Module 4.4 (Palliative Care) Flashcards
Definition of Palliative Care
“Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Essenital elements of palliative care?
Affirms life and views dying as a natural/normal process of life
Neither hastens nor postpones death
Uses a team approach to address the
> psychological
> social
> spiritual
aspects of patient care
- Provides relief from distressing symptoms
- Offers support to help patients live as actively as possible until death
- Uses a team approach to support the patient & family during illness, death & bereavement
Who are the people included when considering palliative care?
People with a progressing life-limiting or life-threatening illness
Will include people with:
– metastatic cancer
– HIV/AIDS
– end-stage organ disease
– progressive degenerative neurological conditions
– older people dying as a consequence of the ageing process
>not dependent on medical diagnosis –> determined by a person’s needs
What can someone with palliative care “also have”?
People with a progressing life-limiting or life-threatening illness
Who also have:
- increasing disability
- frequent hospitalisation
- and/or decreasing benefit from therapies
>includes people of all ages from perinatal to the very elederly
Wha are some patterns of functional decline?
Sudden death
Malginant disease
Organ failure
Frailty
What does continuum of care encompass?
What is a palliative care approach?
Priumary health care –> primary care needs
> effectively meets their needs
Intermediate needs
>exacerbation of symptoms
>access to a specialist pallaitve care for advice
Complex needs
>requires more attention than primary caregivers can provide
>referral to specialist
What is specialist pallaitive care?
- symptoms that require specialist assessment/management … beyond capacity of the primary care team to manage optimally
- patient and/or their family has psychological, social or spiritual needs that require specialist assessment
- patient is dying and the primary care team requires additional support and/or advice
How to access specialist care?
Home
- Silver Chain Hospice Care Service
Residential Care Facility
- Metro Ambulatory Palliative Care Service
Hospital
- Consultancy Services
- FSH, KEMH, PMH, RHCS, RPH, SCGH, SJoG
Palliative Care Units/Hospices
- Bathesda, Glengary, Hollywood, Kalamunda, Murdoch
How to communicate to palliative care patients?
Important to:
Be respectful of the situation
Develop rapport and trust
Reduce stress and anxiety
Convey important information
Be comfortable talking about:
– decision making & care planning care for deteriorating health
– dying
Allow time
What are some thical considerations for palliative care?
- Most concerns centre around cause of death
- Hydration and feeding
- Cardiopulmonary resuscitation
- Requests for assistance to die
- Family concerned that medications causing deterioration
What does advance care planning mean?
Failure to talk about and plan for death is one of the msot significant obstacles to imprvoing the quality of dying
To meet our desire for better deaths
- be informed about the limits of health care
- importance of discussing our preferences for end-of-life care
- the development and implementation of Advanced Health Directives
What are the common physical symptoms in palliative care?
Fatigue
Pain
Dyspnoea
Nausea and vomiting
Constipation
Anorexia
What are the common psychological symptoms?
Emotional Distress
Anxiety
Depression
Confusion
What should be asssessed before treating the previous symptoms?
Evaluation of
- Contributing factors
- Characteristics of the symptoms (intensity, location, quality, temporal nature, frequency, and associated pattern of disability)
- The meaning of the symptom to the person (including beliefs about the symptom and the effect on the person’s physical, psychological, and social well-being)
- Actions that the person is taking to manage or cope with the symptom
Effective symptom management typically requires?
> 3 types of approach
An integrated approach
- multidimensional assessment and management
Target approach
- directed at specific casual pmechanisms and factors contributuing to the problem
Tailored approach
- suitable for individual circumstanses, beliefs and preferences
How is multimodal analgesia achieved in patients with palliative care needs? What are the medications used?
Multimodal analgesia = combined use of different classes of analgesics
Improve the effectiveness of pain relief
Reduction of dose of each analgesic medication and therefore intensity of any side effects
>anticonvulsants
>TCA
>distraction, relaxation, surgery, opioids, ketamine, massage, TENS, NSAIDS, corticosteroids, paracetamol
What are the general principles of pain relief?
By mouth
By the clock –> at fixed intervals
By the ladder
For the individual –> there are no standard doses of opioids
With attention to detail –> monitoring of effect and adverse effects
Wha is thhe WHO analgesic ladder?
