4. Palliative care Flashcards
define palliative care
“an approach
that improves the quality of life of patients and their families facing the problems
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.”
unlicenced vs off-licence medications
Unlicensed medicine: is a medicine without a European or UK marketing authorisation for use in humans and is not licensed to be marketed in the UK.
Off-licence (‘off-label’) medicine: is a licensed medicine used for unlicensed applications, e.g. an unlicensed indication, an unlicensed route or at an unlicensed dose.
broad causes for N&V
Local cause
- reduced gastric motility
-visceral/serosal/oesophageal irritation
Systemic cause
- electrolyte imbalance
- drugs (opioids, chemo, NSAIDs, abx)
- infection (eg UTI)
CNS
- raised ICP
- vetsibular eg motion sickness
Non-organic
- cortical (anorexia nervosa, bulimia, anticipatory)
what can cause reduced gastric motility/gastric outlet obstruction?
Autonomic neuropathy (paraneoplastic).
Drugs (opioid, anticholinergic).
Metabolic (for example hypercalcaemia).
Mechanical obstruction, tumour, nodes, enlarged liver (leading to squashed stomach).
Constipation
what is the most important thing to consider when prescribing an anti-emetic for N&V ?reduced gastric motility
you need to exclude complete bowel obstruction
symptoms:
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
“Tinkling” bowel sounds may be heard in early bowel obstruction
The key x-ray finding in bowel obstruction is distended loops of bowel.
this is because you cannot use a prokinetic agent in complete obstruction
management of n&v caused by reduced gastric motility
If there is no colic: start a prokinetic anti-emetic - for example metoclopramide
management of n&V in complete bowel obstruction
manage bowel obstruction as usual
n&v symptomatic:
1. cyclizine
+ haloperidol
causes of n&v due to visceral/serosal/oesophgeageal irritation
Causes
Cranial nerve irritation (vagal and glossopharyngeal).
Distension, compression, or disturbance of abdominal or pelvic organs (for example bowel or liver)
By
Tumour.
Secretions or sputum, stimulating the gag reflex.
Acid reflux.
Toxins.
Inflammation.
Infection (for example candida, herpes simplex).
Foreign body (for example stent).
Smells from wounds, stomas, food or other sources.
management of n&v caysed by visceral/serosal/Oesophageal irritation
- Cyclizine
- Anticholinergics, for example hyoscine hydrobromide
- Levomepromazine
systemic causes of N&V
Cause
Chemical stimulation of CTZ.
By
Drugs, including cytotoxics and opioids (also delay gastric emptying), NSAIDs, syrupy liquids, antibiotics, antidepressants, anticonvulsants, digoxin/cardiac drugs, alcohol.
Carcinomatosis/chronic inflammation (cytokine induced).
Metabolic, for example uraemia, hypercalcaemia, hyponatraemia, ketoacidosis, infection, Addison’s disease, circulating toxins, hormone imbalance.
MAnagement N&V for systemic cuases of N&V
Haloperidol, metoclopramide or levomepromazine
correct hypercalcaemia if high
management of n&v caused by raised ICP
- Cyclizine
- dexamethasone if raised ICP
- Levomepromazine
Consider referral for radiotherapy for all people with raised intracranial pressure due to a tumour.
what mat caus vestibular n&v?
Related to activation of acetylcholine and histamine (H1) receptors
Most frequently in palliative care is opioid related
Can be motion related, or due to base of skull tumours
Ototoxicity.
Middle ear problems.
vestibular nerve or inner ear stimulation.
management vestibular n&v
- Cyclizine
- Hyoscine hydrobromide
- Cinnarizine
- Levomepromazine
- Prochlorperazine
what can cortical n&v
May be due to anxiety, pain, fear and/or anticipatory nausea
Related to GABA and histamine (H1) receptors in the cerebral cortex
management cortical n&v
Consider non-drug interventions including cognitive behavioural therapy, if appropriate to the stage of disease.
