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Communication skills > End of Life palliative care > Flashcards

End of Life palliative care Flashcards

1
Q

What is Palliative care ?

A

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

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2
Q

What is the North west End of Life Care Model ?

A

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

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3
Q

What is the Referral Criteria ?

A

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

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4
Q

what symptoms might someone with a life limiting illness experience?

A

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

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5
Q

How do patients describe Pain ?

A

Sensory and emotional experience associated with actual or potential tissue damage

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6
Q

What are the types of pain ?

A

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

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7
Q

Acute vs Chronic pain ?

A

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

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8
Q

What is Total Pain ?

A

Psycological
Physical
Emotional
Spiritual
Social

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9
Q

How would you assess pain ?

A

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

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10
Q

How would you assess pain on pt that are unresponsive ?

A

Groaning

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11
Q

How would you treat the pain ?

A

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

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12
Q

What is Adjuvant analgesics ?

It is not a pain relief but has pain relief factors

A

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

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13
Q

Name some opioids ?

A
  • Codeine
  • Tramadol
  • Methadone
  • Morphine
  • Oxycodone
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14
Q

What is the maximum dose of morphine in 24hrs?

A

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

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15
Q

What are the common side effects of opiods?

A

Constipation
Tiredness
Dry mouth
Nausea and vomiting
hypotension

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16
Q

What are the less common side effects by opioids ?

A

Confusion
Hallucinations
Myoclonus
Itch
Hyperalgesia
Respiratory depression

17
Q

How might you start opioids?

A
  • 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
18
Q

What are the important points to remember for opiods ?

A
  • 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
19
Q

What are the signs of opiate toxicity?

A
  • Pin point pupils
  • Drowsiness
  • Confusion
  • Hallucinations
  • Myoclonic jerks
    ↓RR
20
Q

What is the management of opiod toxicity?

A
  • 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

21
Q

What are Neuropathetic agents ?

A

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

22
Q

What are the other treatment modalities?

A
  • Surgery
  • Radiotherapy
  • TENS
  • Topical agents – lidocaine patches, capsaicin
  • SACT
  • Nerve blocks
23
Q

**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

A
24
Q

Clinical findings of case 1 are

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

A
25
Q

What are the investigations ?

A

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

Hypercalacaemic
Renal failure

26
Q

what are the Possible causes for deterioration ?

A
  • Infection
  • Electrolyte imbalance
  • Renal failure
  • Opiate toxicity
  • Intracranial cause
27
Q

What is Hypercalcaemia of malignancy?

A

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

28
Q

What is the management if the patient is asymptomatic ?

A

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

29
Q

What is the management if the patient is symptomatic ?

A

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

30
Q

What are the further management ?

A
  • 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

Communication skills (2 decks)

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