Palliative care Flashcards
What is Palliative care?
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness
Through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual - WHO
What is the definition of “End of Life”
“Approaching the end of life” - likely to die within the next 12 months
Those facing imminent death & those with;
- Advanced, progressive, incurable conditions
- General frailty (likely to die in 12 months)
- At risk of dying from sudden crisis of condition
- Life threatening conditions caused by sudden catastrophic events
Not just cancer!
What are the principles of delivering good end of life care?
- Open lines of communication
- Anticipating care needs and encourage discussion
- Effective multidisciplinary team input
- Symptom control - physical and psycho-spiritual
- Preparing for death - patient & family
- Providing support for relatives both before and after death
What are the features of Pain in palliative care and the potential causes?
Pain;
- Can be multifactorial
- Most patients have more than one pain
- Background (always there) / Breakthrough (moments of it) / Incident pain (when doing something)
Physical causes;
- Cancer related (85%)
- Treatment related
- Associated factors-cancer and debility
- Unrelated to cancer
Overlap of physical / psycho-spiritual causes
What are the different Pain Syndromes?
Pain Syndromes;
Bone pain;
— Worse on pressure or stressing bone / weight
bearing (can be night time at rest)
Nerve pain (neuropathic);
— Burning/shooting/tingling/jagging/altered
sensation (can use amitriptyline)
Liver Pain;
— Hepatomegaly/right upper quadrant
tenderness
Raised Intracranial Pressure;
— Headache (and/or nausea) worse with lying
down, often present in the morning
Colic;
— Intermittent cramping pain
Can be due to metastasis as well!
How do we record pain in Palliative care patients?
Using a Brief Pain Inventory form
- Looks at pain experienced in last 24 hours
- Patient fills out and documents
How can we control Pain in Palliative care patients?
Using the WHO analgesic ladder;
Step 1 - Non-opioid (e.g aspirin, paracetamol or NSAID) +/- adjuvant
Step 2 - Weak opioid for mild to moderate pain (e.g codeine), +/- non opioid, +/- adjuvant
Step 3 - Strong opioid for moderate to severe pain (e.g morphine), +/- non opioid, +/- adjuvant
Adjuvant - specific additional targeting for that patient
What are the features of opioids ?
- Morphine - 1st line strong opioid
Indications;
- Moderate to severe pain / dyspnoea (Helps breathlessness, e.g cardiac failure)
Action;
- Opioid receptor agonist
- Centrally acting
Cautions;
- Long-list in BNF; including renal impairment and elderly; avoid in acute respiratory depression
- “…in the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to use opioid analgesics”
Administration;
- Enterally (oral / rectal)
- Parentally (IM / SC injections)
- Delivery via syringe driver over 24 hours
What should you do when starting a patient on strong opioids?
Principles to go by - moving on to ‘Step 3’;
- Stop any ‘Step 2’ weak opioids
- Titrate immediately release strong opioid
- Convert to modified release form
- Monitor response and side-effects
How can Morphine be Prescribed Practically ?
Modified release;
- ‘Background’ pan relief
- Either twice daily preparation at 12 hourly intervals
- Or once daily preparation at 24 hourly intervals
“Modified-release preparations are available as 12-hourly or 24-hourly formulations; prescribers
must ensure that the correct preparation is prescribed. Preparations that should be given 12-
hourly include Filnarines SR, MST Continus@, Morphgesic@ SR and Zomorph@. Preparations that should be given 24-hourly include MXL” - BNF
Immediate release;
— ‘Breakthrough’ pain
— As required (PRN)
— E.g. Oramorph liquid/ Sevredol tabs
What are the features of Diamorphine ?
Other Opioid - Diamorphine;
- Semi-synthetic morphine derivative
- More soluble than Morphine -> smaller volumes needed
- Can be used for parenteral administration (injection / syringe driver)
What are some Other Opioid options we have and their features?
Oxycodone (Oxynorm / Oxycontin);
- Second line opioid
- Less hallucinations, itch, drowsiness, confusion
Fentanyl patch;
- Second line opioid
- Lasts 72 hours
- Only use in stable pain
- Useful if oral and subcutaneous routes not available
- Useful if persistent side-effects with morphine / diamorphine
Note: Switching opioids - Opioid sensitive pain with intolerable side-effects
What are the Side Effects of Opioids ?
- Nausea & vomiting
- Constipation !
- Dry mouth
- Biliary spasm
- Watch for signs of opioid toxicity
How do we manage the Opioid side effects?
