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Saaliha Part 4 – PM4B > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

What is palliative care?

A
  • Holistic care of patients with advanced progressive illness
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2
Q

What does palliative care involve?

A
  • Pain management
  • Management of other symptoms
  • Psychological, social and spiritual support
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3
Q

Goal of palliative care

A

Achieve best QoL for patients and their families

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4
Q

Conditions you would expect to see in palliative care

A
  • Cancer
  • Respiratory diseases
  • Organ failure
  • HIV/AIDs
  • Neurological conditions e.g. MS, PD, AD, MND
  • Frailty
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5
Q

Individuals involved in palliative care

A
  • Nurse specialists
  • Pharmacists
  • Psychologists
  • OT
  • Physio
  • Social worker
  • Medical staff
  • Volunteers
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6
Q

How is palliative care delivered

A
  • Outpatient/inpatient units
  • Day Hospice
  • Hospice at home
  • Charities
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7
Q

Role of pallative care team in supporting carers

A
  • Juggling responsibilities, respite
  • Emotional support
  • Financial support
  • Making difficult decision, legal issues, planning ahead
  • Bereavement: death certificate, notifying people, probate, funeral arrangements
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8
Q

Role of pallative care team in supporting patients

A
  • Telling family/friends/children you are dying
  • Making a will
  • Planning your funeral
  • Organ donation
  • Power of attorney
  • Where you would like to die
  • Specialist equipment
  • Just in case medicines
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9
Q

Pharmacist role in palliative care

A
  • Dose recommendations and conversions
  • Drug interactions
  • IV/Syringe driver compatibility, dilutions, rate of infusion
  • Patient monitoring
  • Review of long term medications
  • Drug Induced vs disease induced symptoms
  • Drug handling – comorbidities
  • Controlled drug prescribing and disposal
  • Unlicensed drug advice
  • Consultations
  • Writing policies and guidelines
  • Supply EoL medication for patients at home
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10
Q

What is the pharmacist’s role in concordance?

A
  • Emphasise adherence - large numbers of medications, complex regimes
  • Discuss alternative formulation/treatments
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11
Q

What is the pharmacists role in patients beliefs about medication

A
  • Use of opioids
    • Fear of dependence, tolerance
    • Alternative treatments
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12
Q

Key symptoms in palliative care

A
  • N + V
  • Dysphagia
  • Odynophagia (painful swallowing)
  • Dyspnoea
  • Fatigue
  • Bone pain
  • Constipation
  • Anorexia (lack of appetite - not the ED)
  • Xerostomia (dry mouth due to lack of saliva)
  • Anxiety
  • Depression
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13
Q

Common SE of analgesics

A
  • Constipation
  • Drowsiness
  • Confusion
  • Xerostomia
  • Fatigue
  • Hypotension
  • Hallucinations
  • N + V
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14
Q

Pain

A
  • An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
  • Subjective
  • Consider all aspects of pain:
    • Physical aspects
    • Social aspects
    • Physiological aspects
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15
Q

Principles of pain management

A
  • Understand cause to optimize treatment
  • Appropriate level of WHO ladder
  • Use adjuvants where necessary
  • Use oral where possible
  • Assess regularly, use pain charts
  • Encourage patients to take an active role in the management of their pain
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16
Q

Causes of pain

A
  • Nociceptive
  • Somatic
  • Visceral
  • Neuropathic
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17
Q

Opioids for pain management

A
  • 1st line = morphine Appropriate level of WHO ladder
  • Background and breakthrough
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18
Q

Breakthrough pain management

A
  • Regular opioid + Breakthrough opioid
  • Regular opioid = typically long acting 12 or 24 hour preparations.
  • Breakthrough = immediate release preparations, given PRN when pain worsens.
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19
Q

Monitoring

A
  • Use pain charts
  • Individual dose titration
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20
Q

Discuss the use of syringe drivers

A
  • SC
  • Administer meds continuous to pt over a period of time
  • Dose reviewed every 24 hours, titrated up/down as needed - dependent on symptoms/side effects.
  • May still require breakthrough doses
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21
Q

When are syringe drivers useful?

