Blue Book: Palliative medicine and Cancer pain Flashcards
Symptoms may be caused by:
The disease itself
the treatment
unrelated disorder
How to take a pain Hx
SOCRATES effect on work/life/mood Current treatment previous treatment and success Understanding of illness expectations
Name 5 groups of pain in cancer
Bone pain Visceral Pain Infection Neuropathic Headache and raised ICP
Bone pain:
Features and Treatment
Either a dull ache over a large area or localised tenderness. It is often worse my weight baring or movement.
NSAIDS, radiotherapy, bisphosphonates
Visceral Pain
Features and treatment
Including visceral stretch, colic pain and bladder spasm
Dull, deep seated pain, not well localised, maybe tender over an organ (e.g. liver). Can be spasmodic (e.g. bladder spam or bowel colic).
Treatment:
- Analgesic ladder
- Colic pain: antispasmodic: subcut. hycosine butylbromide
- Bladder spasm: oral oxybutynin
Heartache and raised ICP
Features and Treatment
Dull oppressive headache. Pain worse in when waking, coughing or leaning forward. Often associated with nausea and vomiting.
Treatment:
NSAIDs/Paracetamol
Corticosteroid: 16mg Dexamethasone daily (removes oedema)
Neuropathic pain
Features and Treatment
Pain in area of abnormal sensation, localised to dermatomes, numbness, hyperaesthesia, autonomic changes. Character: ‘pin & needles’ or ‘burning’.
Treatment:
- Gabapentin 100-1200mg tds
- Pregablin 25-300mg bd
- Corticosteroids if nerve is compressed (e.g. MSCC)
Explain each stage of the analgesic ladder
Stage 1: Paracetamol 1g qds
Stage 2: Weak opioid (e.g. codeine 240 mg)
+ Stage 1 - often co-codamol
Stage 3: Strong opioid: e.g. Morphine + Step 1
All steps can also have adjuvants.
NSAIDS/anti-epileptics/antidepressents/corticosteroids
What are the 3 strengths of co-codamol. What is the maximum number of tablets that can be taken each day?
8mg/500mg
15mg/500mg
30/500mg
Maximum of 8 tablets a day, normally 2 tablets 4 X a day (can’t have more than 4g of paracetamol each day)
Give 2 examples of quick acting morphine.
How long do they take and long to they stay active for?
Oromorph
Sevredol
Effective after 30 mins and lasts for 4 hours.
Give 2 examples of slow release morphine. How often should they be given?
MST (Morphine sulphate tablets)
Zomorph
Given 12 hourly
What is the maximum daily dose of co-codamol?
This is equivalent to how much morphine?
240mg of co-codamol (30mg/500g, two tablets, ads
24mg morphine
How do you prescribe for breakthrough pain?
Eg for MST 20mg bd
1/6 of the daily dose of morphonie
5-10mg oromorph p.r.n (hourly)
On prescription must write hourly not prn.
If you want to titrate up from co-codamol
Work out daily dose of morphine, co-codamol and how much for break through pain.
eg 240mg co-codamol= 24 morphine + 20mg oromorph = 44mg daily for MST
= 20/25mg mg bd
What opioids can be given trans-dermal?
Fentanyl
Buprenorphrine
Give 3 common side effects of strong opioids. How can they be prevented?
Constipation: Laxative: co-danthramer
Nausea and vomiting: Haloperidol 1.5mg- 5mg po prn
Drowsiness: Do not drive in first 24 hours.
What are symptoms of opioid toxicity?
What drug can reverse it?
Decreased respiratory rate
Confusion
Myoclonus jerks
pinpoint pupils
Naloxone
Name 4 main problems related to the GI tract with palliative care
Oral Thrush
Dry Mouth
Constipation
Diarrhoea
What effect can a dry mouth have on patient?
Prevent eating= weight loss (anorexia)
Increased risk to infections
How do you treat N&V from raised ICP?
Dexamethasone 8-16mg (reduce swelling)
Cyclizine 50mg TDS po/sc (N&V)
Paracetamol (for pain)
How does gastric stasis present?
What are the main causes?
What is the Tx?
When is this Tx contraindicated?
Early satiety, hiccups, heartburn, fullness
Causes: tumour, hepatomegaly, ascites, dysmobility
Metoclopromide 10-20mg po/sc before meals with PPI cover.
CI: Obstruction
What are the main causes of nausea?
Tx? Including dose
Drugs: opoids/digoxin/antiepileptics
Hypercalcaemia
Uraemia
Infection
Haloperidol 1.5-5mg po/sc
Tx of anticipatory/ anxiety induced N&V.
