Palliative care Flashcards
1
Q
Def End of life
A
ANy unexpected change in condton of or symptoms/cirucmstances in a patient with a life limiting illness
2
Q
Palliative care emergencies
A
- Physical- bone, hypercalcaemia, SVC obstruction, SC comp, mI, DVT/PE, Gastric/duodenal ulcer, infection/neutropenic sepsis, haemorrhage, seizures
- Social -
- Spiritual/Existential -
- Psychological -
3
Q
Approach to emergencies
A
- Assess anture o emergency, symptoms
- How reversible is it
- Recent performance status, extend of siease
- Any co-existent co-morbidities
- Effectiveness of treatment v burden
- Patients wishes and preferences
4
Q
How preditabel are emergencies
A
- Some can be predictd from location and nature of some disease
- Eamples - plannign is key, counselling patients, planning for crisis, appropriate supports in place, emergency medications at home, provision of a plan with patient swishes (advance wishes, advance decision to refuse treatments).
5
Q
Spinal cord compression - common palliative care emergency
A
- 5% cancer patients, 10% patients with spinal mets. More common in some cancers. *Prostate, breast*, lung* myeloma, thyroid, kidney
- Ctaastorphic event leading to paraplegia, paraparesis and incontinence if left untreated. Largely clinical diagnosis, Weakness often attributed ot general debility
- Causes: Extradural compression (Vertebral body mets -/+ vertebral collapse) and site of compression (throacic 70%, lubosacral 20%, cervical 10%, more than one level compresison in 20% cases).
-
Presentation:
- Pain 90% - back + nerve root irritation, aggravated by movement, coughing, lying flat, ay preceed other symptoms and signs by up to 6weeks)
- Sensory disturbance >50% can be early sign
- Leg weakness >70% - late sign, motor weakness below level of lesion, stiffness/falls/gait disturbance
- Clinical: Back pain +/- tendern vertebrae on percusiion, leg weakness/altered gait, lesion above L1 (UMN signs and sensory level), Lesion below L1 (LMN signs + peri-anal numbness, caud equina s)
- Ix = MRI investigation of choice. Xray identified 80% extradural but doesnt diagnose (mRI can take a while). Boen scan identifies boen mets but NOT site cord compression.
- Mx - Consider patiwnt sperormance status and wishes before transfer to oncology centre. Steroids asap, Analgesia, refer to oncologist for raidotherapy, conside rurgent surgical debulking, urinayr catheter/bowel regime.
- Outcomes - best predictor of function outcome form radiotherapy for spinal cord compression is degree neuro deifcit at time treatment started.
6
Q
Malignant Hypercalcaemia
A
- Corrected serumc alcium conc above 2.65
- Patho - osteolytic hypercalcaemia (increased osteoclastic boen resorption aroudn alignant cells in marrow space) and humoral hypercalcaemia of malignancy. Reduced renal clearance. 1,25-dihydroyvitamin D secretion (some lymphomas), ectopic secretion of authentic PTH (v rare)
-
Clinical:
- Gen - dehydraiton, thirst, polydipsia, pruritis
- Gastro - anorexia, weight loss, nausea/vom, consitpaiton ileus
- Neuro - fatigue, letahrgy, confusion, droswiness, myopathy, seiures, psychosis, coma
- Cardio - bradycardias, atrial arrhythmias etc, wide t waves, prolonged PR interval….
- Mx = whats happenening, why? Rehydration, calcium lowering agents bisphosphonates which reduc eboen repsortion but side effects like flu like symptons ad then receck calcium 5-7days after) and withdraw hypercalcaemia promoting drugs
- 70% patient srepsonse, av duraiton of repsons 3-4weeks.
7
Q
Neutropenic Sepsis
A
- Can deteriorate quickly. neutrophils lost. COmmon in chemo
- Local policies available - tazocin -/+ gENTAMYCIN nuth.
