General Palliative Care Flashcards
what are the main groups of drugs used in palliative care?
analgesia anti-emetics sedatives (midazolam usually) anti-convulsants aperiants
what are some main goals of palliation?
symptom control for patient
avoid unnecessary intervention
maintain effective communication
ensure support for family/carers
What is the amount of analgesia required for breakthrough pain?
a sixth of 24 hr dose
what is the conversion ratio for morphine (oral) to subcut diamorphine?
3:1
so usually 30mg oral to 10mg parenteral
what is the WHO definition for palliative care?
Palliative care improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement.
what are some ways we can manage cancer pain?
- treat the cancer/shrink the tumour size (immunotherapy/chemotherapy/surgical excision/radiotherapy etc)
- psychological support
- Complementary therapies including acupuncture/massage/heat
- Modifications to the patient’s environment
- pharmacological therapies- analgesia
what are some causes of spinal cord compression in a patient with a hx of cancer?
extradural mets
intradural mets
vertebral collapse
where in the spine are we most likely to be suspicious for spinal cord compression due to bony mets?
thoracic area
what is another ddx for spinal cord compression symptoms?
ischaemic myelitis which is obstruction of the spinal arteries
what are some drugs we may consider in a palliative patient with spinal cord compression, which may help reduce their pain/discomfort?
IR opioids
+/- paracetamol
+/- anti-neuropathic agents
+ dexamethasone
what are some common causes of SVC obstruction?
SVC thrombosis from central lines
primary bronchial carcinomas/lymphomas in mediastinum
(so compression or thrombosis)
how might we manage a SVC obstruction in a palliative sense?
main goal= symptomatic management of dyspnoea and anxiety/distress.
e.g. IR opioid, elevating head, nasal O2 prongs, morphine SC/IV
additionally depending on patient, dexamethasone to reduce tumor mass if required, +/-radio/chemotherapy
+/- anti-coagulation if thrombotic cause
what are the key ways we can manage acute airways obstruction in a palliative setting?
- sit the patient upright
- give O2
- Suctioning away secretions
- morphine/midazolam for anxiety/distress
+/- dexamethasone to reduce tumour size
+/- adrenaline if oedema is a main feature
what are some causes of sudden haemorrhage in a palliated oncological patient?
tumour erosion into artery!
coagulopathies
thrombocytopenia
what are some causes of swallowing difficulty in a cancer palliative patient?
mucositis xerostomia oesophagitis candidiasis other types of oesophagitis obstruction (tumour/bowel obstruction)
what are some ways we can stimulate appetite and facilitate a palliative patient to eat?
appetite stimulants- steroids anti-emetics- metoclopramide/domperidone smaller meal portions referral to dietician for assistance liquidify/puree food if required
what type of aperient do we NOT use in palliative medicine? what aperients are most helpful in palliative medicine?
bulk forming aperiants not used bc can cause obstruction
peristalsic bowel stimulants and stool softeners more useful in palliative setting e.g. coloxyl and senna
what are some general ways we can manage constipation in a palliative setting?
- encourage routine toileting regimes
- ensure adequate hydration
- aperiants
- manual disimpaction if faecal impaction present
- remove any unnecessary constipating meds
- environmental modifications e.g. privacy/increased mobility aid to get to bathroom etc
what are some causes of dyspnoea in palliated patients?
anxiety/distress muscle weakness/cachexia electrolyte disturbance pain airway inflammation/obstruction hypoxia anaemia cardiac issues- heart failure/pericardial effusion delirium
how might we manage dyspnoea in a palliative setting?
- treat any easy reversible causes
- reassurance/relaxation techniques/environmental modifications/change in position
- morphine!
what is a common presentation of hypercalcemia associated with malignancy?
A patient can present initially with confusion or a more pronounced delirium, but nausea and vomiting, constipation, thirst, or polyuria, may also indicate hypercalcaemia, as can increasing pain.
how might we acutely manage hypercalcaemia associated with malignancy?
admission to hospital
fluid resuscitation!
bisphosphonate infusion
management of other symptoms if relevant such as delirium with anti-psychotics
+/- calcitonin infusion if severe hypercalcemia
last resort therapy- dialysis
as a doctor managing the palliative care of a patient, what are some key things you must address with the patient and family?
- Explain the concept of palliation and explain common misperceptions about it (e.g. it is still active care). Explain that death is a normal process of life.
- Explain the options available for palliative care e.g. community/hospice/hospital
- Develop goals of care with the patient and family. Consider cultural views, religious views
- If competent and relevant, organise an advanced care plan
- Talk about other legal issues including POA etc
- Provide ongoing emotional support for family/carers and patient, and throughout the grieving process
what drugs can we use to manage constipation in the palliative setting?