Consider a benzodiazepine (for example lorazepam, 0.5–1 mg sublingually) or levomepromazine (3–6 mg orally or 2.5–6.25 mg by subcutaneous injection).
broad causes of cough
Upper respiratory tract
URTI
Post-nasal drip
ACEi
Bronchus/bronchioles
Allergen
Asthma
COPD
Foreign body aspiration
Bronchiectasis
Interstitium/parenchyma
Interstitial lung disease
Pneumonia
GPA
TB
COVID
Lung ca
VAscualr
PE
Goodpastures
Pulmonary AV malformation
Cardiac
Mitral stenosis
LV failure
Gastro
GORD
what may be used palliative care symptom management of cough
Cough Suppressants (Antitussives)
- Codeine
- Morphine
- Methadone in refractory cases
Demulcents (soothing agents)
- glycerol, syrup, simple linctus
Expectorants
Encourage ‘more productive’ cough
Example: sodium chloride 0.9% nebuliser 5ml PRN (topical mucolytic).Note may need physiotherapy after to help expectorate.
Role in palliative care not clear
management hiccups palliative care
- chlorpromazine
- haloperidol, gabapentin are also used
- dexamethasone is also used, particularly if there are hepatic lesions
what are hiccups
The coordinated contraction of the inspiratory musculature leads to a rapid intake of air that is, within a few milliseconds, interrupted by closure of the glottis. It is this that results in the characteristic sound, the ‘hic’ in hiccups, between 4 and 60 times a minute. In adults, it appears to serve no physiological purpose; however, the frequent observation of hiccups in utero during prenatal ultrasound examinations suggest that it may have a role in training inspiratory muscles in readiness for respiration after delivery
what causes hiccups
Any process that affects the afferent, central or efferent components of the proposed reflex arc can trigger hiccups. The most common cause is distension of the stomach by a large meal or carbonated drinks. The reflex can be triggered also by hot chilli pepper, alcohol, smoking and other irritants to the gastrointestinal or pulmonary tracts. Hiccups can also be triggered by over-excitement or anxiety, especially if accompanied by over-breathing or air swallowing (aerophagia). Patients with persistent or intractable hiccups should be investigated to identify organic pathology
management of secretions palliative care
Conservative:
Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
Educating the family that the patient is likely not troubled by secretions
Medical:
hyoscine hydrobromide or hyoscine butylbromide is generally used first-line
neither the BNF nor NICE Clinical Knowledge Summaries suggest one is first-line over the other
hyoscine butylbromide may be less sedative than hyoscine hydrobromide
glycopyrronium bromide may also be used
broad causes of dyspnoea
Pulmonary
- Pneumonia
- Pleurisy
- Pulmonary fibrosis
- Pulmonary cancer
- Pulmonary embolism
- COPD
- Asthma
Cardiovascular
- Anaemia
- CHF
- Pericardial effusion/tamponade
- superior vena cava obstruction
Neuromuscular
- ALS
- Myasthenia gravis
- Guillain barre
- Transverse myelitis
Systemic
- Acidosis
management of dyspnoea in palliatiev care
Airways Obstruction (Asthma, COPD)
Bronchodilators (e.g. salbutamol)
Corticosteroids (e.g. dexamethasone, steroid inhalers)
COPD, Malignancy
Respiratory sedatives (e.g. morphine)
Heart Failure
Diuretics
ACE Inhibitors
Digoxin
Respiratory sedatives (e.g. morphine)
Superior Vena Cava Obstruction (SVCO)
Corticosteroids (e.g. dexamethasone)
Chemotherapy, radiotherapy, stenting
why does morphine help with dyspnoea
Mechanism of action not fully understood but opioids reduce the ventilatory
response to hypercapnia, hypoxia and exercise, decreasing respiratory effort
and dyspnoea
oxygen in management of dyspnoea?
Most patients requiring palliation for breathlessness will not benefit from
oxygen therapy (unless they are significantly hypoxaemic)
Long term oxygen therapy (LTOT) for chronic respiratory illness should only be
instigated by a respiratory physician
management of mild/moderate bleeding palliative care
topical:
- gauze soaked in adrenaline 1:1000 apply with pressure
- if oral bleeding: tranexamic acid 500mg/5ml
mouthwash/gargle at a dose of 5-10ml QDS - tranexamic acid 500mg/5ml injection
solution. Apply with pressure for 10 minutes
Pharmacological:
tranexamic acid
1g PO TDS-QDS (max 2g QDS).
