End of life care Flashcards
Basic principles of prescribing opioid analgesia in Palliative Care: How should PRN and potency be adjusted?
- PRN Morphone should be one-sixth of total 24hr dose
* Potency (PO:SC = 2:1)
Analgesia in Palliative Care: 65yrs, Carcinoma of breast
• Takes: morphine modified release 30mg BD
• Admitted to hospital with urine infection
Please prescribe her analgesia
Regular opioid:
• Dose: 30mg modified release
• Frequency: 12-hourly (BD)
PRN opioid:
• PO: morphine immediate
release 10mg four-hourly
• SC: morphien injection 5mg fourhourly
Analgesia in Palliative Care: Patient with gastric cancer taking Oxycodone modified release 100mg BD, Admitted with vomiting
What should she be prescribed regular & PRN?
Regular opioid:
• Dose: oxycodone 100mg
CSCI/24hrs#
• Frequency: over 24hrs
PRN opioid:
• PO: ?
• SC: oxycodone injection 15mg-20mg four hourly PRN
#Note frequency of dose important ie csci is over 24hrs
Analgesia in Palliative Care: Patient with Fentanyl
transdermal patch 25micrograms/hour
What would you want to know?
How do you work out a PRN dose?
• Check renal function • Consult patient and BNF • Fent 25mcg/hr = ~90 oral morphine in 24hrs • PO morphine PRN dose ~15mg
Controlled Drug prescriptions must include which elements?
DRUG • Name • Formulation: liquid, tablet, capsule, patch etc • Dose: in words and figures • Frequency • Strength: eg 10mg in 5mL, 10mg tablets • Total quantity (words & figures)
YOU: Prescriber signature, date, address [professional]
PATIENT: name & address, date of birth, hospital/NHS number
Analgesia in Palliative Care: Syringe drivers - what is an appropriate starting dose?
- Morphine 10mg/24hrs
- Oxycodone 5mg/24hrs
- Alfentanil 500micrograms/24hrs
In renal failure: use fentanyl or alfentanil
Complete a MCCoD:
• 64 years, admitted to hospital with chest infection.
• Underlying diagnosis of squamous cell lung cancer, bone metastases.
• Deteriorated despite IV antibiotic. Commenced on
PCPDP.
• PMHx: eczema, hypertension
I(a) Lower respiratory tract infection (b) Metastatic squamous cell carcinoma of the lung. (c) - II -
Complete a MCCoD:
• 54yrs
• Cardiac failure, EF 25%
• PMHx: multiple MIs, angioplasty + stent; Has CRT-P, Diabetes.
• Admitted with pulmonary oedema, deteriorated despite treatment and died suddenly.
I(a) Cardiac failure
(b) Ischaemic Heart Disease
(c)
II Diabetes
Complete a MCCoD:
• 73yrs male
• Admitted with dyspnoea. Found to have pulmonary embolism,
• Deterioration, hospice admission or end of life care 29th July 2018
• Mesothelioma diagnosed 2017
• VATS surgery 2018 (Jan)
You must refer this death to Coroner as mesothelioma
industrial disease
Delirium in palliative care: What is delirium?
- Acute confusional state
- Change in alertness, altered consciousness, impaired cognition
- Fluctuant /Reversible course
- Change from normal baseline
What factors can precipitate delirium?
D: Drugs, Dehydration E: Electrolyte /Endocrine Imbalance L: Level of pain I: Infection /Inflammation R: Respiratory Failure I: Impaction U: Urinary retention M: Metabolic disorder ( Liver/Renal failure, Hypoglycemia)
- Change of environment
- Sensory deficit
- Falls
- Immobility
- Sleep Deprivation
Symptoms of Delirium
• Cognition : concentration, disorientation, fluctuating
consciousness
• Perception : hallucinations
• Impaired Physical function : mobility, appetite, agitation,
restlessness, sleep disturbance
• Social behaviour : combative, lack of cooperation with
reasonable requests, withdrawal
• Attention : difficulty maintaining attention span
4 features of hyperactive delirium
- Aggressive, restless, agitated
- Increased state of arousal
- Hallucinations, delusions
- Sleep disturbed, , hyper vigilant
- Uncooperative, combative
4 features of hypoactive delirium
- Withdrawn, quiet, sleepy
- Less active / inert
- Poor concentration
- Reduced mobility /movement
- Mimics depression
How does the onset differ between delirium, depression and dementia?
