palliative care Flashcards
e.g. simple anaglesia
paracetamol, nsaids
mechanism action paracetamol
inhibits production cns prsotaglandins
mechanism of action nsaids
inhibit cox enzyme in synthesis of prostaglandins
CI to nsaids
GI bleeding, ulcer hx, asthma
strong opioids
morphine, oxycodone, fentanyl, buprenorphine, diamorphine
weak opioids
codeine, dihydrocodeine, tramadol
opioids only used in palliative care
hydromorphone, alfentanil, diamorphine
SE opioid
common: constipation, nausea, sedation, dry mouth
less common: psychometric, confusion, myoclonus
rare: pruritis, resp depression, allergy
breakthrough pain dose
1/10 to 1/6 24 hr dose
strength of codeine and tramadol compared to oral morphine
1/10
what do you prescribe for SE of opioids
stimulant laxative and antiemetic
what opioids come in patches
fentanyl, buprenorphine
renal friendly opioids
oxycodone, fentanyl, buprenorphine, methadone, alfentanil
how strong is SC compared to oral opioid
2x
adjuvant analgesics
AD, antiepileptics, antisposmodics, steroids, benzos, local anaesthetics, bisphosphonates
how much should you increase the opioid dose by?
30-50%
which antiemetics for n+v due to reduces gastric motility
metoclopramide and domperidone
antimetic for chemically mediated N+V
ondansetron, haloperidol, levomepromazine
antiemetics for visceral/serosal N+V
cylclizine, levomepromazine
antimetics for raised icp n+v
cyclicine
antiemetic for vestibular n+v
cyclizine
antiemetic for cortical n+v
short acting benzo=lorazepam
mechanism of action of metocompramide
dopamine antagonist
therefore treats n+v due to gastric dysmotility and stasis
mechanism of action ondansetron
serotonin (5-HT3) antagnoist
therefore treats N+v due to chemotherapy, radiotherapy, post-op, chemical (opiods)
mechanism of action cyclizine
antihistaminic, anticholinergic
therefore treats intracranial causes n+v
mx for agitation and confusion
haloperidol
others: chlorpromazine, levomepromazine
mx agitation and restlessness in terminal phase
midazolam
mx hiccups
chlorpromazine
mx secretions
avoid fluid overload
hyoscine butylbromide or hyoscine hydrobromide
causes and mx dyspnoea
HF: diuretics, ace i, nitrates, opioids
pneumonia: abx
bronchospasm: bronchodilators, steroids
SVCO: steroids, radiotherapy, chemo, stent
tracheal/bronchial obstruction: radiotherapy, stent
effusion/ascites: drain
anxiety: support, anxiolytics
examples of palliative care emergencies
febrile neutropenia, stridor, superior vena cava obstruction, hypercalcaemia, spinal cord compression, opioid OD, haemorrhage
who is neutropenic sepsis common in?
after chemo, haem patients, bone marrow infiltration and pancytopenia
sx neustropenic sepsis
temp>38, infection-often chest or urine
diagnosis neutropenic sepsis
clinical sepsis/>38 degrees, neutrophils < 0.5
mx neutropenic sepsis
dont wait for blood results
broad spectrum abx, fluids,
ix in neutropenic sepssi
fbc, u+e, lfts, crp, lactate, cultures
who is superior vena cava obstruction common in
lung cancer or tumour involving mediostinum
sx SVCO
facial swelling/red, periorbital oedema, engorged conjunctiva, arm swelling, breathless, distended chest veins
can be acute or chronic
ix for SVCO
CT chest
mx SVCO
dexamethason IV to reduce oedema
consider anticoag
stents, radio/chemo therapt
who is stridor common in
head, neck, lung or upper GI tumour
how is stridor detected
inspiratory noise
may not be breathless-late sign
need to visualise airway or ct
mx stridor
dexamethasone, oxygen or heliox
ent or oncology
tracheostomy, stent, radiotherapy
who is malignant hypercalcaemia common in
myeloma, thyroid/breast/lung/kidney cancers
sx maligant hypercalcaemia
acute: thirst, confusion, constipation
chronic; depression, abdo pain, constipatuon, caliculi=BONES, STONES, MOANS AND GROANS
mimics dying
diagnosis malignant hypercalcaemia
corrected Ca>2.6
mx malignant hypercalcaemia
IV fluids, IV bisphosphonates, +/-denosumab
who is malignant spinal cord compression common in
cancers that spread to bone-breast, lung, thyroid, kidney or prostate
sx malignant spinal cord compression
paraesthesia, loss of sensation, weakness, cauda equina, loss of bladder and bowel function
back pain at night
non specific
diagnosis malignant spinal cord compression
MRI
if cant- CT +/- myelography
mx malignant spinal cord compression
dexamethasone, radiotherpay, surgery if fitter
lost function may not be regained
who is massive haemorrhage common in
head/neck/lung/GI tumout
what is a herald bleed
small bleed that gives warning massive haemorrhage may occur
mx massive haemorrhagw
stop anticoag
depends on ceilings of care
if palliative likely terminal event: dark towels, comfort, midazolam 10mg to relieve stress
sx opioid toxicity
decreased consciousness, RR<8, myoclonic jerks, pinpoint pupils
SE opioids
confusion, hallucinations-shadows in corner of eyes, N+V, constipation
mx opioid OD in palliative patient
dont give full dose of naloxone as otherwise will be in pain
usually give 400mcg in 10ml saline and give 20mcg every 2 mins until improves
how to verify death
Identify the patient from their wristband
Feel for a carotid pulse to confirm absence
Assess pain response (i.e. squeeze trapezius muscle) to confirm absence
Use a pen torch to assess pupillary light response and confirm absence (i.e. fixed and dilated)
Auscultate for heart sounds for full minute to confirm absence
Auscultate for breath sounds for a full minute to confirm absence
Death is verified when all 6 of these have been done, and absence of all confirmed. The time at which this is completed should be noted - this is the official time of death for all legal purposes.
which deaths need referring to a coroner
Unknown cause of death
Identity of deceased is unknown
Death occurred during or shortly after a period of police custody
No attending medical practitioner available to sign death certificate
Death may be due to undergoing a medical treatment or procedure
Death may be attributable to a person’s employment
All deaths within 24 hours of admission to hospital
When not seen by a medical practitioner in the 28 days prior to death
Poisoning (deliberate or accidental)
Exposure to toxic substances (including radioactive material)
Intake of medicinal products, controlled drugs or psychoactive substances (i.e. overdoses)
Death may be due to violence, trauma or injury (inflicted by someone else, themselves or an accident, including falls and road traffic accidents)
Death may be due to self-harm, or suicide
Death may be due to neglect, or self-neglect self-neglect or neglect on the behalf of others
Death may be due to an abortion
what is 1a on a death certificate
These are diseases or illnesses which directly cause death - i.e. infections, acute events, life-limiting chronic illnesses
The Royal College of Pathologists issues a regularly updated ‘cause of death’ list (see References and Resources) as a guide
The top 5 causes of death (1a) in England and Wales (as of 2021):
- Dementia
- Ischaemic heart disease
- Lung cancer
- Stroke
- Chronic obstructive pulmonary disease
what are 1b or 1c on a death certificate
1b is what may have led to 1a, and 1c is what may have led to 1b
what is 2 on a death certificate
2 are other contributing conditions (not directly leading to 1a)
how to break bad news-spikes
S Setting
P Perception
I Invitation
K Knowledge
E Emotion and empathic response
S Strategy and summary
managing medicines in last few days of life
current medication reviewed;: unnecessary medicine discontinued, consider alternate route/preparation for essential meds
pre-emptivr prescribing for: Prescribe subcutaneous ‘as required’ pre-emptive medication on the ‘as
required’ part of the medication chart for the following symptoms.
Pain
Breathlessness/Dyspnoea
Terminal Restlessness and Agitation
Nausea and Vomiting
Respiratory Tract Secretions
pre-emptive prescribing
Pain – morphine, ideally in a syringe driver, dose dependent on current medication
Breathlessness – morphine PRN 1-2 hourly
Agitation – midazolam PRN hourly
Secretions – hyoscine butylbromide PRN hourly
Nausea – haloperidol PRN 4 hourly
Mouth care, comfort cares
converting codeine and tramadol to morphine
Codeine and tramadol are 1/10th as potent as morphine
