Palliative Care Flashcards by Katherine Wostenholme

3 parts to palliative care

Physical
Psychosocial
Spiritual

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3 reasons symptomatic relief is important

Reduces QoL
Causes distress
Results in admissions

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Nausea + vomiting causes?
(3B’s + examples)

3 B’s:
1. Bowels - constipation, infection, obstruction, mucositis

Brain - Raised ICP
Biochemical - Meds (e.g. opioids), hypercalcaemia, infection, uraemia

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Central + 4 surrounding systems that play a role in vomiting + their receptors

ALL FEED INTO VOMITING CENTRE - 5HT3, H2, ACh

Chemoreceptor trigger zone (CMT) - 5HT3 + D2

2.Gut wall - 5HT3

Limbic system/Higher centres - Neurokinin 1 + GABA + 5HT3
Vestibular system - H1 + muscAch

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How do causes (3b’s) + systems of vomiting = cause it?

Gut wall –> distension stimulates vagus - constipation, chemo, obstruction = stimulates enterochromaffin cells

Chemoreceptor trigger zone - uraemia, drugs, chemo, hypercalcaemia

Vestibular system –> vertigo+motion sickness

Limbic system –> emotion + hyponatraemia

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Name some antiemetics + which nausea cause (3B’s) they work on.

What is most often used first-line in palliative care + why?

Bowels only:
Domperidone (D2)

Bowels+Brain
Ondansetron (5HT3)
Metoclopramide (D2)

Biochemistry+Brain
Haloperidol (D2) - EPSE!!
Levopromazine (D2, H1, 5HT3, Anti-musc)

Brain only:
Cyclizine (H1, Antimusc)

RECEPTORS ALL A BIT BOLLOCKS - SO DON’T WORRY ABOUT ‘EM

Haloperidol used 1st line - as acts on CTZ = outside blood-brain barrier. Opioids are commonly used in palliative care patients and don’t cross blood-brain barrier, so haloperiodol is good at prevent nausea from these.

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Why shouldn’t you prescribe cyclizine + metoclopramide?

C = constipating

M = Diarrhoea (as is a prokinetic)

the 2 counteract each other in the bowels

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Define pain

An unpleasant sensory or emotional experience associated with actual or potential tissue damage

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WHO pain ladder:
1.What’s it used for
2. Brief outline

used for CANCER PAIN

Outline:
1. weak analgesia
-Paracetamol + NSAIDs
-Adjuvants

Weak Opioids
-Codeine/Tramadol
-Adjuvants
-Non-opioid
Strong Opioids
-Morphine, Oxycodone, Diamorphine, Fentanyl, Bupenephrine…etc.
-Adjuvants
-Non-opioid

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Cautions with paracetamol?

Liver impariment
cachexia

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Cautions with NSAIDs?
(inlcuding CIs + drug interactions)

Renal impairment
Low platelets

CIs:
-GI bleed, asthma

Drugs:
Warfarin,
Digoxin
steroids

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Cautions with strong opioids?

Opioid naive
Renal impairment
Driving
Prescribe for side effect - i.e. GIVE stimulant+softening LAXATIVE
Patient stigma

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What 2 types of pain = trying to be controlled in palliative care?

Background
Breakthrough

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Potency of Codeine/Tramadol to Morphine?

C/T 1:10 Morphine

Morphine is 10x as potent

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Which is stronger Morphine or oxycodone? By how much?

Oxycodone (also better SE profile)
2x

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How much PRN dose should you give (if giving modified release)

1/6th of daily dose

What to prescribe alongside opioids? Why?

Stimulant+softening Laxative

PRN antiemetics

SIDE EFFECTS = common

OPIOIDS

Common SE?
Less common/Serious SE?

Common:
Constipation, sedation, nausea, dry mouth

Less Common:
Myoclonus (jerky movement) - look for sippy cup instead of mug for tea
Confusion

Rare
Resp depression
Pruritus

Morphine - dose adjustments for oral –> IV/SC

Morphine SC/IV = 2x oral

Examples of morphine / oxycodone for background + breakthrough pain?

Background - modified release:
-MST (tablet) - morphine
-Zomorph (Capsule) - morphine
-Oxycontin - (oral) oxycodone

Breakthrough - immediate
-Oramorph (liquid) - morphine
-Oxynorm (liquid/tablet)

What can reverse opioids? When to give?

NALOXONE
RR<8
SpO2<92%

Renal impairment + Morphine/Oxycodone

Renal impairment due to accumulation of morphine

Can use oxycodone with renal impairment = as excreted by kidney differently - doesn’t accumulate

Patient taking morphine = renal impairment - options?

Reduce dose/frequency
use renal-friendly option:
-Fentanyl (e.g. patch)
-buprenorphine
-Methadone
-Oxycodone

When to use fentanly?

-Renal impairment
-For background pain
-If patient cannot take oral medication - it’s a PATCH

Not good though - as conversion charts from morphine–>fentanyl = not precise

Adjuvants? Classes + what they're used for + example

Neuropathic Pain: -Antidepressants - amitryptilline -Antiepileptics - pregabalin, gabapentin Muscle spasms: -Antispasmodics - baclofen -Benzodiazepines - diazepam, clonazepam Bone Pain Bisphosphonates - zoledronic acid Compression symptoms (e.g. spinal cord compression/^ICP) Steroids - dexamethasone

Key concepts in terminal care?

Advance care planning DNACPR (medical decision, but should be informed)

What does advance care planning involve?

Advance statement/decision Power of attorney Advanced decision refuse treatment - MUST SAY that refusal may shorten life Preferred place Bucket list for patient

Symptoms/Change that may signify dying?

Sudden deterioration Weight loss/poor appetite Fatigue Poor mobility Social withdrawal Struggling with medications CV changes (pulse, mottled skin, cool peripheries) Resp changes (noisy secretions, laboured breathing)

5 key symptoms of dying patient + what meds to give to control each?

Pain - morphine PRN (syringe driver w/ patch) Breathlessness - PRN SC opioid / SC benzo Resp secretions - PRN hyoscine hydro/butylbromide Nausea/Vomiting - Haloperidol PRN Distress/Agitation - Midazolam

What to give in constipation in dying patient? What laxatives are poorly tolerated?

Softener (docusate) + stimulant (Senna) Macrogols + lactulose = poorly tolerated

5 priorities of care - if pt going to die in next few days?

1. Idea of dying communicated to pt 2.Sensitive communication - between staff+pt/family 3.Pt/fam involved in treatment/care planning 4.Needs of fam = identified+explored 5.Individual plan of care - inclu. food+drink, symptoms, psychosocial/spiritual support = delivered

Good communication = improves bereavement process. What formal support is offered?

Counselling referral to GP specialist psychological therapy

5 Palliative care emergencies?

Malignant spinal cord compression Superior Vena cava obstruction Malignant hypercalcaemia -Commonly breast/lung/MM -Mechanism - PTHrp(80%) + bone mets (20%) Opioid overdose/toxicity Acute bleeding -Mainly H+N cancers / gastro

Tx for malignant spinal cord compression

8mg IV dexamethasone BD Analgesia

Tx Superior vena cava obstruction

Dexamethasone

Malignant hypercalcaemia Mx?

IV zoledronic acid (bisphosphonate) IV fluids

Mx of acute bleeding?

Pain relief Sedation -morphine 10mg IV/IM + midazolam IV/IM Light pressure with dark, ideally green blanket

DDx confusion in dying + decreased AMT

Hypercalcaemia!! Infection brain mets

Lacks capacity and want to prevent pt leaving, what do you use? Acid test for this?

DOLS = part of MCA Acid test: 1)person under continuous supervison 2) not free to leave 3) cannot consent to these arrangements