Palliative Care Flashcards
what is palliative care?
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)
what are some symptoms that often need controlling as part of palliative care?
breathlessness
nausea and vomiting
constipation
malignant bowel obstruction
what are some examples of treatable causes of breathlessness and how are they treated?
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
how is breathlessness managed?
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
what are some drug options for managing breathlessness?
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
what are some common causes of nausea and vomiting in palliative patients?
- infection
- metabolic
- drugs
- gastric stasis
- GI disturbance
- organ damage
- neurological
- psychological
what are some drugs which cause nausea and vomiting in palliative patients?
Opioids, FeSO4, ABx, NSAIDs, diuretics, digoxin, SSRIs, chemo
describe the vomiting centre and its inputs including the receptors at in the CTZ, VC and VIII nucleus
CTZ - D2, NK1, 5HT3
VC - Achm, H1, 5HT2
VIII nucleus - Achm, H1
What receptors does haloperidol work on?
D2 at the CTZ
what receptors does Metoclopromide work on?
D2 at the CTZ and 5HT3
what receptors does cyclizine work at?
Ach and H1
what receptors does Levomepromazine work at?
D2, 5HTz, Ach, H1
what receptors does ondansetron work at?
5HT3
when is Levomepromazine used?
when other anti emetics have been tried and are unsuccessful
it is a broad choice as it targets a lot of receptors
what are the features of chemical cause of vomiting and which antiemetic is the best option for this?
Persistent, often severe nausea, unrelieved by vomiting, aggravated by the sight/smell of food, drowsiness/confusion
Haloperidol (Metoclopramide)
what are the features of gastric stasis vomiting and what anti-emetic is best for this?
Fullness/regurgitation, reduced appetite, vomiting (often large volume) relieves nausea, epigastric discomfort, hiccups
Metoclopramide Domperidone
what are the features of bowel obstruction vomiting and which anti emetic is best for this?
High: regurgitation, forceful vomiting of undigested food Low: colicky pain, large faeculant vomits, visible peristalsis
Cyclizine
Dexamethasone
what are the features of raised ICP vomiting and which anti emetic is best for this?
Nausea worse in the morning Projectile vomiting. worse on head movement, headache
Cyclizine
Dexamethasone
what are some psychological factors associated with vomiting? and how is this treated?
Anxiety, fear, anticipation
Non-drug, Benzodiazepines
what are some factors that increase the risk of CINV?
- specific chemo agents
- female gender
- age <50 years
- past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)
what is aprepitant, when is it used and name 2 side effects
Neurokinin 1 (NK1) receptor antagonists
NK1 receptors are in the chemoreceptor trigger zone (CTZ) and the vomiting centre
used for more emetogenic chemo
what are some non-pharmacological interventions to help patients with nausea and vominting?
advice and realistic aims
smell
taste - small appropriate meals
hypnosis
acupuncture
what are some causes of constipation in palliative patients?
disease related, fluid depletion, weakness, intestinal obstruction, medication, biochemical, pain, lack of privacy
describe some laxatives and there different uses
what is malignant bowel obstruction?
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
how is malignant bowel obstruction managed?
- 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
how is inoperable malignant bowel obstruction managed?
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
how is inoperable and non resolving malignant bowel obstruction managed?
- 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
summary n&v
