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?
