ONCOLOGY - EoL CARE (CPR + ANTICIPATORY DRUGS)

Question 1

What are the 3 classes of analgesia?

Answer 1

Non-opioid
Opioids
Adjuvants

Question 2

What are examples of weak opioids?

Answer 2

Codeine
Dihydrocodeiene
Tramadol

Question 3

What are examples of strong opioids?

Answer 3

Morphine
Diamorphine
Oxycodone
Fentanyl
Alfentanil
Hydro morphine
Buprenorphine
Methadone

Question 4

What are the side efefcts of opioids?

Answer 4

Constipation (very common so always prescribe a laxative)
Nausea and vomiting (always prescribe a p.r.n. Antiemetic)
Drowsiness
Confusion
Hallucinations and delirium
Respiratory depression

Question 5

What are the symptoms you need anticipatory drugs for at end of life?

Answer 5

Pain
Respiratory secretions
Restlessness and agitation
Delirium
Dyspnoea
Emesis

Question 6

What is anticipatory prescribing?

Answer 6

Medication prescribed in anticipation of symptoms, designed to enable rapid relief at whatever time the patient develops distressing symptoms.

Question 7

Outline the management of pain at end of life for a patient not currently taking any medication for pain?

Answer 7

Start by giving paracetamol or NSAIDs regularly for mild pain
If not sufficient then opioids alone or in combination with non-opioid analgesic for moderate pain

If refractory…
Prescribe diamorphine s/c injection in intimidation
If 2-3 PRN doses are required then commence a syringe driver whilst also maintaining injections for breakthrough pain
Review and reassess pain every 24 hours as a minimum

Question 8

Outline the management of pain at end of life for a patient taking oral morphine?

Answer 8

Convert oral morphine dose to diamophrine s/c (divide 24 hours dose of morphine by 3)
Also prescribe prn diamophine s/c injections for breakthrough pain (1/6th of dose in driver)
Review and reassess pain every 24 hours as a minimum

Question 9

Outline the management of pain at end of life for a patient on fentanyl?

Answer 9

Maintain fentanyl patch at existing dose and prescribe diamophine s/c prn in anticipation of breakthrough pain (divide strength of fentanyl patch by 5)
If 2-3 prn doses are required in 24 hours then commence diamophine s/c via a syringe driver
Review and reassess pain every 24 hours at minimum

Question 10

What should you do for a patient in pain at the end of life?

Answer 10

Undertake a pain assessment
- is this new pain?
- does the pain fit with a known pathology?
- look for underlying causes and reverse if possible
- review current analgesia (efficacy and side efefcts)

Question 11

How much more potent is fentanyl than morphine?

Answer 11

150 times

Question 12

Why do we treat respiratory tract secretions at end of life?

Answer 12

They cause the death rattle which can be extremely disturbing for the family

Question 13

How do we manage a patient who does not yet have increased respiratory secretions/death rattle?

Answer 13

Prescribe in anticipation glycopyrronium or hyoscine butylbromide (antimuscarinics)

Question 14

How should you manage a patient with increased mucus secretions?

Answer 14

Try turning the patient first and explain to the family that the patient may not be distressed by the secretions as they are semi-conscious
Immediately administer glycopyrronium or hyoscine butylbromide and continue to administer s/c PRN doses

Question 15

How can you manage restlessness and agitation?

Answer 15

First look for a cause and reverse if possible

Prescribe midazolam in anticipation if not yet started

If present then administer midazolam
Second line is levomepromazine (more sedation effect)

Question 16

How do we manage delirium?

Answer 16

Look for cause and reverse if possible
Nurse in a quiet, well lit room with family presence/ avoid precipitating factors such as changing environment

Prescribe haloperidol
(2nd line haloperidol and midazolam)
If ineffective then reassess cause and seek advice for palliative care team
3rd line consider levopromazine instead of haloperidol

Question 17

How do you manage dyspnoea at EoL care?

Answer 17

Regular oral morphine

Question 18

How do you manage nausea and vomiting at EoL?

Answer 18

Dependant on underlying cause

Haloperidol - for chemical/metabolic causes
Metoclopramide hydrochloride - for gastric stasis, gastritis and functional bowel obstruction
Hyoscine butylbromide - bowel obstruction with colic
Glycopyrronium - bowel obstruction with colic
Cyclizine - for raised ICP or complete bowel obstruction with colic, motion sickness
Levomepromazine - where cause cannot be ascertained and other anti-emetic drugs are ineffective

Question 19

How can capillary bleeding at EoL be treated?