Delirium: hours to days
Depression: gradual weeks o months
Dementia: gradual months to years
How does the course differ between delirium, depression and dementia?
Delirium: fluctuant, reversible with treatment
Depression: recent changes in mood persistent, worse in morning
Dementia: show chronic progression, irreversible
How does sleep differ between delirium, depression and dementia?
Delirium: disturbed sleep with no set pattern, some day night reversal
Depression: early morning awakening, hypersomnia, disturbed
Dementia: disturbed +/- individual pattern occurring most nights, nocturnal wandering
How does mood differ between delirium, depression and dementia?
Delirium: fluctuant emotions, labile, may have outburst of anger, fearfulness or crying
Depression: withdrawn, persistently low, worthlessness, anhedonia, hopelessness, suicidal
Dementia: depressed, apathy more common
How does perception and cognition differ between delirium, depression and dementia?
Delirium: Fluctuation in alertness, cognition, Perception,
hallucinations, illusions
Depression: Low self esteem & guilt, Suicidal / self harm
Agitated depression OR withdrawn, reduced motivation/interest
Dementia: Delusions +/-
Hallucinations – LBD
Wandering /agitated or withdrawn, co-existent
depression
How do you assess a patient for delirium?
Altered arousal: observe for sleepiness or hyper-alertness, wake them up and talk to them - are they able to follow conversation?
Disordered thinking: “what’s going on today? Anything strange or different?”
Change in baseline: acute onset, fluctuant course, not my mom/dad
Formal tools for assessing delirium
DSM-5 Criteria
CAM - confusion assessment method
4AT
AMTS
Describe the confusion assessment method (CAM) tool
- acute onset and fluctuant course
- inattention
- disordered thinking
- altered consciousness
Must have presence of 1,2 AND
Either 3 OR 4
DSM-5 Diagnostic Criteria for Delirium
A. Disturbance in attention and awareness
B. Develops over a short period of time, Fluctuates in severity
during the course of a day
C. Additional disturbance in cognition not accounted for by
another neurocognitive disorder;
D. Disturbances A and C must not be occurring secondary to
coma;
E. Caused by a somatic factor, medication intoxication or
withdrawal
Non Pharmacological Management of delirium
- Calm, constant environment
- Correct sensory deficit
- Familiar objects & people
- Simple communication/reassure in lucid intervals
- Avoid moving patient between rooms
- Fewer interruptions
- Avoid catheterisation, restraints
Which reversible causes of deliruim should be treated in palliative patients?
Treat potentially reversible causes EVEN in
palliative patients
- Infections: UTI, pneumonia, sepsis
- metabolic: Ca, Na, HF, RF, hypoglycaemia
- dehydration and nutritional deficiencies
- psychological distress, pain
- constipation, urinary retention
Pharmacological Management of delirium: what works?
Haloperidol • Oral & s/c syringe driver • 500 micrograms stat, PRN • Dose range 0.5 mg - 3 mg • Lower doses in elderly
Pharmacological Management of delirium: What cautions must be think about when prescribing haloperidol?
- Parkinson’s Disease, Levy Body Dementia
* Prolonged QT interval, torsade de pointes
Pharmacological Management of delirium: what should be avoided?
• Benzodiazepines WORSEN delirium
• No adequately controlled trials to support the use of
Benzodiazepines in Delirium
• Lorazepam associated with increased side effects
Strategies to prevent delirium
- Orientate
- Hydration / nutrition
- Reassure – use lucid intervals
- Correct sensory deficit
- Encourage visits from family
- Familiarize with surroundings
- Encourage mobility
- Establish sleeping pattern
List 3 benefits of early palliation
Better QOL Less depression Less aggressive EOLC Low symptom burden
Causes of sudden onset breathlessness
asthma
pulmonary oedema
pneumonia
pulmonary embolism
Causes of breathlessness arising over several days
exacerbation of COPD
pneumonia
bronchial obstruction by tumour
SVC obstruction
Causes of breathlessness with gradual onset
congestive cardiac failure anaemia pleural effusion primary/secondary lung carcinoma ascites
Dyspnea in patient with underlying malignancy: how can we determine the cause
malignancy related: directly or indirectly
unrelated: pre-existing pulmonary or cardiovascular disease
treatment related: directly or indirectly
How can malignancy cause dyspnea?
