AC - Palliative Care Flashcards
What are some key components of palliative care?
Can be introduced at any stage of disease/age - can even be introduced along side life-prolonging Rx. Early assessment & strategies better outcome
Doesn’t intend to hasten or prolong death
Aims to improve QOL, prevent suffering and support maximal functioning
Holistic - psychological, physical & spiritual
Team based care - disciplinary and disciplinary
Needs to be culturally safe
Needs to involve family, carers/supports as well as patient
What factors may influence perception & experience of dying process?
Age - age can influence whether people view it as expected or not - this can influence the level of support given
Previous experiences with death - patient may have had a positive or negative experience with relative/friend which impacts on their attitude and coping skills
Culture & religion - may positively or negatively influence coping ability and attitudes - i.e. some cultures may experience distress associated with ‘after-life’
Common palliative care issues which need to be considered/discussed?
Physical, psychological and spiritual problems
Financial & ‘getting affairs in order’ - i.e. wills, POA
Education about the diagnosis & its relation to prognosis
How disease/Rx will impact on function - sexual, social, work, home
How they will manage/cope with symptoms and when they become very ill
Whether they should be managed at home or in hospital
Discussion of possible ethical issues - advanced care directives, when to withdraw certain treatments and when/how to discuss imminent death
Assess carer stress and how family will cope
Define pain
Unpleasant emotional and sensory experience in response to actual or perceived tissue damage
What is nociceptive and neuropathic pain?
Nociocpetive pain - noxious stimuli acting on peripheral nociceptors (small unmyelinated c-fibres)
- can be somatic (localised, sharp) or visceral (vague, dull)
Neuropathic pain - dysfunction within PNS or CNS (unmyelinated c-fibres + alpha-delta myelinated fibres)
- pain in distribution of nerve root/dermatome/peripheral nerve
- shooting, burning, electric shock pains
- may be spontaneous or associted with allodynia or hyperalgesia
Define acute vs. chronic pain
Acute - temporary, usually serves physiological purpose
Chronic - persists beyond expected normal recovery or > 3 months, usually not serving physiological purpose
How can cancer/tumours cause pain?
Hypercalcaemia - generalised muscle aches/pains
Infiltrative or compressive - of nerve
Involvement of bone, soft tissue and viscera
Space occupying - pressure, stretching capsule
Ulceration
Peripheral neuropathy
Obstruction of hollow viscera
What are risk biological risk factors to developing pain
Acute pain - poor response to initial analgesia, initially poorly managed or inadequate initial analgesia
Underlying comorbidities - may restrict Rx available/prevent effective management
Mechanism of pain - Neuropathic pain higher risk
Multiple pains and pain mechanisms
Nature of underlying pathology
Refractory adverse effects from analgesia
What are psychosocial risk factors to developing chronic pain?
ABCDE
A - attitudes to recovery
B - beliefs about seriousness of underlying cause (i.e. catastrophising
C - ongoing compensation/cover claim
D - understanding of the disease/diagnosis, hx of drug/alcohol use
E - emotional, family, work, financial related stressors
What are the general principles of chronic pain mangaement?
4Ps - physical, psychological, pharmacological and procedures/other
Physical - physical reactivation - increase exercise, core strength, stretching/flexibility - consider physio and exercise physiologist referrals
Psychological - CBT, acceptance-based Rx, stress management, mindfulness - consider referral to psychology
Procedures - consider other useful interventions i.e. surgical, nerve blocks, intra-articular steroid injections
Other - modification of the environment, advice on safe lifting/bending etc
Goals need to be realistic - may not be able to completely eliminate pain
Reduce pain to tolerable level and support to develop skills/strategies to cope with pain and limit pain-related handicaps
GP management plan/TCA valuable
What are the general pharmacological options for pain management?
