Care of the dying Flashcards
what to prescribe first for EoL patients?
PRN as required medications
to avoid patient receiving lots of injections?
syringe driver
the major 4 PRN drugs in caring for the dying?
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
how often is morphine/opioid given for pain?
- either immediate-release 30mg 4 hrly
- or modified- release 100mg 12 hrly
- rescue doses
how to manage breakthrough pain?
rescue dose immediate-release
1/10 to 1/6 of regular 24-hour dose
repeated every 2–4 hours PRN
how to increase background regular dose of morphine?
(n.o. rescue doses & response to them should be taken into account)
increase should not exceed 1/3 to 1/2 total daily dose
when to stop the upward titration of morphine?
when pain is relieved or unacceptable S/E
what to use if patients cannot tolerate morphine?
cxycodone hydrochloride
when to avoid oral drugs?
dysphagia
vomiting
bowel obstruction
terminal phase
Tx to use for ↑ ICP, nerve compression, liver capsule pain, soft tissue infiltration?
steroids
Tx for muscle cramp/spasms, myofascial pain?
Muscle relaxants (e.g. baclofen, benzodiazepines)
Tx for bone pain?
Bisphosphonates
Tx for bowel colic, bladder spasm?
Antispasmodic (e.g. hyoscine butylbromide)
opioids if GFR<30?
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
Tx S/E of opioids?
- 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
Sx of opioid toxicity?
myoclonic jerks pin-point pupils hallucination confusion ↓RR
Tx opioid toxicity? (if severe - RR<12, difficult to rouse, cyanosed
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)
how to Tx V from gastric stasis?
Metoclopramide or domperidone
Consider trial of steroid
how to Tx V from ↑ICP?
Cyclizine
Consider steroids
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 ?
superior vena cava obstruction (SVCO)
malignant tumour in the mediastinum
preventing venous drainage from the head, arms and upper trunk
Tx for SVCO?
dexamethasone 16mg stat, daily oxygen manage SOB & agitation escalate: imaging \+/- anticoagulation
stent insertion
what are the FIVE KEY PRIORITIES defined by the Leadership Alliance for the Care of Dying People?
- 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
what for breakthrough pain if patient receiving >25 mcg of transdermal fentanyl per hour?
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)
can you use buprenorphine for breakthrough pain?
has both opioid agonist and antagonist properties (may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids)
