End of Life palliative care

Question 1

What is Palliative care ?

Answer 1

Any patients that needs end of life care
Improve the quality of life

Question 2

What is the North west End of Life Care Model ?

Answer 2

Advancing Disease
Increasing Decline
Last Days of Life
First Days after Death
Bereavement

Question 3

What is the Referral Criteria ?

Answer 3

Pts with
complex unstable symptoms
complex end of life care needs
complex ethical decisions
complex fast track discharge to facilitate a home death
advance care planning discussions
complex psychological needs of the patient or family/carer

assess the patient yourself

Question 4

what symptoms might someone with a life limiting illness experience?

Answer 4

Dyspnoea
Dry mouth
Nausea & Vomiting
Constipation
Anorexia & weight loss
Non- healing wounds
Fever
Delirium, restlessness
Anxiety
Sedation
Fatigue
Depression

Question 5

How do patients describe Pain ?

Answer 5

Sensory and emotional experience associated with actual or potential tissue damage

Question 6

What are the types of pain ?

Answer 6

Neuropathic pain (nerve pain) - damage to the nerve - hard to treat

• can experience electric shock associated with allodynia, paraesthesia , shooting pain , sensory changes, numbness, burning, stabbing,

Nociceptive (tissue damage)

Visceral/soft tissue: dull, poorly localised
Bone pain: usually localised, tenderness, worse on movement
Usually opioid responsive

Question 7

Acute vs Chronic pain ?

Answer 7

Acute is straightforward and easier to treat whereas chronic pain has no purpose and need multiple treatment modalities.

Question 8

What is Total Pain ?

Answer 8

Psycological
Physical
Emotional
Spiritual
Social

Question 9

How would you assess pain ?

Answer 9

Socrates
Site
Onset
Character
Radiation ‘
Associated symtoms
Time
Exacerbating factors
Severity

Question 10

How would you assess pain on pt that are unresponsive ?

Answer 10

Groaning

Question 11

How would you treat the pain ?

Answer 11

Analgesic
* Paracetamol ( 2 tables 4 times a day)
* Nsaids
* Opiods such as codeine, tramadol
* Also use Ketamine in pallative care

Question 12

What is Adjuvant analgesics ?

It is not a pain relief but has pain relief factors

Answer 12

A drug which has a primary role other than pain control
* Antidepressants
* Anti-convulsants
* Anti-cholinergics
* Steroids
* Bisphosphonates

Question 13

Name some opioids ?

Answer 13

• Codeine
• Tramadol
• Methadone
• Morphine
• Oxycodone

Question 14

What is the maximum dose of morphine in 24hrs?

Answer 14

Initially 20–30 mg daily in divided doses using immediate- release preparation on 4 hourly or 12 hr modified- release preparation

Question 15

What are the common side effects of opiods?

Answer 15

Constipation
Tiredness
Dry mouth
Nausea and vomiting
hypotension

Question 16

What are the less common side effects by opioids ?

Answer 16

Confusion
Hallucinations
Myoclonus
Itch
Hyperalgesia
Respiratory depression

Question 17

How might you start opioids?

Answer 17

• Oral morphine 2.5-5mg 4 hourly
• Oral morphine 2.5-5mg PRN 1 hourly
• PRN dose 1/6th – 1/10th total daily dose
• Assess response
• Increase by 30-50% every 24-48 hours
• When pain controlled convert to MR preparation
• Total daily dose divided by 2

Question 18

What are the important points to remember for opiods ?

Answer 18

• Prescribe by strength not volume - mg not mls
• Oral route where possible
• Do NOT prescribe as PO/IV/SC (not the same)
  morphine 10 mg PO = morphine 5 mg SC/IV
• May need anti-emetic
• Don’t forget laxatives

Question 19

What are the signs of opiate toxicity?

Answer 19

• Pin point pupils
• Drowsiness
• Confusion
• Hallucinations
• Myoclonic jerks
  ↓RR

Question 20

What is the management of opiod toxicity?

Answer 20

• Urgent U+E, FBC
• IV + fluids
• History: be wary of stopping opioids if in pain
• In normal renal function reduce opioids by 50%
• Consider opioid rotation esp if renal impairment

If RR drops to 8 or below:
* Naloxone - IV 100-200 mcg boluses
* 30 minute obs - may deteriorate quickly
* Short ½ life - may need to repeat
* Consider IV infusion if MR/renal failure
* Seek advice SPC

Question 21

What are Neuropathetic agents ?

Answer 21

Amitriptyline: 10mg OD -75mg OD max
Gabapentin: 100mg OD – 900mg TDS max
Pregabalin: 25mg BD – 300mg BD max
Duloxetine: 30mg OD – 60mg OD max

Ketamine and Methadone

Question 22

What are the other treatment modalities?

Answer 22

• Surgery
• Radiotherapy
• TENS
• Topical agents – lidocaine patches, capsaicin
• SACT
• Nerve blocks

Question 23

**Palliative care emergencies cases - case 1 **

64 year old lady with metastatic breast Cancer - Liver, Lung and Bone metastases
On MST 60mg BD for pain + oramorph 15mg PRN. Palliative chemotherapy 10 days ago
Lives with husband. Admitted to A&E with general deterioration, confused, drowsy

Question 24

Clinical findings of case 1 are

Temp Apyrexial
Drowsy, slurred speech, confused
Husband reports been dropping drinks
Cardiovascular & respiratory examination unremarkable

Question 25

What are the investigations ?

Answer 25

Bloods: * FBC NAD * Urea 12.7 Creatinine 168 * Corrected Calcium 2.98 CXR shows no acute changes Urine MSU NAD Hypercalacaemic Renal failure

Question 26

what are the Possible causes for deterioration ?

Answer 26

* Infection * Electrolyte imbalance * Renal failure * Opiate toxicity * Intracranial cause

Question 27

What is Hypercalcaemia of malignancy?

Answer 27

Common complication of advanced cancer Common in breast, lung, renal, myeloma, thyroid, cervix, H&N Not all patients need to have bone metastases Ectopic PTH secretion Symptoms vague - easily mistaken for underlying malignancy N&V, constipation, anorexia, confusion, drowsiness, polydipsia, polyuria, dehydration Poor prognosis especially if refractory to treatment

Question 28

What is the management if the patient is asymptomatic ?

Answer 28

If asymptomatic and Corr Ca <3mmol/L * Corr Ca <3mmol/L * Check U&E & Albumin * Stop any thiazide diuretics * Ensure adequate fluid intake 2-3L/24 hours

Question 29

What is the management if the patient is symptomatic ?

Answer 29

If symptomatic or Corr Ca >3mmol/L * IV rehydration 2-4L * IV bisphosphonate Zometa 4mg in 100mls N.Saline 0.9% over 15 mins

Question 30

What are the further management ?

Answer 30

* Rehydration alone often insufficient * Levels start to fall within 48 hours * Normalisation in 90% within 5-10 days * Calcium levels will need regular monitoring * Some patients may need regular oral/IV bisphosphonate * Treat underlying cause * Poor prognostic indicator