- Simple analgesia - paracetamol, NSAIDs
- Opioids
- Neuropathic pain agents
- Steroids (dexamethasone)
- Bisphosphonates
Describe the WHO analgesia ladder
- Simple analgesia +/- adjunct (i.e. antiemetic, laxative, antidepressant, anticonvulsant)
- ADD weak opioid (codeine, tramadol)
- REPLACE weak opioid for strong opioid (morphine, oxycodone, hydromorphone, fentanyl, buprenorphine)
What are important features on Pain history?
4Ps
- Pain - cardinal features
- Pathology/past hx - treating comorbidities may improve QOL and improve ability to cope or may need to be considered with pain management
- Performance - effect on social, physical and occupational function, severity, any fear avoidance
- Psychological - how they are coping, any co-existing or underlying psychological/psychiatric issues (esp. anxiety & depression)
What are pharm Rx options for neuropathic pain?
1st line = amitriptyline (TCA)
2nd line = pregabalin or gabapentin
3rd line = duloxetine
Anticonvulsants and MAOI inhibitors can also be used
Carbamezepine - trigeminal neuralgia
Pregabalin - diabetic neuropathy
What pain is dexamethasone useful in relieving?
Raised ICP - headache
Pain due to stretching of liver capsule
Inflammatory pain
What can improve bony pain/hypercalcaemia pain?
Bisphosphonates
Paliative RTx - especially bony mets to spine
How can severity of pain be assessed/rated?
Visual analogue, numerical and verbal scales
Face scale - esp. in peadiatric, aged care and language barrier
Clinical/behavioural observation (Abbey Scale) - particularly in cognitive impairment
- Verbal, non-verbal cues
- New or increased behavioural issues/disturbances
- Social, food or treatment refusal
- Sleep disturbance
What is PRN dosing in pal care for opioids?
1/6th of daily dose
What are the adverse effects of NSAIDs?
CV (embolic events, worsening of HTN, HF)
GI (PUD)
Renal (reduced eGFR, AKI, worsening of CKD)
What are key characteristics of tramadol?
Weak opioid
Long acting - 12 hrs
Has SSRI effect also
Less constipation & respiratory effects but greater other S/E
Avoid in elderly as increases risk of delirium
What are key characteristics of morphine?
Avoid in renal impairment (metabolites accumulate) but safer in liver impairment
Long (MS contin, 12 hrs) and short acting (3-4 hrs)
What is the conversion of sub/cut to oral morphine and ratio of morphine to oxycodone?
1mg sub/cut = 3mg oral
1:1.5 ratio morphine:oxycodone
Compare use of oxycodone & morphine
Oxycodone used more frequently than morphine as it has less cognitive side effects and more predictable serum levels
It is safer in liver impairment (except targin)
It is stronger than morphine (1.5:1 ratio)
Short acting is oxycodone longer effect than morphine
What are the types of oxycodone?
Short acting (oxynorm, endone, 4-6 hrs) Long acting (targin, oxycontin, 12 hrs)
Targin has naloxone - supposed to reduce constipation effects by reducing GIT absorption. If liver impairment it is absorbed systemically - withdrawal if tolerant, less analgesia
What is the sub/cut to oral conversion of oxycodone?
1mg s/c = 2mg oral
What is the sub/cut to oral conversion of hydromorphone and the conversion to morphine?
1mg sub/cut = 3.5mg oral
1mg hydromorphone = 5mg morphine
What is the conversion of fentanyl to morphine?
12mcg (smallest patch dose)/hr = 15mcg s/c morphine over 24 hrs
What is the conversion of buprenorphine to morphine?
5mcg/hr buprenorphine = 5mg over 24 hrs of morphine
Compare use of hydromorphone & fentanyl
Fentanyl long acting comes in 3day patch (lowest dose 12mcg/hr)
Long acting hydromorphone is s/c or oral lasting 24 hrs
Fentanyl is safer in renal impairment but hydromorphone can still be used in renal impairment
Hydromorphone has less side-effects and is easier to use than fentanyl
How can dyspnoea be managed in pal care?