Other:
Radiotherapy may be useful in cases of lung bleeding
management of major catastrophic bleeds
Follow plan if one has been made… if no plan - follow major haemorrhage protocol
In patients for whom active treatment of such an occurrence is
inappropriate:
- Talk to patient, comfort them
- use dark towels to conceal amount of blood to make it less distressing
- Consider giving midazolam 5-10mg IV/IM/SC to reduce awareness and fear
what are the four components of pain
- Physical pain
- Psychological pain
- Social pain
- Spiritual pain
what are the steps of the WHO analgesic ladder
Step 1: non-opioids (eg paracetamol or NSAIDS) +/- adjuvants
Step 2: weak opioids (eg codeine, dihydrocodeine or tramadol) +/- adjuvants
Step 3: Strong opioid (e.g morphine, oxycodone, methadone, buprenorphine, fentanyl) and non-opiod +/- adjuvants
What are the 5 key principles of the WHO analgesic ladder
By mouth - PO where possible
By the clock - regular intervals
For the individual - according to pain character, type and intensity
By the ladder - follow ladder and start with lowest doses and titrate according to response
Attention to detail
what are some non-pharmacological methods of pain management
education, explanation and reassurance, physiotherapy, electrotherapy, mindfulness, or acupuncture
rung 1/3 of WHO analgesic ladder
Step 1: Consider regular paracetamol use
0.5g – 1g every 4-6 hours; maximum 4g daily
step 2: Add an NSAID (+/- PPI)
Typical drug dosing for (oral) ibuprofen:
Mild to moderate pain: initially 300-400mg 3-4 times a day; increased up to 600mg 4 times a day if necessary; maintenance 200-400mg three times a day
rung 2/3 of WHO analgesic ladder
Step 3: Add codeine/co-codamol
codeine Mild to moderate pain: 30-60mg every 4 hours as required
Step 4: Stop codeine/co-codamol & trial tramadol
Moderate to severe acute pain: initially 100mg, then 50-100mg every 4-6 hours; usual maximum 400mg/24 hours
rung 3/3 WHO analesic ladder
Step 6: Stop tramadol & start morphine
Before prescribing any strong opiate, consider ABC:
Start Antiemetic metoclopramide
Consider Breakthrough pain
Prescribe laxatives for Constipation senna
To titrate morphine:
1. Prescribe the dose on a regular basis/PRN every four hours eg 5mg
2. Reassess after 24 hours, if pain free the total dose that has been administered over the past 24
hours should be added up and converted into a twice-daily sustained/modified release
(SR/MR) dose by dividing the total 24 hour dose by two.
3. If the patient is still reporting pain first confirm adherence and then consider increasing
the dose prescribed and re-assessing after another 24 hours.
Once their MR has been established, add morphine for breakthorugh pain to take ‘PRN’. Commonly 1/10th to 1/6th of
the equivalent total daily dose of the drug every 4 hours PRN
Step 7: Refer to pain management specialists
how to convert from morphine in mg to oxycodone in mg
divide by 2!
name some weak opioids
codeine, dihydrocodeine, tramadol
adverse effects opioids
nausea, constipation, dizziness, drowsiness, neurological and respiratory depression when taken in overdose.
what should be prescribed alongside a weak opioid
advise the person of the risks of constipation, and prescribe a stimulant laxative (such as senna or dantron-containing laxative) at the time of first prescription. Just think that opioids turn the gut off so you need to turn it back on with a stimulant laxative
examples of strong opioids
morphine and oxycodone
indications strong opioids
Rapid relief of acute severe pain eg post-operative or pain associated with MI
Chronic pain where rest of WHO ladder is exhausted
Relief of breathlessness in EOLC
To relieve breathlessness and anxiety in acute pulmonary oedema , alongside oxygen, furosemide and nitrates
moa opioids
Activation of opioid mu receptors in the CNS. activation of these G coupled receptors reduces neuronal excitability and pain transmission.
