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Phase 3b > Palliative care > Flashcards

Palliative care Flashcards

1
Q

What is palliative care?

A

Holistic individual care to patients and family
Continues outside of traditional medicine including spiritual and other issues

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2
Q

What types of care does palliative care provide?

A

Supportive
End of life
Terminal

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3
Q

What is the focus of treatment in palliative care?

A

Patient centred goal setting
Realism
Honesty/hope
Enablement approach
Planning for the future
Community vs specialist inpatient vs outpatient vs hospital support team
Improving survival and QoL

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4
Q

Name 2 simple analgesia

A

Paracetamol
NSAIDs

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5
Q

How does paracetamol work?

A

Inhibits production of CNS prostaglandins

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6
Q

What should you check before starting paracetamol?

A

Liver impairment - reduce dose or consider avoiding if severe
Severe cachexia - less than 50kg max dose 500mg QDS
Slight dose reduction if dialysis dependent

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7
Q

How do NSAIDs work?

A

Inhibit COX the main enzyme in the synthesis of prostaglandins from arachidonic acid
Central and peripheral action

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8
Q

Name a selective NSAID and how this is better

A

Celecoxib
Safer for GI s/e

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9
Q

What should you check before starting NSAIDs?

A

Renal and platelet count
CI - GI bleeding or ulcer Hx, asthma
Concurrent medications - warfarin, digoxin, steroids

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10
Q

Name 2 weak opioids

A

Codeine
Dihydrocodeine
Tramadol

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11
Q

What is the problem with weak opioids?

A

Ceiling effect on analgesia
Maximum dose you can prescribe for weak opioids

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12
Q

Name 2 generic strong opioids

A

Morphine
Oxycodone
Buprenorphine
Fentanyl
Diamorphine

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13
Q

Name 2 specialist palliative care strong opioids

A

Hydromorphone
Alfentanil
Methadone

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14
Q

What should you consider before starting a strong opioid?

A

Tried before? If so, what happened?
Co-morbidities
Patient concerns
Age and frailty
Renal function
Will they take them as prescribed?
Are they driving?
Have you prescribed medications for side effects?

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15
Q

What are the common side effects of opioids?

A

Constipation
Nausea
Sedation
Dry mouth

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16
Q

Name a less frequent side effect of opioids

A

Psychomimetic effects
Confusion
Myoclonus

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17
Q

Name a rare side effect of opioids

A

Allergy
Respiratory depression
Pruritis

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18
Q

What is the issue with constipation as a side effect of opioids?

A

Difficult to get rid of as mechanism of this is the same as the mechanism for pain relief

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19
Q

What is respiratory depression with opioids a sign of?

A

Toxicity

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20
Q

What can you prescribe for the side effects of opioids?

A

Stimulant laxatives
PRN anti-emetic

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21
Q

What is the difference between background and breakthrough pain?

A

Background - pain at rest, ongoing pain
Breakthrough - transient exacerbation, can be predictable such as movement or unpredictable

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22
Q

What is the aim of pain management in palliative care?

A

Adequate background pain control and a way of controlling breakthrough pain

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23
Q

How should you prescribe opioids?

A

Always start low
Titrate dose according to pain and PRN usage

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24
Q

What is the general rule for PRN opioid dosages?

A

1/10th - 1/6th of 24 hour dose

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25
Q

What is the conversion from oxycodone to morphine?

A

Oxycodone is twice as potent as morphine
Need double the amount of morphine as oxycodone
OR
Need half the amount of oxycodone as morphine

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26
Q

What is the conversion of codeine and tramadol to morphine?

A

Codeine and tramadol are 1/10th as potent as oramorph

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27
Q

What are the indications for opioid patches?

A

Intolerable side effects
Oral route difficulties - compliance/dysphagia
Renal impairment

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28
Q

What should you not use patches for and why?

A

Acute/unstable pain
Takes minimum of 3 days to reach analgesic concentrations when first increased

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29
Q

What should you do in renal impairment with opioids?

A

Either stay on current opioid and
- Reduce dose
- Reduce frequency
Or switch opioid to more renal-friendly option
With help from palliative care

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30
Q

Name a more renal friendly opioid

A

Oxycodone
Fentanyl
Buprenorphine
Methadone
Alfentanil

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31
Q

What is the conversion from oral forms of opioids to injectable?

