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 are the features of Total Pain?
Total Pain can be broken down into 4 factors;
- Physical
- Social
- Spiritual
- Psychological
What is the Bereavement and Grief model?
Concept of people being cared for before and after death etc
