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
Anxiety related nausea
Manage anxiety
Benzodiazepine
Chemotherapy-related
a) Early-onset
b) Delayed-onset
a) Ondansetron
b) Metoclopramide
Opioid-related sickness
- Consider switching opioid
- Haloperidol
Advanced care planning
- ADRT
- Where and how you want to be looked after
- Any spiritual needs
- Place of death
- Power of attorney
- Will writing
ADRT
a) examples
b) legality
c) what can’t be refused
d) vs. advance statements
a) - Refusing CPR
- Refusing ventilation
- Refusing feeding tubes
b) Written, signed, witnessed, specific, including statement such as ‘I refuse this treatment even if my life is at risk as a result’
c) Basic care - warm, clean, food and drink
d) Not legally binding, a statement of wishes to guide best interests decisions
DS1500 form
a) What is it?
b) What must be included?
a) A form that allows expediency of benefits with automatic highest level of payment given without assessment - issued to patients whose illness is deemed to be terminal .
b) Diagnosis, proposed treatment, clinical findings, discussion with patient
Power of attorney.
a) Types and powers
b) What to do if capacity is lost?
a) Financial and healthcare. Can make decisions on behalf of person once they have lost capacity
b) Apply to court of protection - to be court-appointed guardian
Death certificates
a) Cause of death
b) Crem forms
a)
b)
