End of Life Care Flashcards
What are the principles for managing the last 48h of life?
- Problem solving approach to symptom control
- Avoid unnecessary interventions
- Review drugs and symptoms regularly
- Maintain effective communication
- Ensure support for family and carers
What do patients experience in the final 48 hours of life?
- Increasing weakness and immobility
- Loss of interest in food and drink
- Difficulty swallowing
- Drowsiness
Method of analgesic delivery and drug of choice if oral administration no longer possible?
S/C
Drug = diamorphine (strong opioid of choice; soluble). Delivered through syringe driver.
Protocol for starting longer acting opioid preparations in patients close to death (i.e. transdermal fentanyl)?
DON’T! Should not be started in patient close to death.
- variable delay in reaching effective levels
- speedy dose titration difficult therefore unsuitable when rapid effect required (i.e. uncontrolled pain)
- if pt already prescribed fentanyl patches, continue as baseline; add morphine / diamorphine titrated to pain
Bone pain therapeutic class best used?
NSAIDs
Best analgesic class to ease pain of muscle spasm?
Diazepam
Opioid treatment starting dose (pain control during palliation)?
Immediate release morphine
- 5mg every 4h
- PO
Increment to increase by when titrating pain medication during palliation?
1/3 current dose (but varies according to breakthrough analgesia in previous 24h)
Breakthrough analgesia dose?
1/6 24h dose
i.e. diamorphine 60mg S/C 24h ==> 10mg S/C PRN
Morphine PO to S/C conversion?
3:1
Management of breathlessness in palliative stages?
- Reverse reversible
- Supportive measures: explanation, position, breathing exercises, fan or cool airflow, relaxation techniques
- Oxygen therapy
- Opioid
- Benzo
- Hyoscine
- Nebulised saline (if no bronchospasm and patient able to expectorate)
Management noisy terminal breathing?
- Reposition
- Hyoscine hydrobromide (if significant secretions)
- > 0.4-0.6mg S/C bolus
- > 2.4mg/24h via syringe driver
- gentle suction sometimes
Causes of restlessness and confusion?
- Drugs: opioids, corticosteroids, neuroleptics, EtOH (intoxication and withdrawal)
- Physical: unrelieved pain, distended bladder or bowel, immobility or exhaustion, cerebral lesions, infection, major organ failure
- Metabolic upset: urea, calcium, sodium, glucose, hypoxia
- Anxiety and distress
Mx restlessness and confusion?
- Treat acute state and address cause
- Environment: stable, safe, soft light, quiet, familiar faces
- Drug choice relates to likely cause
Indications and dose for haloperidol for mx restlessness?
-Drug toxicity
-Altered sensorium
-metabolic upset
>PO 1.5-3mg (rpt after 1h)
>S/C bolus 2.5-10mg
>S/C infusion 5-30mg 24h
Indications and dose for midazolam for mx restlessness?
Anxiety and distress; risk of seizure.
>S/C bolus 2.5-10mg
>S/C infusion 5-100mg 24h
What should be used for altered sensorium plus anxiety management?
Combine haloperidol and midazolam
Site of effect and treatment of choice for N/V due to drugs or biochemical upset?
Chemoreceptor trigger zone (area postrema) via dopamine receptors
Rx: haloperidol
Site of effect and treatment of choice for N/V due to raised ICP?
Vomiting centres via histamine receptors
Rx: cyclizine
Site of effect and treatment of choice for N/V due to uncertain/multifactorial?
Various sites.
Rx: Methotrimeprazine
Site of effect and treatment of choice for N/V due to gastrointestinal stasis?
Gastrokinetic
Rx: metoclopramide, cisapride
Site of effect and treatment of choice for N/V due to bowel obstruction?
Vomiting centres via vagus nerve; GIT secretions
Rx: cyclizine, octreotide, hyoscine butylbromide
What are risk factors for bereavement?
- Pt: young
- Illness: short, protracted, disfiguring, distressing
- Death: sudden, traumatic
- Relationship: ambivalent, hostile, dependent
- Main carer: young, other dependents, concurrent crises
