pal care Flashcards
acute pain- discuss morphine dosages, good starting points, how to increace
morphine sulphate- 1st line strong opiate for those with normal renal function
20-30mg for opioid naiive patients.
4 hour duration
good for cancer patinets.
good starting dose- 20-30mg modified release (12 hour) + 5mg breakthrough
breakthrough should be 1/6th daily dose. - can be given 3x daily.
when increacing, inc by 30-50%
what to use for pain in renal impairment.
how to convert ratios from morphine to other drugs
cant use morphine is less than 50gfr.
oxycodone- for mild- less sedation more itch, more constipation.
oxycodone is 2x power of morphine
tramadol is 10x LESS power morphine
codeine is 10x LESS
so someone on 240mg codeine—> 24mg morph.
what is an advance care plan
contains information about a person that should they become too unwell to communicate their needs and preferences have been set out
e.g place of death/ care
spiritual/ dietary needs
not legally binding, and there is no formal process set out in legistature for this.
what to give for anxiety at the end of life
benzoz- short acting. less worried about the addictive and withdrawal effects.
how to treat constipation in palliative care
give a stimulant e.g senna– if constipated start at 15mg BD, inc to up to 30mg TDS.
give a softening e.g doccusate or lactulose
add macrogol if not sufficient
titrate dose of laxitive with dose of opioid pain relief if having it.
breathlessness in pal care
keep room cool, use a fan (reflex)
pacing/ adapting strategies.
strong opioid- immediate release morph.
benzo for the short term- espesh if related to anxiety.
consider oxygen therapy but only if they are hypoxis (92% on air)
treating cough in palliative care
himidify room, tey simple linctus BP
weak opioid- pholcodine linctus 10ml 3-4x daily.
morphine prn (4hrly) 1-2.5mg unless treating for pain.
seek specialist advice if considering steds.
if cough is moist- nebs- qds 2.5-5ml
carbocisteine- to reduce viscosity.
managing secretions in palliative care
positioning to try and reduce effects
suction if needed
drug treatment if these have not worked.
1st line- glyopyrronium bromide, or hyoscine (2 different types onea a bromine)
if stilll noisy at 12 hours then stop as unlikely to make effect
management of depression in palliative care
generally more aggrressive antidepressant use than normal
in assessment rely more on subjective symptoms rather than wt loss, fatigue etc as they are already going to be feeling those.
trial breif cbt or self help, but even if mild and persisting
give antidepressant.
in mod depression- give
any of these will do
Mirtazapine - 15-45 mg day
Sertraline 50mg (up to 200)
Citalopram 20-40mg day (max 60)
what medications to consider prescribing in anticiaption of death in EOL care
usually done subcut + PRN
pain- morphine
nausea + vom: haloperidol- 0.5-1.5mg Sc
agitation- benzoz- midaz- 2.5-5mg SC
secretions- hyoscine butylbromide 20mg SC
consider doing these with syringe drivers.
management of nausea and vomiting in palliative care
Simple measures:
Ensuring access to a large bowl, tissues, and water.
Eating snacks consisting of a few mouthfuls rather than large meals.
Drinking cool fizzy drinks rather than still or hot drinks.
Relaxation techniques.
Parenteral hydration, if appropriate.
Cognitive behavioural therapy (for anticipatory nausea or vomiting).
If intracranial cause/ vestibular/ bowel obstruction: cyclizine 25-50mg 8hrly.
gastric/ peristaltic stasis: metoclopramide 10-20 every 8 hrs.
if unknown cause: levomepromazine 2.5-5mg subcut 12hrly.
or metoclopramide
or cyclizine
or haloperidol
chop/ add as needed.
in EOL levomepromazine 6.25 mg once daily by subcutaneous injection. Repeat the dose after 1 hour if needed.
management of agitation and terminal agitation in palliative care
- Haloperidol first line- if not dying
- Chlorpromazine second line - if not dying
- Midazolam used in terminal treatments- if dying soon
- Rapid sedation e.g. in aggressively delirious patients at end of life, use phenobarbitone** must be discussed at MDT meeting after use as once used, patients will be heavily sedated for the remainder of their lives.
an allosteric binding drug that modulates GABA receptors and keeps their chloride channels open longer, hyperpolarising and dampening neurone response. Used to treat epilepsy too.