We want to prevent side effects
Constipation;
- Stimulant & softening laxative
- Senna / Bisacodyl + Docusate
- Magrogol (e.g laxido / movicol)
- OR Co-Danthramer alone
Nausea;
- Antiemetic
- Metoclopramide
- Haloperidol (consider QT interval)
What are the symptoms of Opioid Toxicity ?
Opioid Toxicity;
- Shadows edge of visual field
- Increasing drowsiness
- Vivid dreams / hallucinations
- Muscle twitching / myoclonus
- Confusion
- Pin point pupils
- Rarely, respiratory depression
(If notice these scale back dose)
What Adjunct Medication can we use?
Adjunct medication;
Liver capsule pain / raised intracranial pressure;
- Steroids (e.g Dexamethasone)
- Remember to consider gastroprotection
Neuropathic pain;
- Amitriptyline / Gabapentin / Carbamazepine
Bowel / bladder spasm;
- Buscopan (Hyoscine Butylbromide)
Bony pain / soft-tissue infiltration;
- NSAIDs / Radiotherapy
What are the features of Syringe Drivers?
Syringe Drivers;
- Delivery over 24 hours, usually subcutaneous
- Useful when oral route inappropriate
- Often useful for rapid symptom control
- Multiple medications can be added
- Stigma of being on a ‘pump’ (end of life stigma)
What are the features of Total Pain?
Total Pain can be broken down into 4 factors;
- Physical
- Social
- Spiritual
- Psychological
What is Psycho-spiritual distress?
Psycho-spiritual distress can be defined as the impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, nature, or a power greater than oneself.
Psycho-spiritual distress may be expressed as - or magnify the intensity of - physical symptoms. Spiritual distress may occur when the individual is faced with challenges
that threaten an individuals’ beliefs, meaning, or purpose.
Psycho-spiritual distress may occur at various points during the patients’ journey but
in particular
* at diagnosis
* at home after initial treatment
* at disease progression or recurrence
* at the terminal phase
How can we Manage Psycho-spiritual distress?
Management of Psycho-spiritual distress;
Affirm patient by attentive listening. If appropriate, explore current thoughts and feelings with focus on particular fears and anxieties.
Key issues in managing Psycho-spiritual distress include:
* Encouraging hope, purpose and meaning
* Respecting religious/cultural needs,
* Affirming the patient’s humanity,
* Protecting the patient’s dignity, self worth and identity,
* Encouraging relationships,
* Encouraging forgiveness/reconciliation,
* Refer to colleagues in wider MDT / specialist services
How did Covid affect palliative care ?
Covid caused;
Reduced professional support;
- Anxieties around delays and disruptions
- A need for clear and accessible information
- Identifying inequalities and those most at-risk
Risk of reduced quality of care;
- Fears around rationing of care
- Concerns about communication of care preferences
- Maintaining a holistic approach with diminished resources
Strains on informal care networks;
- Increased responsibilities for informal carers
- Fears around caring and risk of infection
- Loss of informal care due to isolation measures
Increased loss, grief and bereavement;
- Heightened risk of complicated grief
- Providing sufficient bereavement support
- Impact of societal grief on mental health
During Covid people couldn’t access these services, there’s a back log now, gave more complicated grief that didn’t feel like had support needed
What is the Bereavement and Grief model?
Concept of people being cared for before and after death etc
What are the different types of Grief?
- Anticipatory grief
- Non-complex (normal) grief (90 - 94%)
- Complex / unresolved grief (6 - 10%)
Grief is not a measure of relationship between the bereaved and deceased !
What are some things your patient may need when bereaving and experiencing grief?
Patients will look to the NHS for a “magical” cure…
Medication;
- Antidepressants
- Benzodiazepine
“Sick lines”
Counselling
Grief is normal don’t go straight to these!
The vast majority of those experiencing grief only require support and space to be heard
What are important things to remember when caring for those bereaving and experiencing grief?
In caring for others we need to;
- Listen
- Hear their story,
- Hold their pain.
Your presence and listening ear is the most important therapeutic intervention you can offer
Listening is the Essence of Palliative & Bereavement Care.
What are some good tips in caring for those bereaving and experiencing grief?
- There is no right or wrong way to grieve — it is a journey not an event
- Grief is a personal journey, unique to each of us
- People may experience a combination of powerful emotions at different times
- Acknowledge the persons loss
- Take time to listen to the persons stories, allow them to talk about their loss, their feelings and how they are coping
- Mirror the words and phrases used by the person
- Acute grief can be highly distressing and disabling, but grief should not be medicalised.
- Grief is the body’s natural response that evolves as a bereaved person adapts to their loss.
- Learn how to recognise anticipatory and unresolved Grief and any complications (especially depression).
