Palliative care Flashcards
Triggers suggesting patients are nearing end of life
- Surprise question: Would you be surprised if this patient were to die in the next few nonths/weeks/days?
W. General indicators of decline, deterioration, increasing need or choice for no further active care - Specific clinical indicators related to certain conditions
Common symptoms during life limiting illenss
pain
Breathlessness
Nausea and vomiting
Agitation
Delirium
Fatigue, weakness
Constipation
Anxiety and depression
Poor appetite
Drowsiness
Two situations in which a DNACPR decision should be made
- CPR willnnot be successful
- CPR may be successful
a) but mat not be seen as clinically appropriate because of the likely clinical outcomes
OR b) patient with mental capacity does not want to be resuscitated
Nociceptive vs neuropathic pain
noficeptive is arising from somatic or visceral tissue damage then reported by an intact nervous system
Neuropathic is from consequence of lesion or disease affecting somatosensory system. More likely allodynia, hyperaesthesia, electric shock, shooting, or burning pains.
Pain step ladder
- non-opioid, eg paracetamol, aspirin, NSAID with or without adjuvant
- Weak opioid (codeine) for mild to moderate pain, +/-non opiate, +/- adjuvant
- Strong opioid for moderate or severe pain (morphone) +/- non opioid +/-adjuvant
concept of total pain
Acknowledging physical, psychological, social qnd spiritual influence on persons pain perception and th effect it is having on a persons life. All areas to be addressed in orde to manage pain
weak opioids example and dose range
codeine 15-60mg QDS
tramadol 50-100mg QDS
*both metabolized to active metabolite, codeine metabolism very variable so wide range of responses
morphine use
first line strong opioid, if opiate naice, start 2.5_5mg PO up to QDS
Oxycodone use
semi synthetic opioid, safer than morphine in renal impairment (eGFR <30)
Fentanyl and alfentanil use
Strong opioids
Not orally available, transdermal, transmucosal or iv possinle
Safe in renal failure
Transdermal good if unable to swallow
Buprenorphine use
available as transdermal patch, useful if unable to swallow
Safe in renal failufe
Common side effects of all opiates
constipation (always coprescribe a laxative)
Nausea
Drowsiness initallt then wears off
Unsteadiness
Dry mouth
Immunosuppression
Sweating
Itch
Urinary retention
Dependence - but less likely when used correctly for pain
Signs of opiate toxicity
drowsiness, delirium, hallucinations, myoclonic jerkinf of the limbs, reduced resp rate
Reduced below 8= potentially life threatening toxicitiy
Just start low and titrate up carefully
Use of naloxone in pall care
if opiate recersl is necessary, naloxone can be used but at much lower dose than in recreational overdose as risk of severe reboound pain and pulmonary oedema.
converting codeine to morphine
codeine PO or dihydrocodein PO /10 –> morphine PO
Converting tramadol to oramorph
tramadol PO /10 –> morphine PO
Converting oramorph to subcut morphine
morphine PO /2 –> morphine SC
Oral morphine formulations
Immediate release = Oramorph, quick acting, lasts 2-6hrs
Modified release = designed to last 12hrs : This should be basically regular with oramorph for PRN topups (1/6 dose of MR)
Steroid side effects
deranged glycemic control
Immunosuppression
Psychiatric disturbance
Proximal muscle wasting
Osteoporosis
Peptic ulceration
Use of anticonvulsants as adjuvants
eg gabapentin, pregabalin, carbemazepine, valproate
For neuropathic pain
Common issues: Tremor, drowsiness, oedema
Use of antidepressants for neuropathic pain
eg amitriptyline and duloxetine
SE: Sedation, dry mouth, postheal hypotension
use of NMDA antagonists for neuropathic pain
Ketamine this is a big new thing I think
SE: Dissociation, haemorrhagic cystitis
Use of bisphosphonates for bone pain
et pamidronate, zoledronic acid
SE: Flu like symptoms. Also very annoying to take
Use of topical agents for neuropathic pain
eg capsaicin, lidocaine, EMLA
