4. Palliative care

Question 1

What is palliative care?

Answer 1

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 2

What is meant by “approaching the end of life”?

Answer 2

likely to die within the next 12 months

Question 3

Non-cancer diseases requiring palliation of symptoms?

Answer 3

Motor Neurone disease / End-stage Cardiac failure / End- stage COPD / Advanced renal disease etc.

Question 4

Key themes for development in palliative care?

Answer 4

 Earlyidentificationofpatientswhomayneed palliative care
 Advance/anticipatorycareplanning(including decisions regarding cardiopulmonary resuscitation (DNACPR))
 Careinlastdays/hoursoflife
 Deliveryofeffectiveandtimelycare

Question 5

Independent review into Liverpool Care Pathway (LCP) in July 2013:
Report findings?
Response of review?

Answer 5

 LCP report findings:
– Where used properly, many people died
peaceful, dignified deaths
– But…in many cases it was associated with poor experiences of care

 Response:
– ‘One chance to get it right’ so 5 priorities for care of dying people
– ‘Care for people in the last days and hours of life’

Question 6

Palliative Care Aims

Answer 6

 Whole person approach
 Focus on quality of life, including good symptom control
 Care encompassing the person with the life- threatening illness and those that matter to them

Question 7

Principles of good end of life care

Answer 7

 Open lines of communication
 Anticipating care needs and encouraging discussion
 Effective multidisciplinary team input
 Symptom control – physical and psycho-spiritual
 Preparing for death - patient & family
 Providing support for relatives both before and after death

Question 8

Common symptoms seen in palliative patients?

Answer 8

 Physical
– Pain
– Dyspnoea
– Nausea/vomiting
– Anorexia / weight loss – Constipation
– Fatigue
– Cough etc, etc...

 Psycho-spiritual

 Medical / surgical emergencies

Question 9

Describe 5 pain syndromes>

Answer 9

Bone pain
– Worse on pressure or stressing bone / weight
bearing

Nerve pain (neuropathic)
–Burning/ shooting/ tingling/ jagging/ altered sensation

Liver pain
– Hepatomegaly/ right upper quadrant tenderness

Raised ICP
– Headache (and/or nausea) worse with lying down, often present in the morning

Colic
– Intermittent cramping pain

Question 10

Stepped symptom control plan?

Answer 10

STEP 1: Non-opioid
E.g. Aspirin, paracetamol or NSAID
+/- adjuvant

STEP 2: Weak Opioid
For mild/moderate pain
e.g. codeine, dihydrocodeine, tramadol
\+/- non-opioid
\+/- adjuvant

STEP 3: Strong opioid
For moderate to severe pain
e.g. Morphine, fentanyl, oxycodone, diamorphine
\+/- non-opioid
\+/- adjuvant

Question 11

Oral benefit of WHO pain ladder?

Answer 11

By mouth

The oral route is preferred for all steps of the pain ladder

Question 12

role of adjuvants in WHO pain ladder?

Answer 12

To help calm fears and anxiety, adjuvant drugs may be added at any step of the ladder”

Question 13

Opioid:
1st strong?
Indications?
Actions?
Cautions
Side effects?
Administration?

Answer 13

 Morphine- 1st line strong opioid
 Indications
– Moderate-severe pain/ dyspnoea
 Action
– Opioid receptor agonist (μ-receptors) – Centrally acting
 Cautions
– Longlist in BNF; including renal impairment and elderly; Avoid in acute respiratory depression
 Side-Effects
– Most common
 N&V, constipation, dry mouth, biliary spasm
 Watch for signs of opioid toxicity
 Administration
– Enterally- oral/ rectal
– Parenterally- im / sc injections
– Delivery via syringe driver over 24 hours

Question 14

S/S of opioid toxicity?

Answer 14

– Shadows edge of visual field 
– Increasing drowsiness
– Vivid dreams / hallucinations 
– Muscle twitching / myoclonus 
– Confusion
– Pin point pupils
– Rarely, respiratory depression

Question 15

“Modified release” options in morphine-practial prescribing

Answer 15

For ‘Background’ pain relief
Used: Either twice daily preparation at 12 hourly intervals
– Or once daily preparation at 24hourly intervals

Question 16

“Immediate release” options in morphine-practical prescribing?

Answer 16

For ‘Breakthrough’ pain
Used: As required (PRN)
– E.g. Oramorph liquid/ Sevredol tabs

Question 17

Main moropine side effects?

What can be given for relief

Answer 17

 Constipation. Relieved by...
– Stimulant & softening laxative 
– Senna / Bisacodyl + Docusate 
– Magrogol e.g. laxido / movicol 
– OR Co-Danthramer alone

 Nausea. Relieved by…
– Antiemetic
– Metoclopramide
– Haloperidol (consider QT interval)

Question 18

When progressing from step 2 to step 3…..

Answer 18

– Stop any ‘Step 2’ weak opioids
– Titrate immediate release strong
opioid
– Convert to modified release form
– Monitor response and side- effects

Question 19

What adjunct meds are given for liver capsule pain/raising ICP?

Answer 19

– Steroids (e.g. Dexamethasone)

– Remember to consider gastroprotection

Question 20

What adjunct meds are given for neuropathic pain?

Answer 20

– Amitriptyline/ Gabapentin/ Carbamazepine

Question 21

What adjunct meds are given for Bowel/ bladder spasm?

Answer 21

– Buscopan (Hyoscine Butylbromide)

Question 22

What adjunct meds are given for Bony pain/ soft-tissue infiltration?

Answer 22

– NSAIDs/ Radiotherapy for bony metastases

Question 23

Diamorphine, class and use?

Answer 23

 Semi-synthetic morphine derivative
 More soluble than Morphine→ smaller volumes needed
 Can be used for parenteral administration (injection / syringe driver)

Question 24

Name 2 second line opioids and their uses>

Answer 24

(Switch due to Opioid sensitive pain BUT intolerable side-effects)

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 25

Use of syringe drivers?

Answer 25

 Delivery over 24 hours- usually sub-cutaneous
 Useful when oral route inappropriate
 Often useful for rapid symptom control
 Multiple medications can be added
 Stigma of being on a ‘pump’

Common meds found in pump:
anti emetics
reducing secretion
terminal agitiation