Step 1 = non-opioids +/- adjuvants
Step 2 = weak opioids + non opioids +/- adjuvants
Step 3 = strong opioids + non-opioids +/- adjuvants
Properties of opioids in palliative care?
Mainstay of analgesia in advanced illness
NOT saved as a last resort or when a person is near to death
No opioid is superior
Choice is based on individual patient factors
Low risk of the person becoming addicted when used in appropriate doses
How to initiate opioids?
Start low and go slow
- Consideration of specific patient factors
Start with imediate rlease, short acting opioids
- Allows more flexiblity in titration
- Results in faster tiration
Give on a regular basis, not prn
- Maintenance of plasma levels
- Waiting for pain to occur may exacerbate pain
Change to extended release for background
- Ensure breaktthrough or rescue available
What are examples of opioids available?
Buprenorphine
Codeine
Fentanyl
Hydromorphone
Methadone
Morphine
Oxycodone
Tapentadol
Tramadol
What are the preferred opioids in palliative care?
Morphine and oxycodone
- Familiarity, cost and availability
- Wide range of oral formulations
- Similar adverse effect profile
Different metabolism
- glucoronidation vs CYP3A4 (morphine) and CYP2D6 (oxycodone)
- nmorphine metaboilite potent
- accumulation in renal dysfunction
What are the other commonly prescirbed opiuoids?
Fentatnyl
- patch and sublingual/buccal
- if oral route not available or preferred
- preferred in renal dysfunction
Hydromorphone
- Potent
- Oral and injectable formulations
Methadone
- Specialist use only
- Potent and complicated kinetics
General principles of management of nausea and vomiting?
Assess likely cause •
Treat any reversible causes •
Use non-pharmacological measures such as:
- avoidance of foods with strong tastes and smells
- small and frequent meals – distraction techniques
Prescribe an anti-emetic depending on the aetiology
Review if necessary and make adjustments such as:
- Up titration of dose –
- Changing the route of administration –
- Adding a second anti-emetic
What are the common causes of nausea and vomiting in palliative care?
Gastric stasis
Medications
Intestinal obstruction
Raised intraocular pressure
Biochemical
Other
What is the mechanism for nausea and vomitting?
What are the neurotransmitters reponsible for nausea and vomitting? And what are the subsequent medications used to treat it?
Chemoreceptor trigger zone
- NT: dopamine, serotonin
- Medications: metoclopramide, haloperidol, prochlorperazine
Cortical
- NT: GABA and serotonin
- Medications: dexamethasone and BZDs
Vestibular
- NT: histamine1, acetylcholine muscarinic
- Medications: promethazine, prochlorperazine and cyclizine
Gastrointestinal
- NT: dopamine, serotonin, acetylcholine muscarinic
- Medications: metoclopramide, hyoscine, ondansetron
Vomiting centre
- NT: acetylcholine muscarinic, histamine, serotonin
- Medications: promethazine, cyclizine, hyoscine
What are the first line antiemetics for palliative care patients?
>prokinetic (gastric stasis)
>chemoreceptor trigger zone (drugs, biochemical)
>vomiting centre (raised intracranial pressure, motion sickness)
Prokinetic (gastric stasis)
- metoclopramide 10mg tds
Chemoreceptor trigger zone (drugs, biochemical)
- haloperidol 0.5-2.5mg bd
Vomiting centre
- raised intracranial pressure, motion sickness
- promethazine 10-25mg bd
- cyclizine 25-50mg tds
How to mange dyspnoea?
- distressing for patient and family
- 70% cancer patients in last 6 weeks
- cardiac disease, lung disease, renal disease
- prevalence and severity increases closer to death
- subjective and does not correlate to objective measures
dyspnoea: difficult or laboured breathing
How to manage dyspnoea (non-pharm pls)?
Treat any reversible casues
Non-pharmacological mangement
- reassurance
- positioning
- calm environment –> help with anxiety
- windows open or fans blowing in face
How to manage dyspnoea (pharm pls)?