Directly:
- pulmonary: lung primary or metastases, lymphangitis spread, lobar collapse, haemorrhage
- cardiac: pericardial effusion
- other: SVC obstruction, dyspnea of malignancy
Indirectly:
- PE from hypercoagulability
- pneumonia from immunosuppression
How can treatment for malignancy cause dyspnea?
Radiation: pneumonitis, pulmonary fibrosis, pericarditis
Chemotherapy: lung toxicity (bleomycin, methotrexate etc), cardiac toxicity (anthracyclines, paclitaxel, Herceptin)
Indirectly: pancytopenia resulting in respiratory infection or severe anaemia, higher risk of CAD with chest wall radiation
Treatment of dyspnoea in palliative patients
Treat potentially reversible causes of Dyspnoea
EVEN in palliative patients
Examples:
Large airway: strent
Small airway: bronchodilators
Decreased gas exchange: ?PE -> LMWH
RT pneumonitis: dexamethasone
Palliation of Breathlessness
Non pharmacological
- Positioning
- Room temperature, air circulation
- Behavioral techniques, relaxation, distraction
- Energy conservation / Pacing
- Controlled breathing
- Loose clothing
- Mouth care
- Walking Aids
Palliation of Breathlessness
pharmacological management
- Bronchodilators
- Nebulised saline
- Carbocistiene
- Dexamethasone
Benzodiazepine if anxiety unmanageable or EOL (less evidence for this)
Palliation of Breathlessness: What is the role of oxygen?
Oxygen no better than air in palliation
A fan may be equally effective
Only for hypoxic patients
Formal assessment for O2 use
Define Cachexia
Multifactorial syndrome associated with protein and muscle loss, as well as systemic inflammation. Traditionally described as involuntary loss of more than 10% of premorbid body weight, Accompanying anorexia. Increases with disease progression.
Can be caused by Cancer, AIDS, heart failure, COPD
Factors exacerbating anorexia in cancer patients
- dry mouth from mouth breathing and oxygen therapy
- drugs: opioids, iron, NSAID
- disease processes - mouth ulcers, candida, mucositis
- treatment related: post-chemo or radiation
- anxiety, depression, pain
Effects of anorexia/cachexia in cancer patients
- Impaired immune response
- Impaired wound healing
- Weakened skeletal muscles
- Weakened respiratory function and mobility
- Poor cardiac contractility
- Reduced quality of life
- Poorer prognosis
Management of anorexia in cancer patients
•Address factors reducing intake •Little & often •High protein / energy meals •“What you fancy” •Food fortification and supplements •Food & fluids separately •Appetite stimulants: Alcohol, Antidepressants, Dexamethasone (glucocorticoid) 2mg mane with PPI, (Megestrol acetate)
Down-regulation of the inflammatory response: •NSAIDs
•Inhibition of IL-6, TNF-a
•Managing insulin resistance?
Causes of nausea and vomiting in palliative cancer care
- Gastric stasis, outflow obstruction, squashed stomach
- Bowel obstruction
- Pharyngeal candida
- Radiotherapy & chemotherapy
- Brain tumour or metastases
- Metabolic - hypercalcaemia, uraemia, tumour toxins
- Drugs (opioids, NSAIDs, iron)
- Pain, cough
- Anxiety/fear of treatment
Non pharmacological management of nausea and vomiting in palliative cancer care
- Control malodour (tumour, colostomy, ulcer)
- Avoid strong food smells
- Someone else cooks
- Calm, unhurried meals
- Small portions
- Acupressure bands
Which drugs stimulate N/V via gastric irritation?
Antibacterials, Corticosteroids, Iron, NSAIDs
Which drugs stimulate N/V via gastric stasis?
