Ageing and End of Life Care Flashcards
What is palliative care about?
Doing everything possible to support someone’s quality of life in the context of an incurable illness
What communication should take place in palliative care?
Proactive communication = recording and sharing discussions is essential
What are electronic advance care plans?
Created by GPs and shared with other professionals involved in patient care = called a Key Information Summary in Scotland
What patients should have a key information summary?
All patients identified with a life limiting illness who are at risk of decline
When is palliative care offered?
At any time from diagnosis = some patients have prognosis of many months or years
Where is most palliative care provided?
By hospitals, nursing homes and community teams = only tiny percentage die in hospice
Why do specialist palliative care teams exist?
Some patients with complex needs require additional support by teams with specialist experience in providing palliative care
What are some examples of specialist palliative care services?
Hospices, community palliative care teams and hospital palliative care teams
What is step 1 for pain management?
Mild pain = paracetamol 1g 4x daily +/- NSAID +/- other adjuvant
What is step 2 for pain management?
Moderate pain = codeine 30-60mg 4x daily or cocodomol 4x daily +/- neoadjuvant
What is step 3 for pain management?
Severe pain = stop codeine and switch to strong opioid (usually morphine) +/- paracetamol/NSAIDs/adjuvants
How is morphine given for background pain?
Modified release = 2x daily tablet
How is morphine given for breakthrough pain?
Immediate release = PRN tablet or liquid (oramorph)
What is the maximum dose of morphine?
No maximum dose but monitor pain to make sure morphine is helping and that there are no unwanted side effects
What patients are likely to suffer withdrawal if their morphine is stopped?
Those established on morphine = opioid tolerant
What are the symptoms of morphine toxicity?
Hallucinations, myoclonus, drowsiness
Why must renal function be considered in a patient with morphine toxicity?
Morphine undergoes renal excretion = if renal function impaired then morphine will accumulate
What is a severe side effect of morphine toxicity?
Respiratory depression
What is used to reverse morphine toxicity?
Naloxone
What are some signs that someone is dying?
Worsening weakness and performance status
Worsening physiological status with no reversibility
Struggling to manage oral medicines
Losing interest in food and fluid
Sleeping more, eventual unconsciousness
What are some conditions that mimic dying?
Opioid/drug toxicity, sepsis, hypercalcaemia, AKI, hypoglycaemia
How is comfort maintained when someone is dying?
Only essential medications continued
Oral medications converted to alternative route where possible if no swallow
Anticipatory medications given for common problems
What is the benefit of syringe drivers?
Smoothest delivery of medicines = gives subcutaneous infusion
What are some features of syringe drivers?
Access via butterfly needle with connector tubing
Up to 3 medicines can be mixed in syringe
Infused over 24 hrs and changed daily
Is subcutaneous morphine the same strength as oral morphine?
No = subcutaneous morphine is twice as strong as oral morphine
How is the dose of subcutaneous morphine needed calculated?
Divide total daily oral morphine dose by 2
What are some examples of anticipatory prescribing?
Pain or SOB = morphine 2mg subcutaneous hourly
Distress = midazolam 2mg subcutaneous hourly
Nausea = levomepromazine 2.5mg subcutaneous 12hr
Secretions = buscopan 20mg subcutaneously hourly
What are Just in Case boxes?
Used for subcutaneous symptom control at home to prevent delays in symptom relief
Why is mouth care important in the final days of life?
People become too weak to swallow food or water = keep mouth moist as symptomatic relief
Are subcutaneous/IV fluids given when a patient can no longer swallow in the final days of life?
Not routinely = risks generally outweigh benefits
Can give artificial hydration if concerned about distress due to symptoms of thirst despite mouthcare
Who can verify expected deaths?
Will usually be “Nurse can Verify”
How do you verify a death?
Check for spontaneous movement
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 reflexes and clouding of cornea
Auscultate heart and lungs for 1 min
What must be recorded when verify a death?
Date and time of death
Presence of pacemaker or other implantable devices
What must be remembered when filling in a death certificate?
Check cause of death with senior and that reporting of death to procurator fiscal isn’t needed
What information is made available to families once a relative has died?
Information packs = registering the death and getting a funeral director as key steps
How audits the accuracy of death certificates?
Death certification review services
