Care of the dying Flashcards

1
Q

what to prescribe first for EoL patients?

A

PRN as required medications

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2
Q

to avoid patient receiving lots of injections?

A

syringe driver

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3
Q

the major 4 PRN drugs in caring for the dying?

A

1) antisecretion
- HYOSCINE H (400 mcg 4 hrly, or continuous S/C infusion 1.2–2 mg/24 hrs)
- hyoscine BB (S/C infusion 20–120 mg/24 hours)

2) agitation
- MIDAZOLAM (10-20mg/24hrs)

3) pain
- MORPHINE 10mg/24hr if new

4) nausea
- CYCLIZINE 150mg/24hr

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4
Q

how often is morphine/opioid given for pain?

A
  • either immediate-release 30mg 4 hrly
  • or modified- release 100mg 12 hrly
    • rescue doses
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5
Q

how to manage breakthrough pain?

A

rescue dose immediate-release
1/10 to 1/6 of regular 24-hour dose
repeated every 2–4 hours PRN

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6
Q

how to increase background regular dose of morphine?

A

(n.o. rescue doses & response to them should be taken into account)

increase should not exceed 1/3 to 1/2 total daily dose

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7
Q

when to stop the upward titration of morphine?

A

when pain is relieved or unacceptable S/E

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8
Q

what to use if patients cannot tolerate morphine?

A

cxycodone hydrochloride

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9
Q

when to avoid oral drugs?

A

dysphagia
vomiting
bowel obstruction
terminal phase

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10
Q

Tx to use for ↑ ICP, nerve compression, liver capsule pain, soft tissue infiltration?

A

steroids

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11
Q

Tx for muscle cramp/spasms, myofascial pain?

A

Muscle relaxants (e.g. baclofen, benzodiazepines)

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12
Q

Tx for bone pain?

A

Bisphosphonates

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13
Q

Tx for bowel colic, bladder spasm?

A

Antispasmodic (e.g. hyoscine butylbromide)

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14
Q

opioids if GFR<30?

A

avoid regular codeine, morphine and oxycodone (low dose immediate release (IR) oxycodone with increased dose intervals may be appropriate sometimes)

Consider fentanyl, buprenorphine or alfentanil depending on type of
pain and preferred route

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15
Q

Tx S/E of opioids?

A
  • C: stimulant laxative (senna) +/- softener (docusate)
  • N/V: PRN anti-emetic (haloperidol/metoclopramide)
  • Sedation: dose reduction, alternative analgesic
  • Dry mouth: good oral hygiene +/- saliva stimulants/artificial
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16
Q

Sx of opioid toxicity?

A
myoclonic jerks
pin-point pupils
hallucination
confusion
↓RR
17
Q

Tx opioid toxicity? (if severe - RR<12, difficult to rouse, cyanosed

A

Stop opioid.
IV 400 micrograms naloxone in 10mls 0.9% sodium chloride
IV 0.5ml (i.e. 20 micrograms naloxone) every 2mins until respiratory recovery

(if mild Sx, ↓ opioid dose by 30-50% + check renal function)

18
Q

how to Tx V from gastric stasis?

A

Metoclopramide or domperidone

Consider trial of steroid

19
Q

how to Tx V from ↑ICP?

A

Cyclizine

Consider steroids

20
Q

Lung CA patient has facial swelling, redness, headache, periorbital oedema, swelling of the arms, prominent distended veins on neck and chest wall.
She’s breathless with a cough, chest pain and cyanosed.
She reports visual disturbance.

what’s going on ?

A

superior vena cava obstruction (SVCO)
malignant tumour in the mediastinum
preventing venous drainage from the head, arms and upper trunk

21
Q

Tx for SVCO?

A
dexamethasone 16mg stat, daily
oxygen 
manage SOB &amp; agitation
escalate: imaging
\+/- anticoagulation

stent insertion

22
Q

what are the FIVE KEY PRIORITIES defined by the Leadership Alliance for the Care of Dying People?

A
  • Recognise: that a person may die within the next few days or hours
  • Communicate sensitively with the dying person and those close to them
  • Involve all in making decisions as far as they indicate they want to be
  • Support the family
  • Plan individualised care
23
Q

what for breakthrough pain if patient receiving >25 mcg of transdermal fentanyl per hour?

A

nasal fentanyl
maximum initial 50 mcg into one nostril, repeated once if necessary after 10 minutes
(max two sprays for each pain episode and a minimum of 4 hours between treatment of each pain episode)

24
Q

can you use buprenorphine for breakthrough pain?

A

has both opioid agonist and antagonist properties (may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids)