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Phase 4 - Katherine > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

3 parts to palliative care

A
  1. Physical
  2. Psychosocial
  3. Spiritual
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2
Q

3 reasons symptomatic relief is important

A

Reduces QoL
Causes distress
Results in admissions

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3
Q

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

A

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

  1. Brain - Raised ICP
  2. Biochemical - Meds (e.g. opioids), hypercalcaemia, infection, uraemia
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4
Q

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

A

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

  1. Chemoreceptor trigger zone (CMT) - 5HT3 + D2

2.Gut wall - 5HT3

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

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

A

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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6
Q

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

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

A

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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7
Q

Why shouldn’t you prescribe cyclizine + metoclopramide?

A

C = constipating

M = Diarrhoea (as is a prokinetic)

the 2 counteract each other in the bowels

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8
Q

Define pain

A

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

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9
Q

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

A

used for CANCER PAIN

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

  1. Weak Opioids
    -Codeine/Tramadol
    -Adjuvants
    -Non-opioid
  2. Strong Opioids
    -Morphine, Oxycodone, Diamorphine, Fentanyl, Bupenephrine…etc.
    -Adjuvants
    -Non-opioid
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10
Q

Cautions with paracetamol?

A

Liver impariment
cachexia

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11
Q

Cautions with NSAIDs?
(inlcuding CIs + drug interactions)

A

Renal impairment
Low platelets

CIs:
-GI bleed, asthma

Drugs:
Warfarin,
Digoxin
steroids

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12
Q

Cautions with strong opioids?

A

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

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13
Q

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

A

Background
Breakthrough

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14
Q

Potency of Codeine/Tramadol to Morphine?

A

C/T 1:10 Morphine

Morphine is 10x as potent

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15
Q

Which is stronger Morphine or oxycodone? By how much?

A

Oxycodone (also better SE profile)
2x

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16
Q

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

A

1/6th of daily dose

17
Q

What to prescribe alongside opioids? Why?

A

Stimulant+softening Laxative

PRN antiemetics

SIDE EFFECTS = common

18
Q

OPIOIDS

Common SE?
Less common/Serious SE?

A

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

19
Q

Morphine - dose adjustments for oral –> IV/SC

A

Morphine SC/IV = 2x oral

20
Q

Examples of morphine / oxycodone for background + breakthrough pain?

A

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

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

21
Q

What can reverse opioids? When to give?

A

NALOXONE
RR<8
SpO2<92%

22
Q

Renal impairment + Morphine/Oxycodone

A

Renal impairment due to accumulation of morphine

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

23
Q

Patient taking morphine = renal impairment - options?

A
  1. Reduce dose/frequency
  2. use renal-friendly option:
    -Fentanyl (e.g. patch)
    -buprenorphine
    -Methadone
    -Oxycodone
24
Q

When to use fentanly?

A

-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

25
Q

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

A

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

26
Q

Key concepts in terminal care?

A

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

27
Q

What does advance care planning involve?

A

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

28
Q

Symptoms/Change that may signify dying?

A

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)

29
Q

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

A

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

30
Q

What to give in constipation in dying patient?

What laxatives are poorly tolerated?

A

Softener (docusate) + stimulant (Senna)

Macrogols + lactulose = poorly tolerated

31
Q

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

A
  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
32
Q

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

A

Counselling
referral to GP
specialist psychological therapy

33
Q

5 Palliative care emergencies?

A

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

34
Q

Tx for malignant spinal cord compression

A

8mg IV dexamethasone BD

Analgesia

35
Q

Tx Superior vena cava obstruction

A

Dexamethasone

36
Q

Malignant hypercalcaemia Mx?

A

IV zoledronic acid (bisphosphonate)

IV fluids

37
Q

Mx of acute bleeding?

A

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

38
Q

DDx confusion in dying + decreased AMT

A

Hypercalcaemia!!
Infection
brain mets

39
Q

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

A

DOLS = part of MCA

Acid test:
1)person under continuous supervison
2) not free to leave
3) cannot consent to these arrangements

Phase 4 - Katherine (26 decks)

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