Soft faeces in rectum- propulsive agent like bisacodyl or senna
hard faeces in rectum- stool softener (docusate) and propulsive agent like bisacodyl +/- macrogol (movicol)
faecal impaction- rectal lubrication like glycerol suppositories and stool softener docusate. Can either manually disimpact under midazolam or use macrogol
refractive opioid induced constipation= methylnatrexone!! (Subcut)
prophylaxis constipation- coloxyl and senna
why might osmotic laxatives may not be the best option for constipation in pall care?
draws fluid into the bowel, which is not good for a patient who has poor fluid intake… however saying that we can still use theml if we deem they are required
if we suspect that constipation is causing intestinal obstruction, what type of aperiant might we suggest?
docusate or softening enemas only
how might we manage constipation in a patient with paraplegia?
encourage to try to defecate after meals; use a rectal propulsive suppository (bisacodyl) at that time
or try an enema like microlax after breakfast every 2nd day
what is the best antiemetic for chemotherapy/radiotherapy induced nausea?
ondanestron!
when might we NOT use metoclopramide for a palliative patient with nausea?
metoclopramide contraindicated in bowel obstruction so if you have a strong suspicion of BO do not use metoclopramide
what are some general causes for nausea in a palliative patient?
anxiety reduced gastric motility metabolic imbalances--> affect CTZ intracranial cause gastric reflux nausea from drugs/chemotherapy/other treatments
what are some alternative, less commonly used options for N+V in a palliative patients other than metoclopramide and stemitil?
you can try antipsychotics such as haloperidol/chlorpromazine/olanzapine, and dexamethasone
also think about adding a PPI or stopping NSAID for gastric reflux
why might fentanyl not be a good analgesic agent for a cachetic cancer patient?
Fentanyl usually is administered subcutaneously and is lipophillic, and if the patient is severely cachetic and does not have a lot of subcutaneous tissue it may not be effective
what are some factors you need to continually monitor in a palliated patient who is on opiate medication?
RR
O2 sats
Level of drowsiness/sedation
Bowels open?
N+V
previous opiate addiction/chronic use or opiate naive?
how many breakthrough doses were required?
Does the administration method need to be changed?
what is an important SE of ondanestron
constipation
describe the management of BO in palliative setting?
generally you have a higher threshold for surgery and try supportive measures first to rest the gut.
NBM
Fluid resuscitation +/- NGT (drip and suck)
Syringe driver- morphine, cyclazine, hyoscine butylbromide
+ dexamethasone
+/- ranitidine
+/- octreotide
what may indicate that a patient may have faecal impaction versus faecal loading
faecal loading is essentially a rectum full of faeces. It is the consequence of a chronic course of constipation.
faecal impaction is acute onset, and technically a bowel obstruction. You should look for signs for bowel obstruction such as tympanic bowel sounds etc
what is generally the dosing schedule for metoclopramide?
metoclopramide 10mg 3-4 times a day
can increase to 20mg QID (so usually max dose is 80mg)
what type of anti-emetic is good for colic pain and why?
cyclizine
reduces bowel peristalsic spasms; promotes GIT stasis
what are some causes of nausea and vomiting in palliative patients with advanced cancer?
gastric stasis biochemical disturbances raised ICP vestibular causes bowel obstruction psychological
often these are due to a combination of direct cancer effect, drug induced or comorbid organ failure and debility( e.g. cachexia/pain/constipation)
what are some IX you would do for a palliative patient with N+V
Bloods- rule out sepsis or infection, renal failure, hypercalcemia so FBE/MSU, UEC, CMP, eGFR
Imaging- may consider an AXR if suspect bowel obstruction/faecal loading
Describe some practice principles about prescribing anti-emetics in a palliative care patient for N+V
For straight forward cases of N+V:
Generally try a dopamine antagonist agent first; titrate to effect. Then if refractive, add on another anti-emetic that covers different mechanisms. Usually an empiric approach is justifiable.
If there are certain reasons for N+V such as bowel obstruction/chemotherapy/other medications, manage these and choose targeted anti-emetics (e.g. avoid metoclopramide in BO etc)
for older patients, what do you need to think about before prescribing metoclopramide for their N+V?
their renal function; if impaired may need to dose reduce accordingly
monitor for EPSE
comorbid conditions such as PD, ESRF etc
when should prochlorperazine be avoided to treat N+V?
if the patient is neutropenic
how might we confirm a death?
- Go get and look at the patient’s notes
- Explain to the family members (if present) the need to confirm a death + condolences
- Go to patient and see if responsive. Take the hand and say ‘can you hear me?’ and squeeze. Can squeeze the trapezius muscle/inner part of the elbow.
- Look for chest rise and fall.
- Palpate the carotid pulse
- Listen to the heart for 2 minutes.
- Listen for breathing sounds for 2 minutes
- Check pupillary reflex (should be dilated and unresponsive)
- Write examination findings into the patient note and the time.
- complete death certificate or call the coroners if relevant.
- Contact the NOK.
what are some signs a patient is approaching death?
peripheral shutdown and cyanosis
changes in respiratory pattern inc cheyne stokes
fluctuations in consciousness
retained upper airway secretions
what are some palliative things we will consider as a doctor if we know a patient is dying?
If not already- transfer to appropriate palliative accomodation, whether as an inpatient or in the community with palliative care nurses/service
- Medication review- remove any unnecessary drugs, symptom control drugs
- Change meds from oral to SC
- Prepare subcut syringe driver
- Family meeting
- Liaise with GP
- Spiritual support if required
- Support for the family
- Do not resuscitate in progress notes
which analgesics can be used in a palliated patient with ESRF?
paracetamol
fentanyl
methadone
bupremorphone
dose reduced oxycodone, hydromorphone
what is a syringe driver?
A syringe driver is a battery-driven portable device that allows a 24-hour infusion of compatible medications to be infused evenly via a subcutaneous butterfly needle.