Non-pharm
- Decrease work of breathing - positioning/posturing
- Increase perception of air - sit near open windows, fan blowing on face
Pharm
- O2
- Morphine (short-acting)
- Benzos (lorazapam, midazolam - medium acting)
How are partial BO managed in pal care?
Chance of spontaneous resolution therefore give some active treatment
Supportive - some oral intake, fluids
Pharm - metoclompramide
- Antiemetic (reduces symptoms), prokinetic (improves motility which may help resolve obstruction)
How is a complete BO managed in pal care?
Need to be sure complete as active Rx may lead to risk of perforation and non-active may reduce chance of clearing - terminal event
Hyoscine butylbromide (buscapan) - antispasmodic (releives colicky pain), reduces secretions (reduces vomiting), antiemetic
Dexamethasone - minimal evidence but still usually given
Octreotide - reduces blood flow to gut - less secretions and vomiting
what is the most common clinical presentation of spinal cord compression in pal care?
Usually insidious, chronic compression rather than acute event
Thoracic > lumbar > cervical
Usually a result of compression from extra-dural mass which impairs vascular in/out-flow leading to cord ischaemia
Will have localised pain and tenderness on examination
May have radicular pain/symptoms
Spinal cord compression vs. cauda equina syndrome
Compression above L2 = spinal cord compression
compression below L2 = cauda equina syndrome
What are the 4 general causative mechanisms of nausea, the receptors and stimuli that affect them?
- GIT - inflammation (toxins, infection), mechanical (obstruction, ileus, gastroparesis), dopamine receptors
- CTZ - biochemical (metabolic, drugs), dopamine and serotonin receptors
- Vestibular system - motion and viruses, histamine, muscarinic and dopamine receptors
- Higher CNS - anxiety, anticipatory, raised ICP
What drugs are effective on GIT mediated nausea?
Domperidone
Metoclopromide
What drugs are effective on CTZ mediated nausea?
1st line = metoclopromide, haloperidol
2nd = prochlorpromezine
Also ondanestron (5-HT3 antagonist) Dexamethasone
What drugs are effective on vestibular mediated nausea?
Cyclizine (antihistamine) Hyoscine butylbromide (anticholinergic) promethazine (dopamine)
What drugs are effective on higher-CNS mediated nausea?
Alprazolam (anxiety)
Dexamethasone
What is a good approach to breaking bad news/talking about death?
SPIKES
- Set-up - appropriate environment, significant others, privacy, manage time restraints
- Perception - check patients understanding of situation and what they’re expecting
- Invitation - obtain patient’s invitation to discuss difficult topic
- Knowledge - provide information about diagnosis, sign post bad news is coming
- Emotions - identify and acknowledge emotions, be empathetic and give them some time
- Summary & strategy - ask if patient wants to discuss treatment plan, check their understanding and manage their expectations
What are appropriate steps and discussions to be taken when discussing end-of-life care?
- communicate to pt and family that they are dying (SPIKES)
- counsel pt and family on - getting affairs in order, process of dying and what to expect, symptoms that may occur and how will be managed/reassure, discuss nutrition and fluids
- Rationalise medications, observations and procedures - only perform those directly impacting/improving symptoms
- Nutrition - remove artificial if not contributing to comfort, other strategies (ice chips, damp sponge in mouth)
- prescribe PRN medications - benzos, opioids, antiemetic, antipsychotic, anti-secretions (buscapan, atropine, glycoparylate)
How would you describe the process of dying to a patient?
Will gradually become less and less aware of surroundings and hunger and thirst will diminish
Will become more tired and sleepy, spending more and more time in bed and asleep than awake
Eventually will become unconscious
What is the process of confirming a death?
- Before - check resus/ACD status, circumstances of death & patient background
- Address family/friends if present - respect
- General inspection - signs of life - movement, colour
- Respiration - signs of respiratory effort
- Response - verbal and pain stimuli
6 . Pupils - fixed and dilated after death - Circulation - palpate carotid artery, heart sounds (1min), lung (3mins)
- Documentation and communication