8
Q
Haemorrhage - Plaliative care emergency
A
- Causes - direct or indirect (drugs, low platelets, related ot tumoru itself)
- Mx - prep + anticipation (support, anticoags, dark towels use, PRN benzos)
- Non- Acute haemorrhage Mx:
- Local/Topical - adrenlaine, silver nitrate sticks to bleeding points, haemostatuc dressings, sucralfrate paste or suspension
- SYstemic - antifibronlytics, haemostatuc agents
- Other -r adiotherapy, diathermy, embolisaton
-
Acute Masisve haemorrhage Mx:
- If not immediately fatal the aim is:
- Locla contorl if poss, sedation of shocked, frightened patient (midazolam), dark towels,reassurance, folow up support for family + staff
9
Q
SVC Obstruction
A
- Def = external compresison of and/or thrombosis of SVC by mediastinal lymph nodes or tumour in region of right main bronchus. 75% by cancer of bronchus, 15% caused by lymphoma, 10% by cancer of breast/colon/oesophagus/testis
- Symptoms = venous hypertension, headache, visual changes, dizziness, swelling of face/neck/arms.
- Signs = Engorged conjuntivae, periorbital oedema, nono-pulsatile dilated neck veins
-
Ix + Mx =
- Prognosis hours to days: Opioid, oxygen, keep bed 30degrees, dexamethasone, furosemide, tx for anxiety or seixures, crisis meds
- prognosis weeks: as previous + CXR, Chest CT, stent from extrinsic compression, stent + thrombolysis fro thrombus obstruction, anticoag for thrombus ass svco
- Prognosis months ot years: s previous + Radiotherapy, chemotherapy
- Overall prognosis: Measured horus to days prior to onset. Wihtotu treatment will progress over several days to death
10
Q
A good death is…
A
COmfortable patient: physically, emotionally, spirituallt, peaceful, dignfified
11
Q
Recognising dying
A
- Cause of deterioration no logner responding to treatment -can this be reversed
- Reversible causes of deterioiration no longer appropriate to treat - should we attempt to reverse?
- Not easy
- Experience helps
- Expected physiolofical changes: Changes in Obs, weakness+ fatigue, decreased oral intake + swallow reflex, decreased blood perfusion, renal failure, incontinence/retention of urine, change in mental state (confusion, disorientation, delerium)
12
Q
A
13
Q
Key to success to palliative care
A
- MDT team work and communciation
- Good comm with family and with healthcare professionals
- Seeka dvice or refer early to specialist palliative services
- Anticipate probable needs sot hat immediate repsonse can be made.
- Always aks what the patient needs - family, meotional etc
14
Q
Syndrome of IMminent death
A
- Time course - 24h to 2weeks. Variability, disease prcoess, physical reserves.
- Adumme patients hear everything, include in convos, touch.
- Family educationa nd anticipatory guidance - confirmation of obs, repetition. These are symptoms assoicated with the nromal process dying.
- Routes for durg treatment - subcut, bucca, rectal, topica, not iM (painful)
- “Transistioning” or early phase - bedbound, incontinent, decrease in ability and/or interest to eat or drink, cognitive changes (social withdrawl, decreased interest in world, disorientation). These are symp ass with nromal process dying.
- Middle phase - Trachela congestion, further cognitive changes (slwo to arouse, brief waefulness/repsonsiveness), no oral intake (assit fam to find other ways t care)
- Late phase - Comatose, temp instability, altered resp pattern, mottling + cool exteemities, absence of peripheral pulses
15
Q
Gneral approach to care in imminent death
A
- Transisition to comfort car eif can, stop intevrentions + monitoring for comfort, treat symp + educate as issues arise, provide excellent oral + skin care. Be present + hoenst, sit down,a ssit with fam concerns/conflicts. Attend to own emotional responses + support.
- DYing in institutions - home like environment (permit privacy,intimacy, perosnal items, photos, remove monitors), continuity of care plans, avoid abrupt changes of settings, consider a specialised unit.
- Spiritual care - deeply personal, lifes meaning + purpose, religion/god, memory boxes etc
