Palliative care

Question 1

What is palliative care?

Answer 1

It is not just for the end of life and it is not just for patients with cancer

should run in parallel with other medical treatments. Good symptoms control is important in any disease for improving quality of life and may even prolong survival

Question 2

WHO analgesic ladder:

Answer 2

Increase and decrease the analgesia required according to the ‘steps’ on the ladder:

1. non-opioid, eg paracetamol
2. opioid for mild to moderate pain, eg codeine, tramadol
3. opioid for moderate to severe pain, eg morphine, diamorphine, oxycodone

Question 3

factors to bare in mind with WHO analgesic ladder

Answer 3

• persisting or increasing pain and side-effects inform the decision to step up and step down. Take one step at a time to achieve pain relief without toxicity (except in new, severe pain when step 2 may be omitted)
• paracetamol at step 1 may have an opiate-sparing effect, and should be continued at steps 2 and 3. stop step 2 opioids if moving to step 3
• use laxatives and anti-emetics with strong opioids
• adjuvants which can be added at all steps include: NSAIDs, amitriptyline, pregabalin, corticosteroids, nerve block, transcutaneous electrical nerve stimulation (TENS), radiotherapy

Question 4

In addition to the treatment of cancer pain: WHO ladder

what other medications should be given?

Answer 4

Medications for neurophathic pain eg. amitriptyline, gabapentin

consider non-pharmacological treatments

Question 5

Highly potent opioid for chronic breakthrough pain?

Answer 5

Fentanyl

Question 6

Non-pain symptoms you may come across in palliative care include?

Answer 6

N+V
Constipation
Breathlessness
Oral problems
Insomnia
Pruritus
Venepuncture
Agitation
Respiratory tract secretions

Question 7

N+V managment?

Answer 7

treat reversible causes, eg laxatives for constipation, analgesia for pain, hypercalcaemia, fluconazole for oral candidiasis

Anti-emetic choice should be based on likely mechanism of nausea

Question 8

Anti-emetic options: palliative care include?

Answer 8

Cyclizine: antihistamine, anticholinergic, central action so good for intracranial disorders

Metoclopramide: blcoks central chemoreceptor trigger zone, peripheral prokinetic effects so good in gastroparesis

Domperidone: peripheral antidopaminergic so no dystonic effects

Haloperidol: dopamine antagonist, effective in drug or metabolically induced nausea.

Ondansetron: serotonin antagonist, good for chemo/radiotherapy related nausea, may cause constipation

Levomepromazine: broad spectrum, but can sedate, may be very effective if fear/anxiety are contributing to symptoms

Question 9

Constipation is common in palliative care due to:

Answer 9

Very common side effect of opioids - better to prevent than treat so prescribe laxatives to all patients on opioids.

Also due to hypercalcaemia, dehydration, drugs or intra-abdominal disease

Question 10

Management of constipation

Answer 10

treat reversible causes. good fluid intake, Medication options include:

• stimulant (eg senna or bisacodyl) at night +/- softner (eg sodium docusate)
• osmotic laxative (eg macrogol)
• rectal treatments (bisacodyl/glycerol suppositories, phosphate enema)

Question 11

Breathlessness management?

Answer 11

• treat reversible causes as appropriate
• if patient remains distressed consider course of low-dose opioids
• benzodiazepines may help anxiety eg lorazepam

Question 12

Insomnia management?

Answer 12

Terminally ill patients may experience physical and emotional exhaustion

appropriate room temp, darkenss, quiet room, glucocorticoids in the morning

Question 13

Pruritus causes?

Answer 13

Itchy skin is an irritating sensation that makes you want to scratch

systemic disease, cancer-related, primary-skin disease, drug reaction