23-10-23 – Palliative Care Flashcards
Learning outcomes
- Discuss principles of delivering good end of life care
- Identify potential causes of pain in a palliative care setting
- Demonstrate awareness of pain syndromes and adjunct medication used in their management
- Identify commonly used opioid medication
- Discuss common opioid-induced side effects and their management
- Identify the role of syringe drivers in symptom management in a palliative care setting
- To identify spiritual and bereavement needs
What is palliative care according to WHO?
- Palliative care according to WHO:
- Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual
What are 2 ways the GMC defines the end of life?
- GMC definition of end of life:
1) ‘Approaching the end of life’
* likely to die within the next 12 months
2) Those facing imminent death & those with:
- Advanced, progressive, incurable conditions
- General frailty (likely to die in 12 months)
- At risk of dying from sudden crisis of condition
- Life threatening conditions caused by sudden catastrophic events
What are 6 principles of delivering good end of life care?
- 6 principles of delivering good end of life care:
1) Open lines of communication
2) Anticipating care needs and encouraging discussion
3) Effective multidisciplinary team input
4) Symptom control – physical and psycho-spiritual
5) Preparing for death - patient & family
6) Providing support for relatives both before and after death
What are 3 different types of pain?
What are 4 physical causes of pain?
What can there be overlap between regarding pain?
- 3 different types of pain:
1) Background
2) Breakthrough e.g if pain meds start to wear off
3) Incident e.g pain on movement - 4 physical causes of pain:
1) Cancer related (85%)
2) Treatment related
3) Associated factors-cancer and debility
4) Unrelated to cancer - There can be overlap of physical/ psycho-spiritual causes
What are 5 different pain syndromes?
How do they each present?
- 5 different pain syndromes:
1) Bone pain
* Worse on pressure or stressing bone / weight bearing
2) Nerve pain (neuropathic)
* Burning/shooting/tingling/jagging/altered sensation
3) Liver Pain
* Hepatomegaly/right upper quadrant tenderness
4) Raised Intracranial Pressure
* Headache (and/or nausea) worse with lying down, often present in the morning
5) Colic
* Intermittent cramping pain
* Affects tubular structures
* Can be caused by constipation from bowel obstruction
Describe the brief pain inventory short form (in picture)
Describe the brief pain inventory short form (in picture)
What are the 3 main principles of the WHO analgesic ladder?
- The three main principles of the WHO analgesic ladder are:
1) By the clock
* By the clock: To maintain freedom from pain, drugs should be given “by the clock” or “around the clock” rather than only “on demand” (i.e. PRN).
* Provides better pain control
2) By the mouth
3) By the ladder
What are the 3 steps of the WHO analgesic ladder for cancer pain?
- 3 steps of the WHO analgesic ladder for cancer pain:
1) Non-opioid
* E.g aspiring, paracetamol or NSAID
* +/- adjuvant
* Paracetamol is commonly used, as it has less side-effects
* An adjuvant is an additional pain relieving medication for something specific in the patient e.g neuropathic pain relief using tricyclics like amitriptyline
2) Weak opioid
* For mild to moderate pain E.g codeine
* Other step 2 (weak opioid): Dihydrocodeine or Tramadol
* +/- non-opioid
* +/- adjuvant
* Can use co-codamol, which is paracetamol and codeine combined
3) Strong opioid
* For moderate to severe pain e.g morphine
* Other step 3 (strong opioid): Diamorphine, Fentanyl, Oxycodone
What line of treatment is morphine?
What are opioid indications?
What are cautions of morphine?
What is the BNF?
How can cautions differ in the terminally ill?
- Morphine is the 1st line strong opioid
1) Indications
* Moderate-severe pain and breathlessness (dyspnoea)
2) Action
* Opioid receptor agonist (µ-receptors) and centrally acting (medicines that lower heart rate and reduce blood pressure)
3) Cautions – long list in BNF
* Cautions Includes renal impairment and the elderly
* It should be avoided in acute respiratory depression
- The British National Formulary is a United Kingdom pharmaceutical reference book that contains a wide spectrum of information and advice on prescribing and pharmacology, along with specific facts and details about many medicines available on the UK National Health Service
- – ‘in the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to use of opioid analgesics’
What are 3 ways morphine can be administered?
- 3 ways morphine can be administered:
1) Enterally- oral/ rectal
2) Parenterally- im / sc injections
3) Delivery via syringe driver over 24 hours
What are 4 principles for moving to step 3 (strong opioids) on the analgesic ladder?
- 4 principles for moving to step 3 (strong opioids) on the analgesic ladder:
1) Stop any ‘Step 2’ weak opioids
* As this could increase toxicity and symptoms
2) Titrate immediate release strong opioid
* So it works quickly
3) Convert to modified release form
4) Monitor response and side-effects
What are 2 ways morphine can be prescribed?
When is each method used?
What are examples of each type?
- 2 ways morphine can be prescribed:
1) Modified release
* ‘Background’ pain relief
* Either twice daily preparation at 12 hourly intervals (e.g MST continus)
* Or once daily preparation at 24 hourly intervals (e.g MXL)
2) Immediate release
* ‘Breakthrough’ pain
* As required (PRN medication) – titrate immediate release strong opioid
* E.g. Oramorph liquid/ Sevredol tabs
What is diamorphine?
Why is it sometimes used?
- Diamorphine is a Semi-synthetic morphine derivative
- More soluble than Morphine, so smaller volumes needed
- Can be used for parenteral administration (injection / syringe driver)
Why might we switch opioids?