A

Injectables are twice as strong as oral

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32
Q

Name 3 types of adjuvant analgesia

A

Antidepressants -> amitriptyline, duloxetine
Antiepileptics -> pregabalin, gabapentin
Antispasmodics -> baclofen, tizindine
Steroids -> dexamethasone
Benzodiazepines -> clonazepam, diazepam
Local anaesthetics -> topical lidocaine plasters
Bisphosphonates -> zolendronic acid

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33
Q

What can antidepressants be used for in pain relief?

A

Neuropathic pain

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34
Q

What can antiepileptics be used for in pain relief?

A

Neuropathic pain

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35
Q

What can antispasmodics be used for in pain relief?

A

Muscle spasms

36
Q

What can steroids be used for in pain relief?

A

Compression syndromes

37
Q

What can benzodiazepines be used for in pain relief?

A

Spasms, ?neuropathic pain

38
Q

What can local anaesthetics be used for in pain relief?

A

Focal areas of pain

39
Q

What can bisphosphonates be used for in pain relief?

A

Bone pain

40
Q

How should you approach a palliative care emergency?

A

Context is key
On-call understand all plans for palliative patients
Communication

41
Q

Name 3 major medical emergencies that are more common in palliative care

A

Febrile neutropenia
SVCO
Stridor
Hypercalcaemia
Spinal cord compression
Opioid overdose
Massive haemorrhage

42
Q

When should you consider neutropenic sepsis/febrile neutropenia?

A

Following chemotherapy 2-3 weeks (day 10 when WCC drops lowest)
Haematology patients
Bone marrow infiltration - pancytopenia

43
Q

What are the S&S if febrile neutropenia?

A

Clinical sepsis and/or pyrexia > 38
Clinical infection - chest, urine, skin, GI, lines
Neutrophil count < 0.5

44
Q

What is the management of febrile neutropenia?

A

IV access
Broad spectrum Abx
Close observation
Fluid resuscitation
Investigations

45
Q

What investigations should you do in febrile neutropenia?

A

FBC, U&Es, LFTs incl albumin, CRP, lactate, cultures

46
Q

What is SVCO?

A

Superior Vena Cava Obstruction
External blockage from mass rather than intrinsic obstruction

47
Q

When should you think of SVCO?

A

Lung cancer/tumour involving RUL or mediastinum

48
Q

What are the S&S of SVCO?

A

Facial swelling, redness
Periorbital oedema, engorged conjunctivae
Arm swelling
Breathlessness
Distended veins on chest

49
Q

How do you diagnose SVCO?

A

CT chest
Findings correlate with clinical presentation

50
Q

What is the management of SVCO?

A

ABCs
High dose steroids - dexamethasone 16mg OD, buys time whilst get more definitive treatment, reduces tumour associated oedema
Consider anti-coags
Stenting - interventional radiology
Radiotherapy/chemo
Discuss with other specialties

51
Q

When should you consider stridor?

A

Head and neck tumour
Lung/upper GI tumour

52
Q

What are the S&S of stridor?

A

Noisy breathing on inspiration
Harsh breath sounds
Breathlessness -> can be late sign of decompensation

53
Q

How do you diagnose stridor?

A

Clinically
Upper airway visualisation - ENT/max-fax
Upper airway imaging - CT

54
Q

How do you manage stridor?

A

ABC - O2, heliox (less dense than air so reduces resp work required when high ventilatory demand/upper airway obstruction)
High dose steroids - dex 16mg
Urgent ENT/oncology review
Tracheostomy - new airway
Stent - open airway
Radiotherapy

55
Q

When should you consider malignant hypercalcaemia?

A

Specific types of cancer
Cancer which has spread to bone -> breast, lung, kidney, thyroid, myeloma

56
Q

What are the S&S of malignant hypercalcaemia?

A

Acute - thirst, confusion, constipation, global deterioration
Chronic - depression, abdominal pain, constipation, calculi (bones, stones, moans, groans)
Can seem like they’re dying

57
Q

How is malignant hypercalcaemia diagnosed?

A

Blood test
Corrected calcium > 2.6 abnormal
Corrected calcium > 2.8 symptomatic

58
Q

How do you manage malignant hypercalcaemia?

A

IV fluids -> immediate, acts as diuretic so get dehydrated quickly, lowers serum Ca, short term and symptom benefit
IV bisphosphonates -> returns Ca to bone, longer term
?Denosumab -> if resistant to bisphosphonates, with specialist advice

59
Q

When should you consider malignant spinal cord compression?

A

Cancer which has spread to bone - breast, lung, kidney, thyroid, prostate
Primary lesions affecting spine less common

60
Q

What are the S&S of malignant spinal cord compression?