May cause skin irritation
Possible non pharmacological methods for pain relief
physiotherapy
TENSmachine
Acupuncture
Radiotherapy
Nerve blocks
Neurosurgical options
Pathophysiology of nausea
Centrally by vomiting centre and chemoreceptor trigger zone - this is in floor of fourth ventricle, so very trigger-able by electrolyte disturbance (hyperfalcaemia, uraemia), or presence of drugs in blood (Plat chemo or opiates)
Also higher cerebral areas triggered by raisedICP and anxiety
Vestibular areas triggered by movements
Autonomic afferents from gut can be triggered by stretch (bowel obstruction) or damage (eg radiotherapt)
prokinetic drugs action and indication
Trigger cholinergic system in wLl of GI tract and centrally on dopaminergic receptors at chemoreceptor trigger zone
Indic: Gastric stasis, ileus, post chemo
Metoclopramide
=prokinetic
Combined D2 receptor antagonist and 5HT4 receptor antagonist
10-20mg up to QDS oral or SC
SE: Extrapyramidal effects, do not use in PD
Domperidone
D2 receptor antagonist
Afts as prokinetic
10mg TDS oral
Must be oral or rectal, otherwise possible arrhythmias
SE: Gynaecomastia, galactorrhoea, amenorrhoea, EPSEs v rare
antipsychotics for emesis action and indication
act centrally on dopamine, histamine serotonin and anticholinergic systems at chemorecceptor trigger zone
Indic: Chemical or metabolic causes of nausea
Haloperidol
0.5-1mg TDS po or SC
D2 receptor antagonist T chemoreceptor zone
SE sedation EPSEs, lowered seizure threshold
levomepromazine
antipsychotic for chemical or metabolic cause of nausea
Acts on multiple receptors
6.25-12.5mg QDS po or SC
Side effects: Drowsiness, antimuscarinic effects, lowers seizure threshold
Antihistamines for nausea action and indication
act on histamine receptors in CNS and gut
Indic: Cerebral and vestibular causes of nausea, eg raised ICP
Cyclizine
antihistamine used for nausea caused by raised ICP or other cerebral/vestibulR cause
50mg TDS oral or SC
Side effecrs: Drowsiness, caution in heart failure (anti muscarinic effect -> tachycardia), constipation
5HT3 antagonists for nausea action and indic
acts on 5HT3 receptors in gut and chemoreceptor trigger zone
Use post op or post chemo or radiotherapy
Ondansetron
5HT3 antagonist for post op/chemp/radio nause fontrol
4-8mg BD po or sc
SE: Constipation, headache
Steps for managing constipation in a hospice
- Examination including PR
- Treat exacerbating factors
- Laxatives
Exacerbating factors for constipation
Drugs eg opioids, anti jistamines, anti cholinergic
Encourage fluid intake and mobilizing
Consider electrolyte derangement
Softening laxatives
Macrogols (laxido, movicol, lactulose): Osmotic action draws fluid into bowl and incr volume of stool which stimulates peristalsis. Need good hydration
Docusate 100-200mg up to TDS. Surface wetter
Stimulant laxatives
senna: 7.5-15mg up to BD, stimulates large bowel
Bisacodyl
when does malignant bowel obstriction occur
typically advanced cancer patients with abdominal and pelvic malignancies. 5.5-42% of those with ovarian carcinoma and 4.4-24% of those with colorectal cancer
Surgical treatments for malignant bowel obstrufiton
resection, stoma formation, stenting
Consider both patient and pathology, eg much more successful in solely large bowel than large and small
And fitness of patient to withstand and recover from major surgery
Decompression tube management of obstructed bowel
NG rube decompression and bowel rest, may be supportive symptomatically and allow recovey
Pharmacological management of malignant bowel obstriction
analgesia to manage pain parenterally
Anticholinergics eg hyoscine butylbromide or octreotide to reduce GI secretions
Steroid eg dex 6-8mg BD SC to reduce bowel swelling
Anti emetics
What anti emetic if partial obstruction (intermittent opening and passing flatus) and no colicky pain
prokinetics eg metaclopramide
Antiemetics for patients with complete obstrufiton or bad pain
cyclizine/haloperidol/levomepromazine (not a prokinetic)