What are 2 second line opioids?
When are they used?
- We may switch opioids if there is opioid sensitive pain with intolerable side-effects
- 2 second line opioids:
1) Oxycodone (Oxynorm/ Oxycontin)
* Second line opioid
* Less hallucinations, itch, drowsiness, confusion
2) Fentanyl patch
* Second line opioid
* Lasts 72 hours
* Only use in stable pain
* Useful if oral and subcutaneous routes not available
* Useful if persistent side-effects with morphine / diamorphine
What are the 5 most common opioid side-effects?
- 5 most common opioid side-effects:
1) N&V
2) Constipation
3) Dry mouth
4) Biliary spasm
5) Watch for signs of opioid toxicity
What is used to treat constipation from opioids?
What are 4 examples of laxatives used for constipation due to opioids?
- Stimulants & softening laxative are used for constipation due to opioids
- 4 examples of laxatives used for constipation due to opioids:
1) Senna
2) Bisacodyl + Docusate
3) Magrogol e.g. laxido + movicol together
4) Co-Danthramer alone
What are 3 medications used for nausea due to opioids?
- 3 medications used for nausea due to opioids:
1) Antiemetic
2) Metoclopramide
3) Haloperidol (consider QT interval)
What are 7 signs of opioid toxicity?
- 7 signs of opioid toxicity:
1) Shadows edge of visual field
2) Increasing drowsiness
3) Vivid dreams / hallucinations
4) Muscle twitching / myoclonus
5) Confusion
6) Pin point pupils
7) Rarely, respiratory depression
What are 4 different conditions that may require adjunct medication?
What are examples of medications used?
- 4 different conditions that may require adjunct medication:
1) Liver capsule pain/raised intracranial pressure
* Steroids (e.g. Dexamethasone)
* Remember to consider gastroprotection, as streroids can cause GI bleeding e.g PPI
2) Neuropathic pain
* Amitriptyline/ Gabapentin/ Carbamazepine (1 is a tricylic, last 2 are anti-epileptics)
3) Bowel/ bladder spasm (colicy pain)
* Buscopan (Hyoscine Butylbromide)
4) Bony pain/ soft-tissue infiltration
* NSAIDs/ Radiotherapy for bony metastases
How is medication delivered via syringe drivers?
What are 3 times syringe drivers?
Why is there stigma around syringe drivers?
- Delivery of syringe drivers is over 24 hours usually sub-cutaneous
- 3 times syringe drivers:
1) Useful when oral route inappropriate
2) Often useful for rapid symptom control
3) Multiple medications can be added - There is a stigma of being on a ‘pump’
What are the 4 factors that make up total pain (in picture)?
What is psycho-spiritual distress?
How might it be expressed?
When might spiritual distress occur?
What are 4 particular times where psycho-spiritual distress can occur?
- Psycho-spiritual distress can be defined as the impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, nature, or a power greater than oneself.
- Psycho-spiritual distress may be expressed as - or magnify the intensity of - physical symptoms.
- Spiritual distress may occur when the individual is faced with challenges that threaten an individuals’ beliefs, meaning, or purpose.
- 4 particular times where psycho-spiritual distress can occur:
1) At diagnosis
2) At home after initial treatment
3) At disease progression or recurrence
4) At the terminal phase
How can we manage psycho-spiritual distress?
- Psycho-spiritual distress management:
- Affirm patient by attentive listening. If appropriate, explore current thoughts and feelings with focus on particular fears and anxieties. Key issues in managing Psycho-spiritual distress include:
1) Encouraging hope, purpose and meaning
2) Respecting religious/cultural needs
3) Affirming the patient’s humanity
4) Protecting the patient’s dignity, self worth and identity
5) Encouraging relationships
6) Encouraging forgiveness/reconciliation
7) Refer to colleagues in wider MDT / specialist services
Covid-19 and grief (in picture)
Old and new concept of bereavement and grief (in picture)
What are the 3 types of grief?
What is grief not a measure of?
- 3 types of grief:
1) Anticipatory Grief
2) Non-complex (normal) Grief (90-94%)
3) Complex / Unresolved Grief (6-10%)
* Can develop into mental health conditions
- Grief is not a measure of the relationship between the bereaved and the deceased.
What are 4 ways bereavement and grief can be managed?
- 4 ways bereavement and grief can be managed:
1) The vast majority of those experiencing grief only require support and space to be heard.
* The other 3 are typically for extended abnormal grief reactions
2) Medication
* Antidepressants
* Benzodiazepine
3) “Sick line”
* Time off work
4) Counselling
Describe the Essence of Palliative & Bereavement Care.
- In caring for others we need to listen, we need to hear their story, we need to hold their pain.
- Your presence and listening ear is the most important therapeutic intervention you can offer.
- Listening is the Essence of Palliative & Bereavement Care.
Bereavement and grief management
- Bereavement and grief management:
- There is no right or wrong way to grieve – it is a journey not an event
- Grief is a personal journey, unique to each of us
- People may experience a combination of powerful emotions at different times
- Acknowledge the persons loss
- Take time to listen to the persons stories, allow them to talk about their loss, their feelings and how they are coping
- Mirror the words and phrases used by the person
- Acute grief can be highly distressing and disabling, but grief should not be medicalised.
- Grief is the body’s natural response that evolves as a bereaved person adapts to their loss.
- Learn how to recognise anticipatory and unresolved
- Grief and any complications (especially depression).