A
  • Intractable pain
  • Vomiting
  • Severe dysphagia (patient too weak to swallow or unconscious)
  • Several drugs can be combined into one syringe - management of multiple symptoms.
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22
Q

Compatibility charts

A
  • For syringe drivers
  • Summarises compatibility information available for drug combinations
  • Determines if drugs can be mixed or if they will precipitate
  • Maximum concentrations
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23
Q

3 examples of palliative care emergencies

A

Neutropenic sepsis
Malignant spinal cord compression (MSCC)
Malignant hypercalcaemia

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24
Q

Malignant hypercalcaemia

A
  • Palliative care emergency
  • Sign that disease has significantly progressed (most paitnets with this die within a year)
  • Ca>2.6mmol/L
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25
Malignant hypercalcaemia - treatment
1. Fluid replacement (1-2L NaCl 0.9% over 24h) - Given before bisphosphonates as nephrotoxic. 2. Bisphosphonates: zolendronate or pamidronate - Treatment effective for 2-4 weeks in 70-80% of pt - Reduce rose in renal impairment - Ca2+ levels fall after 48h and continue to decrease for 6/7 days - Monitor
26
Zolendronate
4mg/100ml in normal salin for 15 mins
27
Pamidornate
- <3.5mmol/L = 60 mg - >3.5 mmol/L = 90 mg - BOTH in normal saline over 2-4 hours
28
Malignant hypercalcaemia - MoA
- Due to parathyroid hormone-related protein - Normally expressed in cells but also secreted by tumour cells - PTHrP stimulates bone resorption - Increased osteoclast activity (breaks down old bones, releases calcium) - Increases calcium reabsorption so decreases urinary excretion of calcium - Higher serum calcium
29
Symptoms of malignant hypercalcaemia
- Symptoms typically present with >3mmol/L - N+V - Drowsiness - Confusion - Constipation - Anorexia - Fatigue - Mood disturbances, delirium - Symptoms are general, so regular monitoring of Ca levels is essential
30
Spinal cord compression
- Pressure on the spinal cord - Nerves in the spinal cord swell and slow down or their blood supply is blocked. - Nerves cannot function as normal.
31
Spinal cord compression - symptoms
- Progressive pain in spine - Spinal pain aggravated by straining - Nocturnal spinal pain preventing sleep - Limb weakness - Difficulty walking - Bladder or bowel dysfunction - Sensory defecits
32
Spinal cord compression - treatment Rationale for using dexamethasone in malignant spinal cord compression
- Dexamethasone - Reduces oedema - Inhibits inflammatory response - Delays onset of neurological symptoms - Better ambulatory outcomes
33
What is Malignant spinal cord compression (MSCC)?
Complications of cancer where there are metastases in spine
34
Symptoms of MSCC
- pain - motor deficits, - autonomic deficits - sensory deficits
35
MSCC Investigation
Palliative care emergency - urgent referral for MRI
36
Malignant spinal cord compression and treatment
- dexamethasone 16mg OD as soon as suspected - analgesia: follow WHO ladder - radiotherapy - surgery - If both radio+surgery, patient has 85% chance of being ambulatory post treatment comapred to 50-60% if just radio
37
Malignant hypercalcaemia - medical emergency
- >4mmol/L - Seizures - Arrhythmias - Untreated will die in a few days
38
Neutropenic sepsis
- Medical emergency - Neutrophil count <0.5 x 10^9/L and a temperature >38, or any symptoms or signs or sepsis - Can occur in any pt who has received chemotherapy within the last 4 weeks - Rapid progression of symptoms - leads to shock and death - Rapid referral essential
39
Treatment of neutropenic sepsis
Broad spectrum abx IV within one hour e.g. tazocin 4.5g TDS + gentamicin 5mg/kg OD
40
Monitoring in neutropenic sepsis
- U&E - FBC - LFTs - CRP - Blood cultures - Urine and sputum cultures - Chest X ray - Look for focus of infection - consider fungal
41
Late signs that pt dying
- Agitation - Decreased consciousness - Mottled skin - Cheyne-stokes breathing (very fast followed by quieter and slower breathing in a cycle) - Noisy respiratory secretions
42
Early signs a patient is dying