Morphine is drug of choice for dyspnoea
- oral or subcutaneous (not nebulised)
- relieves sensation of dyspnoea
- no detrimental effect on respiratory function
- small doses usually effective
>1-2mg prn orally of morphine
- dyspnoea is more severe in patients with unrelieved pain
What are some other medications that may be used for dyspnoea?
Dyspnoea associated with anxiety
Adding BZD to morphine beneficial effect
>lorazepam 0.5-1mg sublingual bd prn
> midazolam 5-10mg/day via subcut infusion
What are the reasons for constipation? What to do and what to avoid?
Very common symptom
>multiple reasons for constipation
- decreased diet, fluids
- disease state
- medications
general good bowel hygiene
- if possible fluids, exercise, dietary fibre
avoid osmotic or fibre products
- if only eating and drinking minimum amounts
What medications are used for constipation?
Stimulants with a softener
- Coloxyl and Senna® 2 nocte – 3 bd
- Coloxyl® 120mg 1-2 bd PLUS Bisalax® 10-20mg nocte OR Senokot® 4-6 nocte
Macrogol
- e.g. Movicol®
- isosmotic 1-6 sachets per day
Methylnaltrexone
- peripheral opioid receptor antagonist
- Indicated for opioid induced constipation
What is terminal restlessness? What is the main cause? e
Delirium particular to the last days of life
- Confusion, agitation, hallucinations
Incidence nearly 90%
Often multifactorial in palliative care patients
- Main cause is often primary irreversible disease (s)
- Other causes:
> decreasing renal and hepatic function, medications, hypoxia, dehydration, hypoglycaemia, infection or drug withdrawal
Non-pharmacological management of terminal restlessness?
Less able to reverse causes
Aim to reduce harm to patient or family
Simple non-pharmacological management
- Regular reorientation and reassurance
- Familiar surrounds and carers, reduce distressing stimulation
- Pain assessment and management
- Correct dehydration, constipation and urinary retention
- Oxygenation may be appropriate if hypoxia
- Avoid physical restrain
Pharmacological management of terminal restlesness? What to add if sedation required?
Management: •
- haloperidol 0.5–1 mg subcut prn •
- haloperidol 2.5-5 mg/day subcut infusion
If sedation required ADD:
- clonazepam 0.2 mg subling prn –
- clonazepam 0.5-1 mg/day subcut infusion –
- midazolam 1 mg subcut prn –
- midazolam 5-10mg /day subcut infusion
what are the factors to consider when elderly take medications?
generally taking many medications
number of medications increases as health deteoriates
- more for symptom management
- secondary prevention medications continued
- increased number high risk medications
- anticholinergic load increased
What is the criteria for assessing medications in terms of deprescribing?
- Beers
- Medication Appropriateness Index
- Drug Burden Index
- Anticholinergic Risk Scale
- STOPP
What are medication considerations?
Life epectancy
Goals of care
Time until benefit
Effects of continuing therapy –> risk-benefit ratio
Short term benefit (anything not going to work in weeks/months = uselss)
>survival
>quality of life
>symptom management
What is the checklist of a newly diagnosed diabetic?
- Cease smoking
- Decrease weight
- Increase exercise
- Control BP
- Treat dyslipidaemia
- Antiplatelet
- Blood glucose control
Aim to decrease complications
>macrovascular (CVD, stroke)
>microvascular (neuropathy, nephropathy, retinopathy)
What are the advantages of using SC infusions (syringe drivers)
- portable
- less infection risk than IV
- reliable absorption
- filled on daily bassis
- increased patient comfort
- can be used easily at home
What are the indications of SC infusions?
Unable to take oral medicatiosn because:
- nausea and vomiting
- dysphagia
- severe weakness or unconscious
- poor oral absorption due to dsease process
What are SC injection sites?
Scapular region
Anterior chest wall
Anterior aspect of thighs
Anterior aspect of upper arms
Anterior abdominal wall
What are some medications infused subcutaneously?
Common medications
- Analgesics
> morphine, hydromorphone
- Antiemetics
> metoclopramide, haloperidol, promethazine
- Sedatives
> clonazepam, midazolam
- Others
> hyoscine butylbromide, glycopyrronium (glycopyrrolate)
