End of life Flashcards
End of life care
Conservative:
- Tx reversible causes
- Hydration
- Regular mouth & eye care
Medical:
- PRN ≥3/day –> syringe driver
- Avoid IM injection
Sx at final days:
- Cheyne-stokes breathing (deep breathing then stops for 15-20s)
- Reduced GCS
- Fatigue
- Loss of appetite
- Agitation
- Resp secretions
- Funct decline + social withdrawal
Palliative Mx of breathlessness?
- Tx reversible causes - HF, pleural effusion, PE, pneumonia, hypoxia
- Low-dose opioid (morphine immediate release) with short acting Benzo e.g., Lorazepam
Laxative use in end of life care
- 1st - Osmotic agent e.g. lactulose OR softening agent e.g. docusate
- 2nd - If this doesn’t work ADD a stimulant agent e.g. senna
Anti-emetics in palliative care
-
Haloperidol - chemical causes, renal failure, drug-induced
- Lowers seizure threshold, parkinsonism
-
Cyclizine - central vomiting, CNS lesions, labyrinthitis
- Irritant SC, severe HF
- Ondansetron - ONLY post-chemo, abdo surgery, abdo radio
- Very constipating, QT prolongation
- Metoclopramide/Domperidone - delayed GIT transit, bowel obstruction without colic
- Bowel obstruction with colic, parkinsonism, cardiac conduction disorders, young women - SE movement disorders
- Levomepromazine - all causes but 3rd line
- Long half life, sedating, lowers seizure threshold, severe HF, CVD, parkinsonism
Important opioid conversions
Opioids:
- Strength of different opioids
- Forms of oral morphine
- Guide to giving morphine
- When to give oxycodone
- Breakthrough analgesia
- Conversion between opioid doses
Strength:
- Weak - codeine, dihydrocodeine
- Moderate - tramadol (surgeons love)
- Strong - morphine, oxycodone, buprenorphine, fentanyl
Oral morphine has 2 forms:
- Oral morphine has 2 forms:
- Immediate-release (e.g. oromorph) - max 4-hourly
- Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD)
Guide to morphine:
- If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV dose
- Immediate-release PRN (max 4-hourly) –> see how much using
- If using a huge amount –> convert to modified-release (12/24-hourly):
- Add up total daily PRN dose = X
- 24-hourly = X (OD); 12-hourly = X/2 (BD)
When to give oxycodone: renal impairment (eGFR 30-60mL/min)
- Immediate-release: oxycodone oral solution, oxynorm
- Modified-release: oxycontin
- NOTE: same logic as above
- NOTE: fentanyl/buprenorphinene is the best if eGFR <30, oxycodone still partially renaly excreted
Breakthrough analgesia:
- Oral morphine/oxycodone
- 1/10-1/6 of total daily dose of modified-release morphine
Example: 60mg Oromorph –> 30mg MST BD + 6-10mg breakthrough dose
Conversion - 10mg oral morphine:
- Oxycodone - 5mg oral (x/2), 2.5mg IV (x/4)
- Tramadol/Codeine - 100mg oral/IV (x*10) - NOTE: codeine has no IV option
What opioids can I use if renal problem?
Fentanyl, Buprenorphine
Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)
Anticipatory meds - 4 to give if palliative?
Anxiety/distress: Midazolam 2.5-5mg SC 1-2hrly PRN
Secretions/colic: Glycopyrronium 0.2-0.4mg SC QDS PRN
Nausea & vomiting: Haloperidol 0.5-1.5mg SC BD PRN (max 5mg/24hrs)
- Could give Cyclizine 50mg SC TDS PRN
Pain: Morphine 2.5-5mg SC 1-2hrly PRN (or Oxycodone 1.25-2.5mg)
Best palliative medicine for secretions/colic?
Glycopyrronium 0.2-0.4mg SC QDS PRN
Palliative Sx - possible reversible causes & drugs if no reversible causes?
Confused & agitated in context of ‘dying’ - Dx? Mx?
Dx: terminal restlessness
Mx: diagnosis of dying so reversible causes have already been excluded
- Midazolam PRN - SC injections/continuous subcut infusion via a syringe driver