Treatment options for dyspnoea
- Specific disease management, eg drain plural effusion
2: Non pharm intervention: Breathing training, walking aids, exercise, handheld fan - Pharm trearmenr: Oxygen and opioids, maybe anxiolytics
Prevalence of cough with advanced disease
very common
43% or general cancer patients, more of lung
Management of cough
- Treatment of cause - radio, chemo, steroids
- Anti-tussives eg simple linctus, codeine, morphine
Patients who get malignant spinal cord compression
25% of patients with lung cancer
16%of patients with prostate cacner
11% patients with myeloma
Often from Mets in bone of spine
Signs and symptoms of malignant spinal cord compression
tumour causes direct or indirect pressure on spinal cord leading to
Acute onset radicilar pain
Pain exacerbated by neck extension/coughing
Weakness is late sign, moves from flaccid paralysis to spasticity
Sensory changes
Bowel/bladder dysfunc
Basically cauda equina
Management of malignant spinal cord compression
immediate high dose (16mg) dexamethasone
Confirm diagnosis with same day MRI
Urgent assessment to consider surgery, radiotherapy or conservative treatment
Not a good prognostic sign
superior vena cava obstruction who and how
extrinsic compression by metastases in upper mediastinal lymph nodes
Lung cancer responsible for 80% of cases
And occurs in 15% of lung cancer patients
Signs and symptoms of superior vena cava obstruction
dyspnoea
Neck and facial swelling, worst in morning
Trunk and arm swelling
Sensation of choking
Thoracic and neck vein distension
Facial oedema and plethora
Tachypnoea
Management of superior vena cava obstruction
High dose Dex 16mg daily
Then SVC stent insertion and maybe chemo/radio if wanted
Malignant hypercalcaemia numbers
Corrected Ca > 2.6
Emergency if >3
Malignant hypercalcaemia who and why
Commonest life threatening metabolic disorder associated with cancer
10-20% of patients with cancer
50% of patients with breast and myeloma, also common in lung and renal
Associated with metastatic disease
80% of those with malignant hypercalcaemia will die within a year, median survival 3-4 months
Common mediator = cancer secreted parathyroid hormone related protein
Signs and symptoms of malignant hypercalcaemia
mild: Polyuria, polydipsia, fatigue, lethargy, mental dullness, anorexia, constipatipn = non specific as anything (moans, stones, bones, groans)
Severe: Nausea, vomiting (-> dehydration), ileus, delirium, drowsiness, coma
Management of malignant hypercalcaemia
rehydrate w IV fluids
Bisphosphonates eg zolendronic acid 4mg over 15 mins IV -takes at least 3 days to improve Ca enough to make symptomsmbetter
What to do if severe haemorrhage is terminal
One person stay with patient and call for help
dark coloured towels
Focus on sedation and comfort
Administer an anxiolytic
Risks for severe haemorrhGe
tumour near blood vessel
Herald bleed/pulsation under tumour
Infection/inflammation in tumour
Recent radio/chemotherapt
Clotting disorders
Drugs
Severe distress at time nearing death
Carefully assess to look for driver of agitated restlessness
If no signs of pain and not improving with analgesia, not hypoxic, not constipated and not distressed then consider whether delirium/fear
importanCe of calm, consistent approach
First line: Haloperidol and midazolam
2nd line: Levomepromazine
3rd line: Phenobarbital and propofol
Tranexamic acid
Can be quite helpful for Reducing volume and frequency of bleeds for something eroding into venous areas/capillary bed.
Will have little impact on an arterial bleed
Key approach to managing a dying patient
Recognise- appropriate recognition of active dying or high risk of dying
Communicate and involve - patient, those close to them, the team. Think how preferences and views may inform plan
Plan and do - to manage symptoms now or concerns in future
Support - consider other needs and ant other professionals needed
Review - regularly to ensure plan is achieving goal and diagnosis of dying remains correct
