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Palliative care > End of Life > Flashcards

End of Life Flashcards

1
Q

What’s the definition of End of Life (EoL)?

A

End of Life

  • last 12 months of life
  • patient likely to die within next 12 months
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2
Q

What types of patients fall into the ‘End of Life’ definition?

A

Patients likely to die within next 12 months

  • imminent death is expected (within days, few hours)
  • advances, progressive conditions
  • general frailty and co-morbidities
  • life-threatening acute conditions
  • premature neonates whose prospect of survival is very poor
  • patients diagnosed with persistent vegetative state from whom withdrawal treatment may lead to death
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3
Q

What aspects constitute to holistic care (4)?

A
  • Physical
  • Social
  • Psychological
  • Spiritual
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4
Q

Legally binding future care planning documents (2)

A
  • Advanced Decision to Refuse Treatment (ADRT)
  • Lasting Power of Attorney (LPA) → health and welfare or finances and property (it’s a legally binding spokesperson)
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5
Q

Informal (non-legal) forms of future care planning (3)

A
  • statement of preferences and wishes
  • named spokesperson
  • preferred priority of care document
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6
Q

How to recognise that a patient is dying? (terminal phase of illness)

A
  • deteriorate day by day or faster, due to their underlying condition
  • becomes progressively weak and fatigued without apparent cause
  • realises and express that ‘they are dying’ or report seeing a person that has already died
  • reduced cognition, drowsy, lethargic, comatose
  • delirious (restless, confusion and agitation)
  • bed-bound
  • little food or fluid intake
  • difficulty in taking oral meds
  • have apnoea or altered breathing patterns
  • peripherally cold or cyanosed
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7
Q

What’s the North West End of Life Care Model?

A

Aims to support people to live well before dying with peace and dignity in the place of their choice

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8
Q

What drugs to stop what to commence in abdominal colic symptoms?

A
  • Stop prokinetics → stop metoclopramide
  • Start anti-spasmodic → hysocine butylbromide
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9
Q

Anti - secretory drugs (4)

A
  • Octerotide → 1st line
  • Hyoscine butylbromide
  • Glycopyrronium
  • Ranitidine (but can’t be used SC)
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10
Q

Drug for tumour related oedema

A

Dexamethasone

  • corticosteroid
  • 5 days trial of Dexamethasone 8mg daily PO (or similar dose SC)
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11
Q

Can we combine Cyclizine and Hyoscine Butylbromide in a syringe driver?

A

NO

Combination of Cyclizine and Hyoscine Butylbromide in CSCI cause crystallisation

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12
Q

What class of laxatives should be used in end of life care?

A

Stool softeners should be used

*we should not use laxative stimulants

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13
Q

What meds can we use to reduce nausea and vomiting? + cautions for these meds (5)

A
  • Cyclizine →not with hyoscine butylbromide as cause crystallisation in syringe driver)
  • Haloperidol → may cause extra-pyramidal effects
  • Levomepromazine → may cause sedation
  • Metoclopramide → contraindicated in bowel obstruction
  • Ondansetron
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14
Q

What drug classes may cause constipation?

A
  • opioids
  • diuretics
  • anti-cholinergics
  • ondansetron
  • chemotherapy
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15
Q

Causes of constipation

A
  • drug-induced
  • dehydration
  • reduced mobility
  • hypercalcaemia
  • environmental e.g. lack of privacy
  • concurrent disease
  • altered dietary intake
  • neurological
  • intestinal obstruction
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16
Q

What classes of oral laxatives should we use in a palliative (non-end of life) patient?

A
  • combination of stool softeners + stimulant laxatives
  • osmotic agent can be added either on PRN or regular basis
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17
Q

Examples of stimulant laxatives (3)

A
  • Docusate sodium
  • Senna (tablets and syrup)
  • Bisacodyl tablets
18
Q

What’s the name of combination laxative used only in a terminally ill patient (end of life)?

A

Codanthramer Strong

(capsules and suspension)

  • may cause abdo colic
  • may cause skin irritation
  • avoid in faecal incontinence
19
Q

Examples of osmotic laxatives +cautions (3)

A
  • Macrogol → contraindicated in bowel obstruction
  • Lactulose → may cause abdo colic and flatulence
  • Magnesium hydroxide → avoid in cardiac disease and poor renal function
20
Q

What drug to use for opioid-induced constipation that has failed to respond to standard measures?

A

Naloxegol

21
Q

What to do in case of seizure that does not respond to buccal Midazolam or rectal Diazepam and the patient is to stay at home or hospice?