- Antimuscarinics (e.g. Tricyclic antidepressants)
* Opioids
Which drugs stimulate N/V via central stimulation?
- Opioids
- Antibacterials
- Cytotoxics
Which drugs stimulate N/V via 5HT3 receptor stimulation?
- Antibacterials
- Cytotoxics
- SSRIs
Causes of N/V via central stimulation (dopamine, serotonin, NK1)
uraemia
hypercalcaemia
morphone
Causes of N/V via GI tract (serotonin, dopamine, stretch receptors)
abdominal radiotherapy
chemotherapy
distension
Causes of N/V via 8th nerve nucleus (AChM, H2)
motion sickness
vertigo
Causes of N/V via cerebral cortex (GABA, serotonin, D2)
fear, anxiety, anticipatory nausea
Which anti-emetics work as D2 antagonist?
metoclopramide, domperidone, haloperidol, olanzapine, levomepromazine
Which anti-emetics work as H2 antagonist?
Cyclizine
Levomepromazine
Which anti-emetics work as muscarinic antagonists?
Cyclizine
Olanzapine
Levomepromazine
Which anti-emetics work as 5HT antagonists?
5HT2:
Olanzapine
Levomepromazine
5HT3:
Ondansetron
Which anti-emetic works as NK1 antagonists?
Aprepitant
How does metoclopramide act as a pro kinetic?
D2 antagonist (Upper GIT, CTZ)
5HT4 agonist (Upper GIT)
Triggers cholingeric system in GIT wall
Crosses BBB
Indications for metoclopramide as pro kinetic
Gastric stasis/upper GI dysmotility
Early in bowel obstruction
Delayed N&V due to chemotherapy
Side effects and cautions of metoclopramide as pro kinetic
Diarrhoea Extrapyramidal reactions (avoid in Parkinsons disease)
Indications for domperidone as pro kinetic
Gastric stasis/upper GI dysmotility
Key difference between pro kinetics metoclopramide and domperidone
metoclopramide crosses the BBB whereas domperidone does not
Action of Cyclizine
- AchM (antimuscarinic antihistamine)
- directly on vomiting centre
- Decreases activity in vestibular system
Indications for Cyclizine
- Raised ICP
* Motion induced nausea and vomiting
Cyclizine: Side effects/cautions
- Mutual antagonistic effect with Metoclopramide
* Severe cardiac failure (tachycardia)
Action of Haloperidol as anti-emetic
- Potent D₂ antagonist
- Acts directly on CTZ
- May have some gastric prokinetic effect
Indications for Haloperidol as anti-emetic
- Metabolic causes (e.g. renal failure, hypercalcaemia)
- Morphine induced sickness
- May help obstructive vomiting in small doses
Side-effects and cautions for Haloperidol as anti-emetic
- Some sedation
* Avoid if possible in Parkinsons disease
Action of Olanzapine as anti-emetic
- Antagonist at
- Multiple D receptors
- Muscarinic receptors
- Multiple 5HT receptors
- H₁ receptors
Indications for Olanzapine as anti-emetic
Chemotherapy induced nausea and vomiting resistant to other drugs
Cautions and side effects of Olanzapine as anti-emetic
Can cause:
•Drowsiness
•Orthostatic hypotension
Action of levomepromazine as anti-emetic
Antagonises D₂, 5HT₂ₐ, muscarinic receptors
Indications for levomepromazine as anti-emetic
- Broad spectrum – helps with many causes of vomiting
- Anxiolytic
- (Used in larger doses for agitation at the end of life)
Cautions and side effects of levomepromazine as anti-emetic
Drowsiness at doses >25mg/24hrs – therefore not used first line
Action of ondansetron as anti-emetic
- 5HT₃ antagonists
* Block effect on vagal nerve
Indications for ondansetron as anti-emetic
- Developed to control sickness associated with highly emetogenic chemotherapy
- Any situation where 5HT₃ is released in excess:
- Radiation induced damage to GI mucosa
- Intestinal distension
- Severe renal impairment with platelet release of 5HT
Side effects of ondansetron as anti-emetic
- Headache
* Constipation
