6. Palliative Care Flashcards
What are the essential components of palliative care?
- Effective communication
- Team working
- Complex decision making
- Continuity of care
- End of life care
- Bereavement support
How is End of Life Care for adults defined?
- This includes people who are likely to die within 12 months, people with advanced, progressive, incurable conditions and people with life-threatening acute conditions
- It also covers support for their families and carers
What is IMPACT stand for regarding symptom control?
I: Identify concerns M: Make an accurate assessment P: Plan your action A: Act C: Continuously re-evaluate T: Talk to other HCP
What are approaches to pain management?
- Analgesics
- Anaesthetics
- Palliative
- Neurological
- Supportive care
- Inhibition of pain transmission
- Psychotherapeutic apporaches
What is a Opioid Rotation?
- switch from one opioid to another
- aim is to provide a better balance analgesia and side effects
What are the considerations before opioid conversions?
- calculate the 24hrly requirements
- convert back to oral morphine
- then convert to alternative opioid
- ensure adequate breakthrough
- consider a dose reduction
Describe Fentanyl patches
- not any more effective as an analgesic than morphine
- mu receptor agonist
- 50-100x more potent than morphine
- constant drug delivery for 72 hrs
Indication
- stable and chronic pain
- opioid responsive
- When oral route is not available
What is Hydromorphone?
- analogue of morphine
- 7.5x more potent
- only one major active mtabolite (H3G)
- indicated as an alternative strong opioid in cases of intolerable adverse effects with morphine
- problems at large dose
What is Oxycodone?
- 1.5-2x more potent than morphine orally
- Available as quick and slow release formulations
- K-opioid receptor agonist
- titratable
What is Oxycodone?
- mixed pharmacology (NMDA and opioid activity)
- variably long half life and potential for accumulation
- useful when there is a complex element of neuropathic pain
- available as tabs, liquid injection and suppository
How do you start methadone?
- give morning dose of MR opioid
- continue to use breakthrough doses of opioid for 24 hrs
- 30mg stat methadone 6 hr after morning opioid
- give prn doses methadone 3hrly
What are Bone Targeted Agents (BTA) for bone pain?
Biphosphonates
- have been shown to reduce the incidence of skeletal complications
- inhibit osteoclast activity
- Consider Strontium Ranelate
: radioactive isotopes - Denosumab
How is Antidepressants used in Palliative care europathic pain?
- Potentiates inhibitory pathways
- Amitriptyline
: start at 10mg
: usually need at least 50mg - limited by side effects
How is Anticonvulsants used in Palliative care europathic pain?
- Activates pain suppression pathways
- Sodium Valproate
: 200-1000mg daily
: 4~5 days to steady state
: no clinical trials - Carbamazepine
: common adverse effects
: drug interactions
How is Gabapentin used in Palliative care neuropathic pain?
- increases GABA synthesis in CNS
- licensed for neuropathic pain
- caution in renal impairment
- Two dosing regimes
: day 1 300mg ON
: day 2 300mg BD
: day 3 300mg TDS
: then up to 600~1200mg TDS
How is N&V treated in Palliative care? (steps)
Document the most likely cause
Treat reversible causes
Prescribe the most appropriate anti-emetic
Review every 24hrs
Check cause / route if poor response
Add or substitute second line agent
Continue indefinitely if necessary
What is Metoclopramide and how is it dosed?
- Nausea
10mg TDS-QDS or
30-100mg / 24 hr CSCl
What is Cyclizine and how is it dosed?
- Targets Vomitting centre
50mg TDS or
100-150mg / 24 hr CSCl
What is Haloperidol and how is it dosed?
CTZ anti-emetic
- for most chemical causes of vomitting e.g morhpine, hypercalcaemia, uraemia
- blocks dopamine receptors
- 5-3mg ON or
- 5-10mg / 24hr CSCl
What is Levomepromazine and how is it dosed?
- effective broad spectrum anti-emetic
- high response rate
- low dose 12.5-50mg / 24hrs
- can give SC
- useful in agitation and restlessness
- S/E = sedation and anticholinergic
What are second line drugs for anti-emetics?
Anti-secretory
- Hyoscine Butylbromide 80-160mg / 24hr CSCl
- reduces GI motility and secretions
Give an example of Sedative drug
Midazolam
- Short acting
- Activates GABA
- Half life prolonged in some patients
- Dose CSCl 30mg/24hr
- Useful in patients with Epilepsy or fitting due to brain metastases
Describe Hypercalcaemia of malignancy in Palliative care
- 10% of patients with cancer develop hypercalcaemia
- Poor prognosis
Clinical features
- dehydration, polydipsia, pruritis, N&V, constipation, fatigue, confusion, myopathym, cardiac complications
Treatment
- Rehydration
- Biphosphonate
Describe use of Corticosteroids in Palliative care
Indications
- inflammation
- cerebral oedema, metastases
- N & V
- Spinal cord compression
- Analgesia
Caution in
- diabetes
- psychosis
- peptic ulcer disease