Lorazepam (anxiety)
Benzodiazepam
CBT
Complementary
Name 2 softener laxatives.
Any side effects?
Lactulose (bloating & flatulence)
Docusate
Name 2 stimulant laxatives.
When can you not use them?
Senna
Dantron
Do not use stimulant laxative with colic
Name a combination laxative
Movicol
Co-danthraner
Symptoms of intestinal obstruction.
What drug can you not give.
N & V, colicky pain, abdo distension, pull achy pain, diarrhoea or constipation
3 causes of sudden onset dyspnoea and Tx
Asthma: Bronchodilator
PE : Anticoagulant: Tinzaparin
Pulmonary oedema: Diuretic and diamorphine
4 causes of dyspnoea arisen over several days and Tx
Exacerbation of COPD: antibiotics and broncho dilators
Pneumonia
Bronchial obstruction by tumour (dexamethasone and stent)
Superoir vena cava obstruction (Dex and stent)
4 causes of dyspnoea arisen with gradual onset and Tx
Congestive heart failure: Diuretic, digoxin and ACEi
Anaemia: transfusion
Pleural effusion: pleural aspiration or pleurodesis
Ascites: paracentesis if app.
Tx of non-reversible dyspnoea.
Opioids: decreased resp rate oromorph 2.5mg 4 hourly
Benzodiazepine: Lorazepam (if panic attacks)
What is the role of palliative care?
- Provides relief from pain and other distressing symptoms
- Integrates physical, psychological, social and spiritual care
- Affirms life and regards dying as a normal process
- Neither hastens or postpones death
- Helps patients live as actively as possible until death
- Offers support to help the family/carers during the patients illness and into bereavement.
The scope extends beyond patients with cancer but includes a range of progressive illnesses.
Who is involved in a palliative care?
primary and secondary care such as doctors, nurses, social workers, chaplains, physiotherapists, occupational therapists, and psychologists.
What is advance care planning?
“a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment”
- Advance statement of wishes to inform subsequent best interest judgments
- Advance decisions to refuse treatment which are legally binding if valid and applicable
- Appointment of Lasting Powers of Attorney for ‘Health and Welfare’ and/or ‘Property and Affairs’.
What symptoms and signs indicate a short prognosis?
- Profound weakness
- Confined to bed for most of the day
- Drowsy for extended periods
- Disorientated
- Severely limited attention span
- Losing interest in food and drink
- Too weak to swallow medication
How to communicate short prognosis
Check patient understanding and negotiate treatment. Encourage open communication and explore fears.
Understand family wishes.
Be prepare to seek help for legal, financial, interpersonal and spiritual issues.
May need to find faith leader: chaplain, priest, Rabbi.
Place of care: home, hospice, hosptial, considering needs and wishes of patient and family/carers.
Discuss nursing and food/fluids.
Nursing: treat dry mouth, assess immobility and pressure areas, consider catheter or pads for incontinence.
Food/Fluids: reduced F&F is normal in dying process, support by mouth as long as tolerated. Artificial hydrationj can worsen comfort and symptoms.
Discuss medication in end of life care.
What drugs must be stopped if they cant swallow.
Only continue medication for symptom management. If oral route not available use rectal, transdermal, subcut.
- Vitamins/iron
- Hormones
- Anticoagulants
- Corticosteroids
- Antibiotics
- Antidepressants
- Cardiovascular drugs
- Anticonvulsants used for pain
Patients can be prescribed analgesic, antiemetic, antisecretory and anxiolytics give by a syringe driver.
How to treat terminal restlessness?
Look for reversible cause: pain, urinary retnetion, faecal impaction. resp
If not, sedation= midazolam
stat: 2.5-5mg SC
Infusiuon: 10mg in 25 hours.
Levomepromazine may be needed.
What is ‘death rattle’.
How to treat.
Rattling noise produced by the movement of secretions in upper airway who are too weak to expectorate. Often distressing to family.
Re-position. Antisecretories:
Hyoscine Butylbromide
Hyoscine hydrobromide (may cause agitation)
Documentation
The Liverpool Care Pathway for Dying or a personilised end of life care plan to guide and document care in the last days of life.
‘After death’ care
Anticipate if a patients religion may necessitate special procedures after death.
Provide death certificate and inforom GP within 24 hours.
Warn relatives when referal to HM Coroner may be needed (Mesothelioma)
Provide information about the role of a funeral director, how to register a death, common feelings of gried and support available.
