ILA 7 - Dying patient Flashcards
5 key symptoms to pre-emptively prescribe for
- and the medications/doses to prescribe
- Pain - morphine 1.25 - 2.5 mg SC / 2.5 - 5.0 mg PO
- Dyspnoea - “ “
- Respiratory secretions - Buscopan 20 mg SC PRN
- Nausea - Haloperidol
- Agitation - Midazolam
End of life signs.
- Signs: Cheyne-Stokes, noisy secretions
- Agitation, deteriorating GCS
- Progressive weight loss and loss of appetite, fatigue
Types of pain
- Neuropathic
- Soft tissue
- Visceral
- Bone pain
Analgesia
a) Core treatment
b) Adjuvant drugs
c) Adjuvant interventions
d) Methods of delivery
a) Non-opioids, weak opioids, strong opioids
b) Neuropathic drugs
c) Physio, chemoradiotherapy, surgery, nerve blocks, TENS
d) Oral, SC, transdermal, IM, IV, spinal, rectal, nerve blocks
Breakthrough pain relief.
a) How to calculate
b) Also give 30 minutes before…?
a) The standard dose of a strong opioid for breakthrough pain is usually one-tenth to one-sixth of the regular 24-hour dose, repeated every 2–4 hours as required (up to hourly may be needed if pain is severe or in the last days of life).
b) Activity that will be painful (eg wound dressing)
Opioid switching: steps 1 - 5
- Determine clinical necessity
- Choose medication to switch to (and direct or cross-tapering switch)
- Calculate equianalgesic dose (select dose 20% lower than before generally, and titrate up)
- Agree switch with patient and discuss side effects and withdrawal symptoms
- Review within 2 weeks
Opioid switching: drug choice
a) 1st line
b) 2nd line
c) 3rd line
a) Morphine
b) Oxycodone
c) Fentanyl/buprenorphine patches
Syringe drivers.
a) Indication
b) When to switch from morphine to diamorphine
a) Swallowing difficulties, reduced consciousness, agitation, bowel obstruction/malabsorption
b) When volumes of morphine solution getting too high (diamorphine needs less fluid)
Nausea and vomiting: simple measures
- Access to a bowl, tissues and water
- Avoid triggers (certain foods and drinks)
- Consider parenteral nutrition
- Consider complementary therapies/CBT
Nausea and vomiting: causes
- Drug induced (e.g. opioids)
- Metabolic
- Intracranial
- Gastric irritation
- Vestibular
Drug-induced nausea: management
- take with food/ take small doses
- stop if not necessary
- Treatment: haloperidol (centrally-acting)
Metabolic causes: treatment
Haloperidol
Intracranial-related nausea (e.g. brain mets)
- Cyclizine
- Dex 8-16mg
Vestibular-related nausea
Cyclizine
Intestinal-related nausea
a) Non-colicky pain
b) Colicky pain
a) Metoclopramide (prokinetic antiemetic)
b) Treat constipation, treat nausea with cyclizine, treat colic with hyoscine