A

Depends on level - paraesthesia/sensory loss, weakness/functional loss, cauda equina, loss of bladder/bowel function
Back pain - red flag when waking up from sleep not on movement
Can be non-specific - off-legs with pack pain common

61
Q

How do you diagnose malignant spinal cord compression?

A

MRI spine - gold standard
If can’t have MRI - CT +/- myelography

62
Q

How do you manage malignant spinal cord compression?

A

High dose steroids - Dex 16mg
Nurse lying down
Radiotherapy
Surgery

63
Q

What can cause a major haemorrhage in palliative care?

A

Head and neck tumours
Lung tumours with Hx of bleeding
GI tumours with Hx of bleeding
Tumours near large blood vessels - direct invasion

64
Q

What often occurs before a major haemorrhage in palliative care?

A

Herald bleed
Small bleed before

65
Q

What are the S&S of a major haemorrhage?

A

Large volume of rapid blood loss
Rapidly loses consciousness

66
Q

How do you diagnose a major haemorrhage?

A

On sight
Consider in case of patient suddenly becoming shocked

67
Q

How do you manage a massive haemorrhage in palliative care?

A

Stop anticoagulation
Very dependent on care patient wanted -> medical emergency Tx if appropriate
If palliative likely terminal event - dark towels, remain with patient, midazolam 10mg stat

68
Q

When should you consider an opioid overdose in palliative patient?

A

On strong opioids
Change in condition including sudden improvement in pain

69
Q

What are the S&S of opioid toxicity?

A

Reduced level of consciousness
Reduced RR < 8/SpO2
Myoclonic jerks
Pinpoint pupils

70
Q

How do you diagnose an opioid overdose?

A

Clinical assessment
Response to treatment

71
Q

What is the management of opioid toxicity?

A

Naloxone -> different in palliative
Don’t want to completely reverse opioid action as don’t want them in pain
Dilute 400 micrograms in 10ml N saline and 20mcg every 2 mins until RR/conscious level improves
Close observations
Review dosing and discuss with senior/palliative care re need for further naloxone

72
Q

What is end of life care?

A

Likely to die within next 12 months

73
Q

Who is offered end of life care?

A

Patients whose death in imminent (hours to days)
Advanced, progressive, incurable diseases
General frailty and co-morbidities that mean they are expected to die within 12 months
Those at risk of dying from sudden acute crisis in existing condition
Life-threatening acute conditions caused by sudden catastrophic events

74
Q

What is advanced care planning?

A

Discussion with patients and those important to them about their wishes and thoughts for the future

75
Q

What is formal advanced care planning?

A

What they want to happen - not legally binding, advanced statement of wishes
What they don’t want to happen - advanced decision to refuse treatment, legally binding
Who will speak for them - lasting power of attorney for health and welfare

76
Q

What are the signs that someone may be dying?

A

Weight loss and poor appetite
Deteriorating mobility
Needing more assistance for ADLs
Social withdrawal
Changes in consciousness
Fatigue and sleeping more
Struggling with medications
CVS changes - pulse strength, change in colour, mottled skin
Resp changes - noisy secretions, laboured breathing, apnoeic episodes, Cheyne-Stokes breathing

77
Q

What are the 5 priorities in care of the dying?

A

Recognition
Communication
Involving family and patient
Needs of those identified as important to dying person actively explored, respected and met
Individual plan agreed and delivered with compassion

78
Q

What are the 5 key symptoms that can be controlled in the dying person?

A

Pain
Breathlessness
Respiratory secretions
N&V
Distress/agitation (delirium)

79
Q

What medication can be given for pain?

A

Morphine

80
Q

What medication can be given for breathlessness?

A

Morphine

81
Q

What medication can be given for secretions?

A

Buscopan

82
Q

What medication can be given for agitation?

A

Midazolam

83
Q

What medication can be given for nausea?

A

Haloperidol

84
Q

What should you always do in terms of nutrition and hydration for those dying?

A

Mouth care -> keep clean and moist
Support oral food and drink for as long as someone wants it and is able - enjoyment not quantity
Regular review for symptoms related to reduced fluid intake

85
Q

What should you ensure if the decision is made to use fluids?

A

Ensure no harm to patient
Agree an aim
Agree when you will review and when you would stop
Decide on a route and volume
Basic care still needed - support with oral fluids and regular mouth care, regular review to assess fluid status

Phase 3b (6 decks)

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