Palliative Care

Question 1

what is palliative care?

Answer 1

Palliative care is the active, total care of the patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of social, psychological and spiritual problems is paramount. European Association for Palliative Care (2010)

Question 2

what are some symptoms that often need controlling as part of palliative care?

Answer 2

breathlessness

nausea and vomiting

constipation

malignant bowel obstruction

Question 3

what are some examples of treatable causes of breathlessness and how are they treated?

Answer 3

anaemia - transfusion

pe - LMWH, DOAC

CCF - diuretics, ACEi

COPD - bronchodilators

resp infection - abx

pericardial effusion - paracentesis, steroids

SVCO - stent, RT, steroids

anxiety - CBT, relaxation, benzos, SSRIs

Question 4

how is breathlessness managed?

Answer 4

aim to reduce perception

non drug options initially

adjust position - use gravity to aid and not hinder weak diaphragm/chest wall muscles

air flow across face - fan/open window

trial of oxygen if hypoxic

Question 5

what are some drug options for managing breathlessness?

Answer 5

oramorph 1-2mg orally PRN

morphine 1-2mg SC PRN

morphine 5-10mg/24 hr SCSD

lorazepam 0.5-1mg SL PRN

midazolam 2.5mg SC PRN

midazolam 5-10mg/24 hr SCSD

Question 6

what are some common causes of nausea and vomiting in palliative patients?

Answer 6

• infection
• metabolic
• drugs
• gastric stasis
• GI disturbance
• organ damage
• neurological
• psychological

Question 7

what are some drugs which cause nausea and vomiting in palliative patients?

Answer 7

Opioids, FeSO4, ABx, NSAIDs, diuretics, digoxin, SSRIs, chemo

Question 8

describe the vomiting centre and its inputs including the receptors at in the CTZ, VC and VIII nucleus

Answer 8

CTZ - D2, NK1, 5HT3

VC - Achm, H1, 5HT2

VIII nucleus - Achm, H1

Question 9

What receptors does haloperidol work on?

Answer 9

D2 at the CTZ

Question 10

what receptors does Metoclopromide work on?

Answer 10

D2 at the CTZ and 5HT3

Question 11

what receptors does cyclizine work at?

Answer 11

Ach and H1

Question 12

what receptors does Levomepromazine work at?

Answer 12

D2, 5HTz, Ach, H1

Question 13

what receptors does ondansetron work at?

Answer 13

5HT3

Question 14

when is Levomepromazine used?

Answer 14

when other anti emetics have been tried and are unsuccessful

it is a broad choice as it targets a lot of receptors

Question 15

what are the features of chemical cause of vomiting and which antiemetic is the best option for this?

Answer 15

Persistent, often severe nausea, unrelieved by vomiting, aggravated by the sight/smell of food, drowsiness/confusion

Haloperidol (Metoclopramide)

Question 16

what are the features of gastric stasis vomiting and what anti-emetic is best for this?

Answer 16

Fullness/regurgitation, reduced appetite, vomiting (often large volume) relieves nausea, epigastric discomfort, hiccups

Metoclopramide Domperidone

Question 17

what are the features of bowel obstruction vomiting and which anti emetic is best for this?

Answer 17

High: regurgitation, forceful vomiting of undigested food Low: colicky pain, large faeculant vomits, visible peristalsis

Cyclizine

Dexamethasone

Question 18

what are the features of raised ICP vomiting and which anti emetic is best for this?

Answer 18

Nausea worse in the morning Projectile vomiting. worse on head movement, headache

Cyclizine

Dexamethasone

Question 19

what are some psychological factors associated with vomiting? and how is this treated?

Answer 19

Anxiety, fear, anticipation

Non-drug, Benzodiazepines

Question 20

what are some factors that increase the risk of CINV?

Answer 20

• specific chemo agents
• female gender
• age <50 years
• past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)

Question 21

what is aprepitant, when is it used and name 2 side effects

Answer 21

Neurokinin 1 (NK1) receptor antagonists

NK1 receptors are in the chemoreceptor trigger zone (CTZ) and the vomiting centre

used for more emetogenic chemo

Question 22

what are some non-pharmacological interventions to help patients with nausea and vominting?

Answer 22

advice and realistic aims

smell

taste - small appropriate meals

hypnosis

acupuncture

Question 23

what are some causes of constipation in palliative patients?

Answer 23

disease related, fluid depletion, weakness, intestinal obstruction, medication, biochemical, pain, lack of privacy

Question 24

describe some laxatives and there different uses

Answer 24

Question 25

what is malignant bowel obstruction?

Answer 25

blockage of the bowel:

mechanical - tumour within gut lumen or outside bowel wall

functional - infiltration of myenteric plexus/ gut musculature

combination of both and has a gradual onset

Question 26

how is malignant bowel obstruction managed?

Answer 26

• Surgical intervention for single level: high post op morbidity, mortality and re -obstruction rate
• Endoscopic stenting
• Venting gastrostomy to decompress
• Cautious use of pro -kinetic may help partial/functional obstruction

Question 27

how is inoperable malignant bowel obstruction managed?

Answer 27

Rest bowel initially to see if will resolve

Limit oral fluids to sips and give IVI

NG tube for large volume vomiting

Correct electrolyte imbalance (low K, low Mg)

Analgesics (opioids and antispasmodics), antiemetics and antisecretory drugs

Trial of dexamethasone

Question 28

how is inoperable and non resolving malignant bowel obstruction managed?

Answer 28

• Syringe driver usually key
• Aim to reduce symptoms
• Control pain and nausea
• Minimise vomiting
• Permit sufficient oral fluids to maintain hydration
• Prognosis may be weeks – months

Question 29

summary n&v

Answer 29