Answer 19

Tranexamic acid by mouth
Vitamin K if associated with prolonged clotting in liver disease (give parenteral if chronic cholestasis as it prevent absorption)

Question 20

How should constipation be managed at EoL?

Answer 20

Decal softener with a peristaltic stimulant e.g. co-danthramer
Or lactulose solution with a senna preparation

If its opioid induced then use methylnaltrexone bromide

Question 21

How can you temporarily help with Dysphagia at EoL?

Answer 21

Dexamthasone

Question 22

How can you reduce hiccups at EoL?

Answer 22

Antacid with antiflatulent
If this fails then metoclopramide hydrochloride can be used

Question 23

What is advanced care planning?

Answer 23

Advance care planning offers people the opportunity to plan their future care and support, including medical treatment, while they have the capacity to do so.

Not everyone will want to make an advance care plan, but it may be especially relevant for:
- People at risk of losing mental capacity - for example, through progressive illness.
- People whose mental capacity varies at different times - for example, through mental illness.

Question 24

Why is advanced care planning important?

Answer 24

Promotes patient centred care
Patients recieve care consistent with their preferences
Raises likelihood that healthcare providers and families understand and comply with a patient’s preferences for medical care when the patient lacks capacity
Increases probability that patients die in their preferred place
Reduces delusional burden of families
Improves bereavement experiences of families
Enhances family’s satisfaction with end-of-life care and understanding of what to expect
Positively impacts QOL and EoL care - prevents unwanted hospitalisations and increases utilisation of palliative and hospice services
Decreases in hospital deaths
Reduces the cost of EoL care

Question 25

What is the AMBER care bundle?

Answer 25

The AMBER care bundle provides a systematic approach to managing the care of hospital patients who are facing an uncertain recovery and who are at risk of dying in the next 1–2 months—but who are not clearly in the last few days of life—and for whom active medical management may still be appropriate. It is an intervention that can fit within any care pathway or diagnostic group for patients whose recovery is uncertain

Question 26

What is GSF?

Answer 26

Gold standards framework - GSF is a practical systematic, evidence-based end of life care service improvement programme, identifying the right people, promoting the right care, in the right place, at the right time, every time
Enables people to live well until they day

Question 27

What is a lasting power of attorney?

Answer 27

This involves giving one or more people legal authority to make decisions about health and welfare, and property and finances.

Question 28

What is SPICT?

Answer 28

Supportive & palliative care indicators tool
It helps identify people with deteriorating health (dying within 12 months) due to advanced conditions or serious illness, and prompts holistic assessment and future care planning

Question 29

What are the discharge rates after in-hospital arrest?

Answer 29

Less than 15%

Question 30

What is ReSPECT?

Answer 30

Recommended Summary Plan for Emergency Care and Treatment
A summary of personalised recommendations for a persons clinical care in a future emergency in which they do not have capacity to make or express choices

Question 31

What is a DNACPR?

Answer 31

Do not attempt cardiopulmonary resuscitation
A decision made by you and a healthcare team that says if your heart stops no attempt will be made to restart it

Question 32

What is an advanced decision to refuse treatment?

Answer 32

a written statement of your wishes to refuse a particular treatment in a specific situation. It is a way of making sure that everyone knows what treatment you don’t want to have if you’re unable to make your own decisions in the future.

Question 33

What happens if you are unable to make or discuss a DNACPR decision in advance of your heart stopping?

Answer 33

Check for an advanced decision to refuse treatment
Check for a lasting power of attorney to make decisions
If neither than its a best interests decision made by the senior doctor - they must ask the people who are important to you about your wishes and preference

Question 34

Is a DNACPR legally binding?

Answer 34

No
If you want to make it legally binding then you should write an advanced decision to refuse treatment

Question 35

What are the conditions for a valid advanced refusal of treatment?

Answer 35

The advance refusal is made by a competent adult (18 and over).
It is entered into voluntarily - the individual was not coerced into making the statement.
The individual is sufficiently informed about the medical prognosis if the advance refusal is respected.
It is applicable to the circumstances that arise.