Palliative and End of Life Care Flashcards
How should you manage bone pain in palliative patients?
Discuss with an oncologist (for example, regarding radiotherapy or bisphosphonates for bone metastases).
Urgent advice from an orthopaedic surgeon if there is evidence or suspicion of an actual or imminent fracture.
For symptomatic relief:
Apply hot or cold packs.
Use standard analgesia in a stepwise approach.
If incident pain occurs on movement, encourage the person to take a dose of their breakthrough analgesia 20-30 minutes before anticipated movement.
If pain is difficult to manage, seek advice from a specialist (such as a palliative care specialist or an anaesthetist with an interest in chronic pain).
How should you manage intestinal colic in palliative patients?
Consider if is a treatable underlying cause: e.g. constipation, bowel obstruction (surgery/patient willing).
If symptomatic management is appropriate, consider hyoscine butylbromide (an antispasmodic), 20mg immediately by subcutaneous injection, then 60-100mg/24 hours via syringe driver continuous infusion.
How should you manage neuropathic pain in a palliative patient?
What is the first cause to exclude?
Exclude simple reversible causes i.e. B12 deficiency.
Specialist input for underlying disease e.g. bone metastasis, soft tissue disease.
Choice of anti-neuropathics include standard ones: amitryptline, gapapentinonids.
How should pain from raised intracranial pressure be managed in palliative care patients?
Consider whether a treatable underlying cause is present.
Discuss with an oncologist regarding the need for radiotherapy.
Use standard analgesics in a stepwise approach.
Also consider a trial of dexamethasone at a dose of 8-16 mg daily (taken in the morning), titrated down to the lowest dose that controls symptoms:
If the volume of tablets or injection is difficult to manage in a single dose, it is acceptable to split the dose, in which case it should be given at 8am and 12pm.
Have a low threshold for considering gastroprotection with a PPI.
Response to dexamethasone should be assessed after 3 days, but extensive cerebral oedema may take 2-3 weeks to resolve.
If there has been no response, discontinue dexamethasone immediately.
If there has been a benefit, review frequently and reduce to the lowest dose that controls symptoms (for example, reduce by 2 mg every 5th day.
How should you manage muscle spasm pain in palliative patients?
Consider whether there is a treatable underlying cause.
Try simple measures (such as heat pad, massage, relaxation).
Consider transcutaneous electric nerve stimulation over the trigger point if the pain is myofascial.
If trigger points are multiple or the muscle spasm is widespread, consider a muscle relaxant, such as a benzodiazepine (e.g., diazepam) or baclofen:
Several different doses of diazepam have been suggested by experts. These range from 2-10mg at night to 2-5 mg three times a day; the higher doses may be helpful if there is coexisting anxiety.
The dose may need to be reduced depending on clinical response.
The suggested dose of baclofen to treat muscle spasm is 5-10 mg three times a day. However, baclofen should be titrated slowly, which may limit its usefulness in people requiring palliative care.
The choice of drug will also depend on any other actions (for example, benzodiazepines may be more appropriate for people with coexisting anxiety) and the potential for limiting adverse effects.
If these measures are not effective, or there are only a few trigger points, consier referral. Other drugs or injection of trigger points with local anaesthetic may be considered in secondary care.
According to the Mental Capacity Act (2005), what should be assumed about every patient’s capcity?
Every patient should be assumed to have capacity unless proven otherwise.
In an emergency situation, how should decisions be made for a patient who lacks capacity?
Acts in the patient’s best interests.