Action of Aprepitant as anti-emetic
- Potent NK₁ inhibitors
* Act at CTZ
Indications for Aprepitant as anti-emetic
- Delayed phase of chemotherapy induced emesis
* Combination therapy with Dexamethasone and 5HT₃ inhibitor
Side effects/cautions for Aprepitant as anti-emetic
Lassitude, constipation, decreased appetite, dyspepsia, headache, hiccups
Actions and indications of dexamethasone as anti-emetic
- Direct action on vomiting centre,
- Direct anti-inflammatory effect on damaged tissue
- Reduces expression of serotonin receptors
- Reduces swelling around solid tumour mass
- Short term relief of ICP due to brain metastases (use up to 2 weeks)
Side effects/cautions for dexamethasone as anti-emetic
- Arousal/disturbed sleep
- Psychosis
- Hyperglycaemia
- Myopathy
- Increased susceptibility to infection
Actions and indications of lorazepam as anti-emetic
Action: GABAmimetic (cerebral cortex)
Indications:
•Chemo related and post op nausea and vomiting
•? Anxiolytic for anticipatory nausea
Side effects/cautions for lorazepam as anti-emetic
- Drowsiness
- Can cause respiratory depression
- Paradoxical agitation (<10%, risk in psychiatric comorbidity)
Choice of antiemetic
Raised intracranial pressure or vestibular irritation
Start with centrally acting drug, e.g. Cyclizine
Choice of antiemetic
Chemical cause of vomiting (CTZ), such as Morphine, hypercalcaemia, renal failure
Start with drug acting principally at CTZ, e.g. Haloperidol
Choice of antiemetic
Gastritis, gastric stasis, functional bowel obstruction
Start with a prokinetic, e.g. Metoclopramide
Management of constipation
- Ask about bowel function frequently
- Increase fluid intake
- Increase fruit/fibre in diet
- Encourage mobility
- Assist to toilet/raised toilet seat
- Provide privacy
How do direct stimulant laxatives work?
Direct stimulants
•Act by direct contact with submucosal and myenteric plexus, stimulating peristalsis
•Increase water secretion into bowel lumen
•Softer, larger stool stimulates bowel
How do softener laxatives work?
- Act as detergent, allowing water to penetrate stool
* Softer, larger stool stimulates bowel
How do osmotic laxatives work?
- Retain water in bowel lumen
* Softer, larger stool stimulates bowel
List 3 oral laxatives and how they work
Softener:
•Docusate tablet or liquid (100-200mg BD)
Osmotic:
•Macrogol (Movicol or Laxido, in 100ml water)
Direct stimulant:
•Senna tablet or liquid, 7.5-15mg nocte
Combination:
•Sodium picosulphate tablet or liquid 5-15mg nocte
Reversal of opioid induced constipation:
•Methylnaltrexone SC (stop other laxatives)
•Naloxegol PO (evidence lacking in palliative patients)
List 3 rectal laxatives and how they work
Suppositories
•Glycerine (stool softening)
•Bisacodyl (rectal stimulant)
Enemas
•Phosphate (osmotic)
•Sodium citrate Microlax (osmotic)
•Arachis oil (softening, avoid in peanut allergy)
“Spinal regime” for laxatives in palliative care
Lack of peristalsis due to malignant spinal cord compression or neurological disease
•Alternate nights: Senna 1-2 tablets PO
Following mornings
•Glycerine suppository
•Bisacodyl suppository
•Microlax enema
Bowel obstruction in palliative care: what is Medical management?
Likely to represent peristaltic failure, Try to get the bowel going…
•Metoclopramide via CSCI, 30-100mg/24hrs
•Stool softening laxative (stop stimulants)
•Consider Dexamethasone 6mg SC OD for 5-7 days with Ranitidine 300mg/24hrs CSCI
May resolve partial proximal obstruction
May precipitate colic or vomiting in complete obstruction
Bowel obstruction in palliative care: what is Medical management of colic?
