23-10-23 – Palliative Care

Question 1

Learning outcomes

Answer 1

• 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

Question 2

What is palliative care according to WHO?

Answer 2

• 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

Question 3

What are 2 ways the GMC defines the end of life?

Answer 3

• 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

Question 4

What are 6 principles of delivering good end of life care?

Answer 4

• 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

Question 5

What are 3 different types of pain?

What are 4 physical causes of pain?

What can there be overlap between regarding pain?

Answer 5

• 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

Question 6

What are 5 different pain syndromes?

How do they each present?

Answer 6

• 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

Question 7

Describe the brief pain inventory short form (in picture)

Answer 7

Question 8

Describe the brief pain inventory short form (in picture)

Answer 8

Question 9

What are the 3 main principles of the WHO analgesic ladder?

Answer 9

• 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

Question 10

What are the 3 steps of the WHO analgesic ladder for cancer pain?

Answer 10

• 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

Question 11

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?

Answer 11

• 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’

Question 12

What are 3 ways morphine can be administered?

Answer 12

• 3 ways morphine can be administered:

1) Enterally- oral/ rectal

2) Parenterally- im / sc injections

3) Delivery via syringe driver over 24 hours

Question 13

What are 4 principles for moving to step 3 (strong opioids) on the analgesic ladder?

Answer 13

• 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

Question 14

What are 2 ways morphine can be prescribed?

When is each method used?

What are examples of each type?

Answer 14

• 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

Question 15

What is diamorphine?

Why is it sometimes used?

Answer 15

• Diamorphine is a Semi-synthetic morphine derivative
• More soluble than Morphine, so smaller volumes needed
• Can be used for parenteral administration (injection / syringe driver)

Question 16

Why might we switch opioids?

What are 2 second line opioids?

When are they used?

Answer 16

• 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

Question 17

What are the 5 most common opioid side-effects?

Answer 17

• 5 most common opioid side-effects:
  1) N&V
  2) Constipation
  3) Dry mouth
  4) Biliary spasm
  5) Watch for signs of opioid toxicity

Question 18

What is used to treat constipation from opioids?

What are 4 examples of laxatives used for constipation due to opioids?

Answer 18

• 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

Question 19

What are 3 medications used for nausea due to opioids?

Answer 19

• 3 medications used for nausea due to opioids:
  1) Antiemetic
  2) Metoclopramide
  3) Haloperidol (consider QT interval)

Question 20

What are 7 signs of opioid toxicity?

Answer 20

• 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

Question 21

What are 4 different conditions that may require adjunct medication?

What are examples of medications used?

Answer 21

• 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

Question 22

How is medication delivered via syringe drivers?

What are 3 times syringe drivers?

Why is there stigma around syringe drivers?

Answer 22

• 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’

Question 23

What are the 4 factors that make up total pain (in picture)?

Answer 23

Question 24

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?

Answer 24

• 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

Question 25

How can we manage psycho-spiritual distress?

Answer 25

• 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

Question 26

Covid-19 and grief (in picture)

Answer 26

Question 27

Old and new concept of bereavement and grief (in picture)

Answer 27

Question 28

What are the 3 types of grief?

What is grief not a measure of?

Answer 28

• 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.

Question 29

What are 4 ways bereavement and grief can be managed?

Answer 29

• 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

Question 30

Describe the Essence of Palliative & Bereavement Care.

Answer 30

• 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.

Question 31

Bereavement and grief management

Answer 31

• 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).