Palliative Flashcards
What is supportive care?
care for patients who are potentially curative, but could die
What are the 3 categories for causes of nausea and vomiting?
bowels, brain, biochemical
Name 3 antiemtics
haloperidol, cyclizine, ondansetron, domperidone
What are 5 things that may indicate that someone is starting to die?
respiratory effort is laboured or shallow consiousness levels fluctating more decreased mobility social withdrawal struggling to take meds worsening performance Cardio - pulse strength weaker, mottled skin Resp - noisy due to secretions Vital sign changes weight loss and poor appetite
Which key things do you need to help with when someone is dying?
pain
secretions
medication review
reverse causes of agitation e.g. constipation
What are the 5 priorities of care for dying?
communication
dying person and their loved ones are involved
people important to patient are listened to and respected
care is tailored to individual and delivered with compassion
possibility of person dying shortly is recognised and clearly communicated
Which 5 things do pre-emptive medications need to be provided for and give examples?
pain - morphine breathlessness - morphine resp secretions - buscopam/ glycopyrronium N&V - haloperidol distress/agitation - midazolam
What are 3 palliative care emergencies?
neutropenic sepsis spinal cord compression Superior vena cava compression stridor opioid overdose malignant hypercalcaemia massive haemorrhage
What are signs of malignant hypercalcaemia?
bone pain, confusion, constipation, depression, abdominal pain
How would you treat malignant hypercalcaemia?
IV fluids and bisphosphonates, denosumab
How would you treat an opioid overdose in a palliative case?
nalaxone - dilute in 10ml N saline - 20mcg every 2 minutes
- 400mcg stat if life threatening
How would you treat spinal cord compression?
dexamethasone
What are some signs of superior vena cava compression and how would you treat it?
facial swelling, oedema, arm swelling, breathlessness
dexamethasone, anticoagulation, stenting, radiotherapy
What are two opioids that can be given by transdermal patch?
fentanyl or buprenorphine
What is an unlicensed medicine?
medicine without European or UK marketing authorisation for use in humans
What is an off-licence/off-lable medicine?
a licensed medicine used for unlicensed application
- up to 1/4 of palliative prescriptions
What are some mechanisms of vomiting?
biochemical upset (e.g. drugs) anxiety raised intracranial pressure motion sickness GI tract - gastric stasis, intestinal obstruction, gastric irriation
What are some non-pharmacological managements of nausea?
control odours - e.g. colostomy
minimise sight/smell of food
give small snacks not large meals
acupressure wrist bands
What are some drugs to manage nausea and vomiting?
haloperidol (chemical causes)
metoclopramide, domperidone (GI or chemo)
levomepromazide (non-specific)
cyclizine (motion sickness, raised ICP)
granisetron (chemo, radio, post-op)
hyoscine (smooth muscle spasm, secretions)
What are some cough suppressants (antitussives)?
codeine, morphine, methadone
What are some demulcents (antitussives)?
soothing agents e.g. glycerol syrup
What are some expectorants (protussives)?
encourage more productive cough
- sodium chloride neb 0.9% 5mL PRN
How would you treat surface bleeding?
tranexamic acid 1g Po tds-qds
low dose radiotherapy
What is the analgesic ladder?
non-opiod e.g. paracetamol, NSAIDs
weak opioid - codeine phosphate
strong opioid - morphine
What are some examples of adjuvant analgesics?
amitriptyline, carbamazepine, gabapentin, pregabalin, clonazepam, duloxetine, oxcarbazepine, corticosteroids, bisphosphonates, baclofen, antidepressants
How would you initiate strong opioids?
four hourly prn
regular 4 hourly
and assess pain after 24 hours
if pain free add up total given over 24 hours and convert into twice daily sustained/modified release
What are the two types of breakthrough/episodic pain?
predictable/incident
unpredictable/unexpected
What are some SE of morphine?
N&V constipation congnitive impairment respiratory depression urinary retention hallucinations dry mouth sweating pruritus
What are some alternatives to morphine?
oxycodone fentanyl buprenorphine alfentanil methadone ketamine
What should be consulted when switching between types of medication?
opioid conversion chart
What are the indications for a syringe driver?
patient unable to take oral meds
poor absorption of oral meds
intestinal obstruction
What is preferred injection route?
subcut
IM - painful, hard in wasted patients
IV - hazardous, hard to get access
What is an acronym to support care in the last hours or days of life?
ADD CARING
Assessment
Discussions
Documentation
Confirm who is responsible for care Attitudes, awareness, environment Review plan Identify additional people who need to be involved Nutrition and hydration Goals - confirm and document changes
Which anti-emetic would you give in gastric stasis?
metoclopramide
10mg x3/daily orally
What anti-emetic would you give for PD and gastric stasis and why?
domperidone - doesn’t cross blood-brain barrier as metoclopramide does
What would you give to reduce anxiety?
benzos - lorazepam, medazolam
What can you use topically to stop bleeding?
tranexamic acid
adrenaline
How do you convert immediate to modified release morphine?
Add up total and half
If patient was sleepy/hallucinating on morphine what would you switch to?
oxycodone
- methadone as last line
If the dosage conversion of morphine to fentanyl is in the middle what should you do?
Go down a patch
- tolerance and different receptors hit
How long should you continue morphine after fentanyl patch added?
continue morphine for 12 hours
What should be prescribed alongside syringe driver?
What the drug needs to be mixed with
- water
occaionally saline
What adult weight should you be careful when prescribing paracetamol?
50kg
Which pain killers are better for neuropathic pain?
amitriptyline
gabapentin
pregabalin
What are some SE of amytriptyline?
constipation, dry mouth
Which painkiller is quite last resort?
methadone
What is involved in emergency bleed plan?
dark sheets and towels ready
stay with patient and support them - DO NOT LEAVE
midazolam IM
