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4. Palliative care Flashcards

1
Q

define palliative care

A

“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.”

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2
Q

unlicenced vs off-licence medications

A

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.

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3
Q

broad causes for N&V

A

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)

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4
Q

what can cause reduced gastric motility/gastric outlet obstruction?

A

Autonomic neuropathy (paraneoplastic).
Drugs (opioid, anticholinergic).
Metabolic (for example hypercalcaemia).
Mechanical obstruction, tumour, nodes, enlarged liver (leading to squashed stomach).
Constipation

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5
Q

what is the most important thing to consider when prescribing an anti-emetic for N&V ?reduced gastric motility

A

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

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6
Q

management of n&v caused by reduced gastric motility

A

If there is no colic: start a prokinetic anti-emetic - for example metoclopramide

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7
Q

management of n&V in complete bowel obstruction

A

manage bowel obstruction as usual

n&v symptomatic:
1. cyclizine
+ haloperidol

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8
Q

causes of n&v due to visceral/serosal/oesophgeageal irritation

A

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.

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9
Q

management of n&v caysed by visceral/serosal/Oesophageal irritation

A
  1. Cyclizine
  2. Anticholinergics, for example hyoscine hydrobromide
  3. Levomepromazine
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10
Q

systemic causes of N&V

A

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.

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11
Q

MAnagement N&V for systemic cuases of N&V

A

Haloperidol, metoclopramide or levomepromazine

correct hypercalcaemia if high

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12
Q

management of n&v caused by raised ICP

A
  1. Cyclizine
    • dexamethasone if raised ICP
  3. Levomepromazine

Consider referral for radiotherapy for all people with raised intracranial pressure due to a tumour.

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13
Q

what mat caus vestibular n&v?

A

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.

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14
Q

management vestibular n&v

A
  1. Cyclizine
  2. Hyoscine hydrobromide
  3. Cinnarizine
  4. Levomepromazine
  5. Prochlorperazine
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15
Q

what can cortical n&v

A

May be due to anxiety, pain, fear and/or anticipatory nausea
Related to GABA and histamine (H1) receptors in the cerebral cortex

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16
Q

management cortical n&v

A

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).

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17
Q

broad causes of cough

A

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

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18
Q

what may be used palliative care symptom management of cough

A

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

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19
Q

management hiccups palliative care

A
  1. chlorpromazine
  2. haloperidol, gabapentin are also used
  3. dexamethasone is also used, particularly if there are hepatic lesions
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20
Q

what are hiccups

A

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

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21
Q

what causes hiccups

A

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

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22
Q

management of secretions palliative care

A

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

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23
Q

broad causes of dyspnoea

A

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

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24
Q

management of dyspnoea in palliatiev care

A

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

25
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
26
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
27
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
28
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
29
what are the four components of pain
1. Physical pain 2. Psychological pain 3. Social pain 4. Spiritual pain
30
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
31
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
32
what are some non-pharmacological methods of pain management
education, explanation and reassurance, physiotherapy, electrotherapy, mindfulness, or acupuncture
33
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
34
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
35
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
36
how to convert from morphine in mg to oxycodone in mg
divide by 2!
37
name some weak opioids
codeine, dihydrocodeine, tramadol
38
adverse effects opioids
nausea, constipation, dizziness, drowsiness, neurological and respiratory depression when taken in overdose.
39
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
40
examples of strong opioids
morphine and oxycodone
41
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
42
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
43
why do opiods cause nausea and vomiting? management?
stimulation of CTZ Haloperidol, metoclopramide or levomepromazine
44
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,
45
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”
46
ABC of strong opioid prescribing
Start Antiemetic (metoclopramide) Consider Breakthrough pain Prescribe laxatives for Constipation (stimulant - senna)
47
?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.
48
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
49
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.
50
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
51
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
52
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
53
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.
54
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
55
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.
56
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)
57
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.
58

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