combination of drugs. Sometimes with the involvement of so-called invasive methods. These are certain blockades, the use of so-called epidural anesthesia, spinal anesthesia, and so on.

Pain syndrome in oncology is a very complex problem. And these problems were raised in 2022 at an interdisciplinary conference that took place in May in Almaty under the title “Manage Pain-22” or “Pain Management Case”. It was a conference with international participation, which was organized by the Koishibayev Institute of Neurology together with the First Moscow Sechenov Medical Institute (in online and offline format). At this conference, I had a report “Chronic pain syndrome in oncology. Clinico-pharmacological aspects”.

Port systems and their application

Marat Sarsenbekov: Yuri Vitalievich, please tell me, how can you relieve pain in a patient with thin veins?

Yuri Voynovsky: There are situations when a patient’s veins are very bad – either from birth or spoiled by numerous infections, especially in aged patients. How can this be managed? There are various venous accesses available. It is established by anesthesiologists. It is the catheterization of central veins, such as the subclavian vein or the jugular vein in the neck. A catheter can be placed in the femoral vein. In some cases, especially if prolonged chemotherapy is indicated, so-called port systems are installed. That is, a vein is catheterized, either surgically or anesthetically by puncture access. Then a pocket is formed in the subclavian region, where the so-called head of the port system is located – it is the port itself. The port and the port system are connected to each other. The system is located under the skin. The port system must be flushed periodically. Unless chemotherapy is being given, no intravenous injections are given. The port system is flushed once every 28 days. This time is usually between courses of chemotherapy. Chemotherapy is given depending on the disease and the drug. In some cases, once every 14 days. Sometimes, once a month. Many chemotherapy drugs used to treat diseases irritate the peripheral vein. The drugs cannot be administered into peripheral veins. In these cases, patients are given venous access by inserting a regular central venous catheter. There are also Pickline catheters, but they are practically not used in Kazakhstan.

Yuri Voynovsky: Under ultrasound control, a vein is located on the shoulder – the catheter is installed. The end of the catheter is at the right atrium. This catheter can last about a year. Central venous catheter is normal – theoretically lasts about a month, as the instructions say. In some cases, with proper care, if the reactivity is normal, that is, the immune response of the body is normal – the catheter lasts much longer. Well, and port system implanted under the skin – serves up to five years. The membrane of the port system can withstand up to 5,000 piercings with a special Huber needle. According to the opinion of the Heidelberg Clinic for Port Implantation in Germany (there is a separate clinic for port-system implantation at the Heidelberg Medical University): if the subsystem serves normally, and works normally at the end of its service life – there is no need to remove it. Port systems are installed in Almaty (in the Institute of Oncology), in Astana, and in many regional dispensaries. But not in all of them. And in some private clinics, of course, on a commercial basis. And in public institutions, they can be established on the portal of hospitalization. In developed countries, to which, unfortunately, we do not belong yet, port systems are installed in 30-40% of patients during chemotherapy. Unfortunately, we do not have statistics on the installation of port systems.

Where and how to get palliative treatment

Marat Sarsenbekov: Yuri Vitalievich, please tell me, is there any sense for a patient at the last stage to go abroad for palliative care?

Yuri Voynovsky: It seems to me that if the patient is in the fourth clinical group, that is, he is not shown specific treatment for oncology, it makes no sense to go abroad. If there is a need to receive palliative care, then on the portal of hospitalization it can be received in Almaty in the center of palliative care, or at the place of residence in regional dispensaries. Those who wish to receive palliative care in private institutions can receive it in private medical institutions at a fairly high level. This is what we have in Kazakhstan.

Marat Sarsenbekov: Thank you very much for your answers. Would you like to wish something to our readers?

Yuri Voynovsky: What can I wish our readers? Be examined in time, and go to a medical institution. And, in general, do not get sick. And if you are sick – treat not by reference book. Not on the Internet. Once the great therapist Botkin was asked: “Is it possible to treat by reference book?”. “You can!”, Botkin replied. “But there’s a very good chance of dying from a typo.” Good health to all of you.