ONCOLOGY - EoL CARE (CPR + ANTICIPATORY DRUGS) Flashcards
What are the 3 classes of analgesia?
Non-opioid
Opioids
Adjuvants
What are examples of weak opioids?
Codeine
Dihydrocodeiene
Tramadol
What are examples of strong opioids?
Morphine
Diamorphine
Oxycodone
Fentanyl
Alfentanil
Hydro morphine
Buprenorphine
Methadone
What are the side efefcts of opioids?
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
What are the symptoms you need anticipatory drugs for at end of life?
Pain
Respiratory secretions
Restlessness and agitation
Delirium
Dyspnoea
Emesis
What is anticipatory prescribing?
Medication prescribed in anticipation of symptoms, designed to enable rapid relief at whatever time the patient develops distressing symptoms.
Outline the management of pain at end of life for a patient not currently taking any medication for pain?
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
Outline the management of pain at end of life for a patient taking oral morphine?
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
Outline the management of pain at end of life for a patient on fentanyl?
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
What should you do for a patient in pain at the end of life?
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)
How much more potent is fentanyl than morphine?
150 times
Why do we treat respiratory tract secretions at end of life?
They cause the death rattle which can be extremely disturbing for the family
How do we manage a patient who does not yet have increased respiratory secretions/death rattle?
Prescribe in anticipation glycopyrronium or hyoscine butylbromide (antimuscarinics)
How should you manage a patient with increased mucus secretions?
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
How can you manage restlessness and agitation?
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)
How do we manage delirium?
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
How do you manage dyspnoea at EoL care?
Regular oral morphine
How do you manage nausea and vomiting at EoL?
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
How can capillary bleeding at EoL be treated?
Tranexamic acid by mouth
Vitamin K if associated with prolonged clotting in liver disease (give parenteral if chronic cholestasis as it prevent absorption)
How should constipation be managed at EoL?
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
How can you temporarily help with Dysphagia at EoL?
Dexamthasone
How can you reduce hiccups at EoL?
Antacid with antiflatulent
If this fails then metoclopramide hydrochloride can be used
What is advanced care planning?
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.
Why is advanced care planning important?
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