A

SC infusion of Midazolam 20-30mg over 24 hours

22
Q

Management of Superior Vena Cava Obstruction

A
  • Dexamethasone 16mg orally or paraenterally (in one or two divided doses IMMEDIATELY
  • discuss with oncologist
  • possibility of radiological stenting
23
Q

Symptoms of Hypercalcaemia

A
  • fatigue
  • weakness
  • constipation
  • nausea and vomiting
  • polyuria
  • polydipsia
  • cardiac arrhythmias
  • delirium
  • drowsiness
  • coma
24
Q

Management of hypercalcaemia

A
  • rehydration with 0.9% sodium chloride (1-3 liters)
  • IV bisphosphonates (after administration of saline fluids)

* check corrected Ca++ after 5-7 days of IV bisphosphonates

25
Q

Management of suspected metastatic spinal cord compression

A
  • Dexamethasone 16mg PO or convert dose to SC
  • prescribe gastric protection
  • analgesia (opioid) to enable transport for admission/Ix
  • nurse flat (if pain of spinal instability)
  • urgent admission and MRI
  • radiotherapy or spinal surgery (possibly)
  • physiotherapy and OT
  • titrate steroids
26
Q

Management of catastrophic haemorrhage in a terminally ill patient

A
  • member of staff needs to stay with patient to support all the time
  • dark coloured towels → to hide blood loss
  • Midazolam 10mg IM, buccal or SC
  • keep patient warm
  • analgesics if needed
27
Q

What to discuss/consider when we PLAN last days of care?

A

Discuss:

  • CPR
  • facilitate a preferred place of care/ death
  • how to support fluid/food intake
  • when to stop/continue vital obs/ investigations
  • start/stop of clinically assisted hydration/nutrition
  • review long term meds → stop those that are not longer needed or adjust the route
  • anticipatory prescribing
28
Q

What are 5 key priorities in end of life care

A
  • Recognise
  • Communicate - to pt, family, team
  • Involve - family, team, pt in decision making, planning
  • support - family, pt
  • plan
29
Q

What’s target BM in the end of life care diabetic patient?

A

6-15

30
Q

What sides should we avoid insertion of syringe pump drivers?

A

Alle either due to discomfort, risk of infection, poor perfusion, poor drug absorption:

  • oedematous areas
  • bony prominences
  • irradiated sites
  • skin folds, near to a joint or waistband area
  • broken skin
31
Q

Locations on the body where we can consider insertion of syringe driver

A
  • scapula region
  • the anterior aspect of upper arms
  • anterior chest wall
  • anterior abdo wall
  • anterior tights
32
Q

What is anti-emetic preferred in end of life patient with renal impairment?

A

Haloperidol or Levomepromazine

33
Q

What corticosteroid is preferred to be used in palliative care?

A

Dexamethasone

This is because:

  • high anti-inflammatory properties
  • lower incidence of fluid retention and biochemical disturbance
34
Q

What’s potency of Dexamethasone compared to Prednisolone

A

1 mg of Dexamethasone = 7.5 mg of Prednisolone

35
Q

What time of days should we administer corticosteroids?

A
  • before noon → to minimise insomnia
36
Q

Use of corticosteroids (as adjuncts) in palliative care - indications

A
  • anorexia
  • adjuvant analgesic
  • anti-emetic
  • obstructive syndromes
  • spinal cord compression
  • raised intracranial pressure
37
Q

Adverse effects of steroids use (re to palliative care)

A
  • glucose metabolism → steroids can increase BMs
  • insomnia → give before noon
  • dyspepsia → give after food; PPI
  • psychiatric disturbance
  • change in appearance → moon face, truncal obesity, negative body image
  • MSK problems → proximal myopathy, osteoporosis, avascular bone necrosis
  • Increased risk of infections
  • skin changes
  • other: hypertension, oedema, pancreatitis
38
Q

How to stop steroid treatment? (if needed to be monitored)

  • when to monitor
  • how
A

Monitored if: 3 or more weeks of steroid treatment, daily dose of more than 6mg Dexamethasone, risk of adrenal suppression, risk of severe symptoms returning

How:

  • firstly halve the daily dose (to 4mg a day)
  • then reduce slowly by 1-2 mg weekly

Patients on systemic steroids for >3 weeks must be given MEDIC ALERT steroid card

39
Q

What’s meant by ‘ceilings of treatment’?

A

How far to actively manage and when to stop e.g. when not to take antibiotics, when not to go to the hospital, when not to treat AKI

40
Q
A

Palliative care (11 decks)

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