Ageing and End of Life Care Flashcards
what is involved in palliative care?
symptom control
communication and emotional support
what are ACPs?
advanced care plans
created by GPs and shared with other professionals involved in patients care (also called KIS in Scotland)
created for everyone with life limiting illness at risk of decline
common diagnoses of patients in palliative care?
cancer
organ/system failure
frailty and dementia
how does illness trajectory differ in different groups of conditions?
terminal illness = steep deterioration in function until death
organ failure = fluctuating level of function over a general decrease over time until death
frailty = wavering decrease in function over time until death, slight slope
step 1 pain management?
paracetamol 1g 4X daily
and/or NSAID 500mg 2X daily
an/or any other adjuvant (antidepressants, nerve block-gabapentin etc)
step 2 pain management?
codeine 30-60mg 4X daily
or can use codeine with paracetamol (co-codamol 30/500) 2 tabs 4X daily
and/or adjuvant
step 3 pain management?
stop codeine and switch to strong opioid - usually morphine
can use in conjunction with paracetamol/NSAID/adjuvants
describe cancer pain?
constant background pain
instances of more severe breakthrough pain
what is modified release morphine?
MST/zomorph
lasts for 12 hours
used for background pain
what is immediate release morphine?
sevredol/oramorph
lasts for 4 hours
used on top of modified release for breakthrough pain
how much immediate release morphine should be given?
1/6 of total background daily dose
e.g if patient is taking 2 15mg doses of MST (30mg total), immediate release should be 5mg
morphine dosing?
modified release morphine given twice daily
immediate release morphine given as needed every 4 hours
depending on amount of “as needed” immediate release morphine needed, background morphine can be titrated up
what are the risks of morphine?
opioid tolerance
toxicity
respiratory depression
how is morphine excreted? why is his significant?
renally excreted
means you should check renal function if a patient becomes opioid toxic as this would cause morphine to accumulate
how might opioid toxicity present?
hallucinations
myoclonus (sudden jerky movements)
drowsiness
how is opioid resp depression managed and what is the risk of this?
naloxone can reverse morphine very quickly
if too much given or too quickly, can cause very severe withdrawal symptoms
how is opioid toxicity managed?
dose adjustment/switch to another strong opioid
how are opioids changed?
dose will change if type or route of strong opioid changes
what strong opioid is commonly used to replace morphine?
oxycodone
twice as strong as morphine
what features indicate dying?
worsening weakness and performance status
worsening physiological status with no reversibility
struggling to manage oral medicines (swallowing function)
lost interest in food and fluids
sleeping more, eventual unconsciousness
MUST BE NO REVERSIBLE FACTORS
what conditions can mimic dying?
opioid toxicity hypoactive delirium sepsis hypercalcaemia AKI hypoglycaemia
are reversible factors always reversed?
no
not always the best thing for the patient if the deterioration has been sudden and QoL would be bad
how is medication managed at end of life?
only essential medications continued (stop statins, anticoagulants etc)
oral meds converted to other route if no swallow
prescribe anticipatory medications for common problems
stop routine obvs/monitoring
take out unused cannulas
common cause of agitation at end of life?
urinary retention
what are syringe drivers?
continuous battery operated subcutaneous infusion of medicine
used when oral route not possible
how is a syringe driver used?
sub cutaneous access via butterfly needle
up to 3 medicines can be mixed together in the syringe
infused over 24 hours
changed daily
portable
how does subcutaneous morphine compare to oral morphine?
twice as strong
dose must therefore be divided by 2 if changing from oral to subcutaneous
standard prescribing for pain/shortness of breath?
morphine 2mg subcutaneous every hour
standard prescribing for distress?
midazolam 2mg subcutaneously every hour
standard prescribing for nausea?
2.5 mg levomepromazine subcutaneously 12
standard prescribing for secretions?
20mg buscopan every hour
how is hydration and nutrition managed in the final days of life?
meticulous mouth care
s/cut or IV fluids generally not used as risks outweigh benefit
can trial artificial hydration if concern that patient is distressed due to thirst/dehydration
how is death confirmed?
check for spontaneous movement (including resp effort)
check for reaction to voice and pain
palpate at least 2 major pulses for 1 min
inspect eyes for dryness, fixed dilated pupils, absence of corneal reflex and clouding of cornea
auscultate heart and lungs for 1 min
note if a pacemaker or other device implanted (risk during cremation)