May represent mechanical obstruction
Stop prokinetics and stimulant laxatives
Use CSCI:
•Opioid for pain
•Cyclizine and/or Haloperidol for nausea/vomiting
•Hyoscine butylbromide for colic 30-120mg/24hrs
•Consider nasogastric tube (only for large volume frequent vomits)
Pain management in palliative care: 46yrs female with Carcinoma of lung and Widespread cutaneous metastases. Pain in skin metastases; dull ache; constant
- What is pain?
- What type of pain do you think this person is describing?
- What else would you want to ask?
- What analgesics would you use?
- Nociceptive pain
- Recognise
- Assess: Pain history: [type], severity
•Treat
Non-opioids: paracetamol, ibuprofen
Opioids: morphine
Pain management in palliative care: 70yrs male with lung cancer with right axillary mass, Shooting pain with pins and needles down right arm.
What type of pain do you think this person is describing? What else would you want to ask? What analgesics (groups) might you use?
Neuropathic pain
- Recognise
- Assess: Pain history: [type], severity
- Treat: Neuropathic analgesics
Total pain: management
pharmacological
•As nociceptive/neuropathic pain
•But caution: potential to escalate drugs with no benefit (be prepared to reduce)
Non-pharmacological •TENS, acupuncture •Physio •Counselling •Address social issues •Manage anxiety/depression •Distraction
Pain management in palliative care: What practical things do you need to consider when choosing a painkiller?
- Costs
- Mode (ease) of delivery & dosing – PO, SC, TD, CSCI
- Toxicities (more later in renal disease)
- Regular, route, re-assess (titrate)
- Potencies PO:SC (IM)
- 2:1 for morphine, oxycodone
Pain management in palliative care: Starting dose for syringe driver opioids
- morphine 10mg/24hrs
- Oxycodone 5mg/24hrs
- Alfentanil 500micrograms/24hrs
Pain management in palliative care: Starting dose for syringe driver non-opioids
- ketorolac 30-90mg/24hrs
- ketamine 100-500mg/24hrs
Pain management in palliative care: special considerations for opioid prescribing
- Driving
- Tolerance, Dependence, Addiction?
- Travel abroad
- Patient Information Leaflets
- What questions/concerns do you think a patient may have when starting opioids for the first time?
Pain management in palliative care: Management of Total pain at end of life “pain crisis”
Requires rapid, multi-modal treatment escalation
Environment, family/friends
Analgesia:
•Opioid – one hourly & CSCI
•Ketamine CSCI
Sedative anxiolytics
•Midazolam PRN & CSCI
•Levomepromazine
Pain management in palliative care: List 4 drugs that could be used for muscle spasm and spasticity
baclofen, clonidine, clonazepam, tizanidine, gabapentin, ?Sativex
painful syndromes in end-stage renal disease?
What might you ned to consider about pharmacokinetics/dynamics?
- Renal osteodystrophy
- Muscle spasms, cramp, restless legs
- Diabetic problems – neuropathy
- Ischaemic pain (IHD, PVD), calciphylaxis
- Medications affecting renal perfusion: NSAIDS
- In dialysis: some medications removed (fentanyl is not) - paracetamol, tramadol, morphine, gabapentin
Analgesia in end-stage renal disease: What might you need to consider about pharmacokinetics/dynamics?
- Medications affecting renal perfusion: NSAIDS
- In dialysis: some medications removed (fentanyl is not) - paracetamol, tramadol, morphine, gabapentin
Opioids
•Avoid morphine & oxycodone where possible
•Oxycodone with caution – use small doses with the increased time between
Safer opioids:
•Tramadol low dose is fine
•fentanyl, alfentanil, hydromorphone
Consequences of unmanaged
lymphoedema
Cellulitis, pain, reduced mobility, body issues and psychological
impact, skin conditions, leg ulceration, social & financial impact, clothing & shoe issues, cost burden to the NHS.
Main causes of Lymphoedema in End of Life
- Often – Limb dependency
- Cancer mass (internal or fungating tumours) causing an
obstruction to the lymphatics - Consequence of cancer treatments
- Low albumin
If sudden development, evaluate for DVT or SVCO
Lymphorrhea
Lymphorrhea is an abnormal flow of lymph that drains externally from disrupted lymphatic vessels or is retained within a wound
