EoL Flashcards
Define palliative care
life-limiting illness, prevention/relief of suffering (physical, psychological, spiritual)
Define terminal care
Last day management, symptoms focused not prevention
What are the signs of EoL?
Death rattle breathing - due to resp secretions (breathing through phlegm) Cheyne-stokes - shallow/deep, start/stop breathing Mottled skin Cachexia Gaunt (cachexia) (temporalis wasting) Cold Decreased GCS Decreased urine output Decreased BP Agitation
What are the functional changes at the EoL?
Diff swallowing Decreased mobility Social withdrawal Decreased communication Decreased performance status
What are the symptoms of EoL?
Fatigue
Impending sense of death
Loss of appetite
Weight loss
What are the causes of N+V in advanced disease?
Hypoglycaemia Renal impairment HyperCa Infection Liver failure Medications - morphine, anticholinergics Anxiety RICP - cerebral mets/haemorrhage, meningeal disease Vestibular disturbance Constipation Malignant bowel obstruction
When is haloperidol used?
= metabolic/drug (chemical)
D2 blocker
SE = extra-pyramidal, restlessness, sedation
When is metoclopramide used?
= chemical, gastric stasis
D2 blocker
SE = extra-pyramidal (muscle spasms, tardive dyskinesia)
When is cyclizine used?
= bowel obstruction, raised ICP, motion sickness
Anti-cholinergic and H1 antagonist
Blocks conduction in vestibular-cerebellar pathway and acts at VC
SE = hypotension, urinary retention, dry mouth,
constipation, restlessness
When is levomepromazine used?
= EoL
Acts at vomiting centre and CTZ
SE = drowsiness
When is ondansetron used?
= reduce serotonin release (RT on bowel, surgery of bowel, chemo)
5HT3 antagonist; peripheral (vagal N) and central (CTZ) action
SE = constipation, headache
Give some examples of laxatives and how they work
Senna (stimulant) = reduce bowel transit time
Docusate (softener) = increase water penetration
Na picosulfate (stim/soft)
Lactulose (osmotic) = pulls water in
Movicol/laxido (osmotic) = pulls water in
Glycerin (suppository) = softener
Bisacodyl (suppository) = stimulant
How should breathlessness be treated?
Intractable breathlessness (untreatable, aim is to reduce perception)
- Position patient - use gravity to aid and not hinder weak diaphragm/chest wall muscles
- Air flow across the face: fan or open a window
- Trial of oxygen (if hypoxic)
- Breathing techniques
- Energy conservation
- Distraction
- Anxiety reduction
- CBT
- Goal setting
- NIV
- Small dose of morphine (oromorph 1-2mg)
- Benzodiazepines in anxiety
Pharmacological
- Bronchodilators - trial of salbutamol
- Opioids - morphine 2.5mg/4h
- Corticosteroids - dexamethasone 4-8mg (reduce peri-tumour oedema)
- Benzodiazepines - lorazepam 0.5mg SL PRN/8h (anxiety)
- Oxygen
- Air
What factors affect pain?
State of mind - anger, anxiety, depression, grieving, sleep, lack of understanding, acceptance, relaxation, relief of other symptoms
What is nociceptive pain and how does it feel?
Normal nervous system, identifiable lesion causing tissue damage
Somatic = skin, muscles, bone
- Sharp, throbbing, well localised
Visceral = hollow viscus, solid organ
- Diffuse ache, diff to localise
What is neuropathic pain and how does it feel?
Malfunctioning nervous system, nerve structure is damaged
- Stabbing, shooting, burning, stinging, allodynia, numbness, hypersensitivity
Outline the WHO analgesic ladder
1 = non-opioids = paracetamol, NSAIDs
2 = weak opioids (mild-moderate pain) = dihydrocodeine, codeine phosphate, tramadol, co-codamol), hydrocodone
3 = strong opioid (moderate to severe pain) = oxycodone (oxynorm), morphine, fentanyl, diamorphine
What is adjuvant pain relief?
= drugs whose primary indication is not for pain
- Amitriptyline, duloxetine (antidepressant)
- Gabapentin (anti-convulsant)
- Dexamethasone
- Bisphosphonates for bony pain
What should be prescribed for neuropathic pain?
Amitriptyline (TCA), 10-25mg nocte
Gabapentin, 300mg, TDS over 3/7
Pregabalin 75mg BD
What are the signs and symptoms of opioid toxicity?
Pinpoint pupils, hallucinations, drowsiness, N+V, confusion, myoclonic jerks, resp depression
Aetiology = dose escalated too quick, renal impairment
How should codeine be prescribed?
Comes in 3 strengths = 8/15/30mg (max 240mg/24hrs) + 500mg paracetamol
Safe ratio = 10:1 (240mg codeine equates to 24mg of morphine)
How should a controlled drug prescription be written?
Name and ID of patient
Write prescription as normal
Then write SUPPLY and give the pharmacist EXACT instructions
Drug name and formulation (be explicit re tablets/capsules/patches)
Total number of tablets or amount of drugs in words and figures
For palliation of shortness of breath with a significant anxiety component, what would be the best initial management?
Breathing exercises
Lorazepam 0.5mg SL PRN QDS
OTHER:
- Oral morphine sulphate (oromorph) 1mg PO (10mg/5ml)
- If renal function was impaired and eGFR 30-60, then oxycodone immediate release solution would be a good choice
What medications can be prescribed for secretions at the end of life?
Glycopyrronium
Hyoscine hydrobromide
What medications can be prescribed for agitation at the end of life?
Levomepromazine
Midazolam
Which analgesic drugs are most appropriate to be used in renal failure?
Alfentanil
Fentanyl
Buprenorphine
Outline performance status
Performance status is a measure of a patient’s activity.
0= no symptoms from cancer.
1= minimal symptoms from cancer, patient able to complete light work without symptoms.
2= resting in bed/chair less than 50% of the day.
3= resting in bed/chair more than 50% of the day, able to mobilise to independently manage limited self care.
4= patient bed bound.
What should be prescribed for bowel colic at the EoL?
Hyoscine butylbromide
How should intractable hiccups be managed?
Chlorpromazine or haloperidol