In the medulla they blunt the response to hypoxia and hypercapnia, reducing respiratory drive and breathlessness. By relieving pain, breathless and associated anxiety, opioids reduce sympathetic nervous system activity. The theory extends that in Mi and acute pulmonary oedema they may decrease cardiac work and oxygen demand,a s wella s relieving symptoms
why do opiods cause nausea and vomiting? management?
stimulation of CTZ
Haloperidol, metoclopramide or levomepromazine
how does opioid overdose present?
neurological depression and drowsiness, respiratory depression and associated cyanosis (blue lips and peripheries) , pupil constriction, flushing of the skin, itching,
how does opioid withdrawal present?
Opioid withdrawal is the opposite of the opioid effects
anxiety, pain, breathlessness, pupil dilation, skin is cool and dry with piloerection pt has gone “cold turkey” and appears like a “cold turkey”
ABC of strong opioid prescribing
Start Antiemetic (metoclopramide)
Consider Breakthrough pain
Prescribe laxatives for Constipation (stimulant - senna)
?opioid overdose, what do you prescribe?
Naloxone
small incremental dose 200-400 mcg IV every 2-3 minutes until satisfactory reversal has been achieved. In patients who develop[ opioid toxicity in the context of chronic use (especially in palliative care) - smaller incremental doses should be used e.g. 40-100mcg.
why is it important to monitor aptients that you needed to give naloxone to?
closely monitor patient fot at least an hour. This is beacuse the action of naloxone (20-60 mins) is shorter than most opioids so opioid toxicity can reoccur
How do you titrate morphine
To titrate morphine:
1. Prescribe the dose on a regular basis/PRN every four hours eg 5mg oromorph
2. Reassess after 24 hours, if pain free the total dose that has been administered over the past 24
hours should be added up and converted into a twice-daily sustained/modified release
(SR/MR) dose by dividing the total 24 hour dose by two.
3. If the patient is still reporting pain first confirm adherence and then consider increasing
the dose prescribed and re-assessing after another 24 hours.
How do you prescribe for breakthorugh pain- morphine?
Once their MR has been established, add morphine for breakthorugh pain to take ‘PRN’. Commonly 1/10th to 1/6th of
the equivalent total daily dose of the drug every 4 hours PRN
agitation and confusion management palliative care
Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the following may be tried:
first choice: haloperidol
other options: chlorpromazine, levomepromazine
In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
What is pre-emptive prescribing?
This is the prescribing of medications for the 5 key symptoms which can occur in the
last days/hours of life.
Pain
Dyspnoea
Nausea & Vomiting
Agitation
Respiratory tract secretions
what route are anticipatory medications prescibred
Anticipatory medications are prescribed as subcutaneous injections (SC, injected under the skin) as patients nearing the end of life are often unable to take oral medications. They should be prescribed PRN, or ‘as needed’, rather than regularly.
what are the core 4 of pre-emptive prescribing? doses?
ANALGESIC - Morphine for opiod naive pts 1 – 2.5mg SC. Do not repeat within 1-hour, maximum 4 doses in 24 hours. For non-opiod naive pts the PRN anticipatory dose is generally 1/6th of the total subcutaneous background dose in 24 hours.
ANTIEMETIC Haloperidol 0.5 – 1.5mg SC. Do not repeat within 4 hours, maximum dose 3mg in 24 hours.
ANTISECRETORY Hyoscine butylbromide 20mg SC. Do not repeat within 1-hour, maximum dose 120mg in 24 hours
ANXIOLYTIC/SEDATIVE Midazolam 2.5 – 5mg SC Do not repeat within 1 hour, maximum 4 doses in 24 hours.
Water for injection
what are syringe drivers?
Syringe drivers are small battery-powered pumps used to deliver medications as a continuous subcutaneous infusion (CSCI) over a 24-hour period.
Indications for use of a syringe driver in patients nearing the end of life?
Requiring two or more doses of any one of the anticipatory medications in a 24 hour period
Being unable to take oral medications that need replacing (e.g. modified release opiates, anti-epileptic medications)
what is the key benefit of a syringe driver?
Continuous infusion provides a constant level of medication to the patient, which helps to achieve better symptom control.
