pallative care Flashcards
how do you identify the dying phase?
The patient may be dying if two or more apply:
* Bed bound and/or has profound weakness
* Reducing level of consciousness
* Taking only sips of fluid
* Unable or having difficulty taking oral medication
* Deteriorating day by day
how do you review a pallative patients regular medication?
Non-essential drugs should be discontinued
Essential regular oral drugs (analgesics, anti-emetics, anticonvulsants,
steroids) should be converted to alternative route if possible, usually SC, either
as stat dose or via a continuous subcutaneous infusion (CSCI) i.e. a syringe
driver
PRN medication should be prescribed for any anticipated symptoms, to be
administered subcutaneously
what is anticipatory medication at the end of life?
PRN subcutaneous medication should be prescribed (proactively) for:
* pain
* agitation / restlessness
* respiratory tract secretions
* nausea / vomiting
* breathlessness
if a patient isnt on regular analgesia and pain free what should be prescribed for pain?
PRN subcutaneous analgesia should be prescribed: Morphine injection 2.5mg – 5 mg PRN up to hourly SC
what should the patient be prescribed for pain if not on any regular analgesia and in pain?
Morphine injection 2.5mg STAT SC
if patient is feeling the effect of stat dose of morphine whilst in pain and no other analgesia prescribed what should be done?
Morphine injection 10mg SC over 24 hours via CSCI andPRN morphine as above
when converting oral morphine to sc what do you have to remeber?
to include the break through doses in the total daily dosage and to divide answer by two
what can drugs be mixed with in the syringe driver?
- Mix with water for injection or 0.9% sodium chloride
how many drugs are usually mixed in a syringe driver?
usually 2, sometimes 3
what happens if there is too many drugs/ incompatible?
may use more than 1 syringe driver
what must you consider about the drugs when using syringe driver?
- Consider prescribing longer acting drugs separately as stat SC doses
eg levomepromazine, haloperidol
what should you prescribe if syringe driver irritating to skin?
consider adding dexamethasone
can oxycodone be used in patients with renal impairment?
with caution
who is alfentanil mostly used in and why?
- Not excreted renally therefore used in CSCI to manage opioid sensitive pain
in patients with severe renal impairment
why is aldentanil not practical for community use?
Very short half life (1-2 hours) therefore not practical to use as PRN dose in
community - low dose oxycodone injection used instead
what is allodynia?
Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin
what is hyperalgesia?
An increased response to a stimulus which is normally painful
what is the strategy for the management of neuropathic pain?
- Avoid escalating opioid doses when pain appears refractory and poorly opioid sensitive
- Higher risk of opioid toxicity
- Consider the use of adjuvant analgesics
how does the neuropathic pain ladder go?
steroid, antidepressant, anticonvulsant, NMDA antagonist, spinal anlagesia
what are some causes of nausea and vomiting?
- Drugs opioids,
chemotherapy, digoxin etc. - Radiotherapy especially
gut area - Biochemical
hypercalcaemia, uraemia,
sepsis - Liver failure
- Gastric stasis
- Bowel obstruction
- Constipation
- Raised intracranial pressure
- Brain tumour/metastases
- Squashed stomach
- Anxiety, fear, conditioned,
anticipatory
what should be done if patient needs antiemetic but already prescribed on?
his should be converted to subcutaneous route and given via a syringe driver
Note: domperidone cannot be given by injection, therefore convert to alternative prokinetic e.g. metoclopramide
what should be given if metabolic, infective or drug induced cause is likely nausea and vom?
Haloperidol injection
0.5-1.5mg SC hourly PRN (max 3mg SC in 24hours)
what do you give for n/v caused by bowel distension/ obstruction, vestibular problems, raused ic pressure?
cyclizine SC 50mg hourly
who should not be prescrived cyclizine and why?
patients in severe hf or renal failure- tachycardia
alt- haloperidol or levomepromazine
what is gastric stasis? what may cause it?
- Gastric stasis – large volume vomits; hiccups; belching. Unlikely to startin
dying phase - Check for over-feeding first
- if PEG fed, reduce or stop feed and stop IV/SC fluids when dying
- if family feeding patient, suggest reduce intake or stop
what should be given if patients do not respond to antiemetic?
a combination of antiemetics should be considered or a broader spectrum
antiemetic, such as Levomepromazine injection
why may nausea and vomiting failed to be controlled?
Wrong Drug
Wrong Dose
Wrong route of administration
Plumbing problem
what is agitation?
Restlessness:
Finding no rest, uneasy, agitated
Constantly in motion and fidgeting
Agitation:
Shaking, moving, unsettled can be both mental and/or physical
Terminal agitation means agitation that occurs in the last few days of life
Delirium:
Disordered state of mind with incoherent speech hallucinations / paranoia
what can cause agitation?
Medication, pain, nausea,
emotional distress, anxiety, fear,
insomnia, neurological deficit
what is usually given for agitation in the dying phase/
Midazolam injection
2.5 - 5mg SC PRN hourly
f agitation does not settle with increasing doses of midazolam up to 60mgs /
24hrs, consider use of:
Levomepromazine injection
6.25mg / 12.5mg SC PRN can be up to hourly
what can be used to treat respiratory tract secretions?
Hyoscine hydrobromide injection or
Hyoscine butylbromide injection (non sedating)
If patient still has secretions despite hyoscine HB/BB, consider prescribing
Glycopyrronium injection
what should a patient be given for breathlessness if not prescribed an opioid?
prescribe opioid injection 2.5mg-5mg SC up to hourly PRN
(prescribe the same opioid as used for analgesia)
what should patient be given for breathlessness if on opioid?
prescribe midazolam 2.5mg-5mg SC
up to hourly PRN
