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4.1. Cancer Care > EoL > Flashcards

EoL Flashcards

1
Q

Define palliative care

A

life-limiting illness, prevention/relief of suffering (physical, psychological, spiritual)

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2
Q

Define terminal care

A

Last day management, symptoms focused not prevention

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3
Q

What are the signs of EoL?

A 
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
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4
Q

What are the functional changes at the EoL?

A 
Diff swallowing
Decreased mobility
Social withdrawal
Decreased communication 
Decreased performance status
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5
Q

What are the symptoms of EoL?

A

Fatigue
Impending sense of death
Loss of appetite
Weight loss

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6
Q

What are the causes of N+V in advanced disease?

A 
Hypoglycaemia
Renal impairment 
HyperCa
Infection
Liver failure 
Medications - morphine, anticholinergics
Anxiety
RICP - cerebral mets/haemorrhage, meningeal disease
Vestibular disturbance
Constipation 
Malignant bowel obstruction
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7
Q

When is haloperidol used?

A

= metabolic/drug (chemical)

D2 blocker

SE = extra-pyramidal, restlessness, sedation

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8
Q

When is metoclopramide used?

A

= chemical, gastric stasis

D2 blocker

SE = extra-pyramidal (muscle spasms, tardive dyskinesia)

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9
Q

When is cyclizine used?

A

= 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

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10
Q

When is levomepromazine used?

A

= EoL

Acts at vomiting centre and CTZ

SE = drowsiness

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11
Q

When is ondansetron used?

A

= reduce serotonin release (RT on bowel, surgery of bowel, chemo)

5HT3 antagonist; peripheral (vagal N) and central (CTZ) action

SE = constipation, headache

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12
Q

Give some examples of laxatives and how they work

A

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

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13
Q

How should breathlessness be treated?

A

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
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14
Q

What factors affect pain?

A

State of mind - anger, anxiety, depression, grieving, sleep, lack of understanding, acceptance, relaxation, relief of other symptoms

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15
Q

What is nociceptive pain and how does it feel?

A

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

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16
Q

What is neuropathic pain and how does it feel?

A

Malfunctioning nervous system, nerve structure is damaged

- Stabbing, shooting, burning, stinging, allodynia, numbness, hypersensitivity

17
Q

Outline the WHO analgesic ladder

A

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

18
Q

What is adjuvant pain relief?

A

= drugs whose primary indication is not for pain

  • Amitriptyline, duloxetine (antidepressant)
  • Gabapentin (anti-convulsant)
  • Dexamethasone
  • Bisphosphonates for bony pain
19
Q

What should be prescribed for neuropathic pain?

A

Amitriptyline (TCA), 10-25mg nocte

Gabapentin, 300mg, TDS over 3/7

Pregabalin 75mg BD

20
Q

What are the signs and symptoms of opioid toxicity?

A

Pinpoint pupils, hallucinations, drowsiness, N+V, confusion, myoclonic jerks, resp depression

Aetiology = dose escalated too quick, renal impairment

21
Q

How should codeine be prescribed?

A

Comes in 3 strengths = 8/15/30mg (max 240mg/24hrs) + 500mg paracetamol

Safe ratio = 10:1 (240mg codeine equates to 24mg of morphine)

22
Q

How should a controlled drug prescription be written?

A

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

23
Q

For palliation of shortness of breath with a significant anxiety component, what would be the best initial management?

A

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
24
Q

What medications can be prescribed for secretions at the end of life?

A

Glycopyrronium

Hyoscine hydrobromide

25
Q

What medications can be prescribed for agitation at the end of life?

A

Levomepromazine

Midazolam

26
Q

Which analgesic drugs are most appropriate to be used in renal failure?

A

Alfentanil

Fentanyl

Buprenorphine

27
Q

Outline performance status

A

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.

28
Q

What should be prescribed for bowel colic at the EoL?

A

Hyoscine butylbromide

29
Q

How should intractable hiccups be managed?

A

Chlorpromazine or haloperidol

4.1. Cancer Care (17 decks)

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