- Fatigue - Weight loss/loss of appetite - Decreased mobility and performance - Social withdrawal - Changes in communication
43
Aim when a patient is dying
- Comfort and symptom management - Stop unnecessary investigations, observations and medication
44
Common symptoms at end of life
- Pain - Anxiety, agitation, delirium - N+V - Respiratory secretions
45
Malignant bone pain
- Localised, aching pain - Secondary bone cancer: - Osteoclasts break down too much bone - Increased risk of fractures - Causes malignant bone pain
46
Osteoblasts
Help build up new bone
47
Osteoclasts
Break down old bone
48
Treatment of malignant bone pain
- Denosumab - human Mab - Targets RANKL protein which is needed for new osteoclasts to be made and function - Stops production of osteoclasts - Prevent further breakdown of bone, reduces bone pain, reduces risk of fractures
49
N+V and management
- Determine root cause - Look at neuronal pathways, find trigger
50
N + V caused by higher cortical centres
Benzodiazepines - Stomach or small intestine: 5-HT3 antagonist
51
N + V caused by chemoreceptor trigger zone
- Histamine antagonist - Muscarinic antagonist - Dopamine antagonist - Cannabinoids
52
What to give in n+v caused by cancer chemo or radiotherapy
* 1st line: ondan, dex * Need to follow cancer guidelines
53
What antiemetic to give when N+V has uncertain cause
1st line: haloperidol and/or cyclziine 2nd line: levomepromazine
54
What to give in n+v caused by drugs/biochemical
1st line haloperidol 2nd line levomepromazine
55
Neuropathic pain
- Shooting, stabbing, electric shock-like sensation - Occurs due to nerve damage caused by cancer
56
Neuropathic pain - amitriptyline
- Increases NA in spinal cord, which directly inhibits neuropathic pain through the A2 adrenergic receptors - Increased NA also acts on local coeruleus and improves function of descending neurogenetic inhibitory system - Dopamine and serotonin can reinforce noradrenergic effects to inhibit the neuropathic pain
57
Neuropathic pain - gabapentin
- Binds to the A2D1 which normalises the NMDA-R targeting and inactivity - Thus reduces neuropathic pain - Neuropathic pain tend to have overexpression of A2D1
58
A2D1
Potentiates pre and post-synaptic NMDA-R activity of the spinal dorsal horn neurones. Causes pain and hypersensitivity
59
Constipation
- Mild to very severe - Very severe = faecal impaction or partial bowel obstruction - - Risk of intestinal obstruction - Causes Pain
60
Causes of constipation
- Poor food and liquid intake - Lack of exercise - Lack of privacy - off putting for patients to pass stool - Drugs - Opioids - Ondansetron, octreotide, iron - Hypercalcaemia - Hypokalaemia - Hypokalaemia
61
Management of constipation
○ Address diet - Increase fluid + fibre intake if possible, - Increase mobility - Good toilet hygiene/privacy - If on opioids give regular laxatives: - Combination - Softener and stimulant e.g. macrogol with senna, docusate with sodium picosulfate
62
Are bulk forming laxatives e.g. magrogol given in opioid induced constipation
No
63
Confusion/agitation & causes
* Dementia * Cerebral metastases * Infection e.g. UTI * Medication * Electrolyte disturbances - high calcium, low sodium, low blood glucose * Drug or alcohol withdrawal, psychological distress + pain * Constipation or urinary retention
64
Treatment of confusion/agitation
- Consider reversible/ underlying cause - Treat as for delirium: - Benzodiazepines: midazolam, lorazepam - Antipsychotics: low dose, e.g. haloperidol
65
Role of pharmacist in palliative care emergencies
- Early spotting of symptoms can improve outcomes - Advice on dosing of medications and monitoring
66
What does the MDT do when a pt admitted to pallaitve care
- Medicine - remove uncessary meds/make switches - Review pain levels - Home situation: - Hospice or home? - If at home, provide appropriate bed/carer
67
Common symptoms and treatments for it at EoL
Pain - Morphine, diamorphine (more potent) Anxiety, agitation, delirium - Midazolam N+ V - Haloperidol Respiratory secretions - Hyoscine antimuscarinic dries out the secretions - Poor oral availability - SC injection - 20mg PRN or put in syringe driver

Saaliha Part 4 – PM4B (73 decks)

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