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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
Q

Malignant hypercalcaemia - treatment

A
  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
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26
Q

Zolendronate

A

4mg/100ml in normal salin for 15 mins

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27
Q

Pamidornate

A
  • <3.5mmol/L = 60 mg
  • > 3.5 mmol/L = 90 mg
  • BOTH in normal saline over 2-4 hours
28
Q

Malignant hypercalcaemia - MoA

A
  • 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
Q

Symptoms of malignant hypercalcaemia

A
  • 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
Q

Spinal cord compression

A
  • 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
Q

Spinal cord compression - symptoms

A
  • 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
Q

Spinal cord compression - treatment
Rationale for using dexamethasone in malignant spinal cord compression

A
  • Dexamethasone
  • Reduces oedema
  • Inhibits inflammatory response
  • Delays onset of neurological symptoms
  • Better ambulatory outcomes
33
Q

What is Malignant spinal cord compression (MSCC)?

A

Complications of cancer where there are metastases in spine

34
Q

Symptoms of MSCC

A
  • pain
  • motor deficits,
  • autonomic deficits
  • sensory deficits
35
Q

MSCC Investigation

A

Palliative care emergency - urgent referral for MRI

36
Q

Malignant spinal cord compression and treatment

A
  • 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
Q

Malignant hypercalcaemia - medical emergency

A
  • > 4mmol/L
  • Seizures
  • Arrhythmias
  • Untreated will die in a few days
38
Q

Neutropenic sepsis

A
  • 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
Q

Treatment of neutropenic sepsis

A

Broad spectrum abx IV within one hour
e.g. tazocin 4.5g TDS + gentamicin 5mg/kg OD

40
Q

Monitoring in neutropenic sepsis

A
  • U&E
  • FBC
  • LFTs
  • CRP
  • Blood cultures
  • Urine and sputum cultures
  • Chest X ray
  • Look for focus of infection - consider fungal
41
Q

Late signs that pt dying

A
  • Agitation
  • Decreased consciousness
  • Mottled skin
  • Cheyne-stokes breathing (very fast followed by quieter and slower breathing in a cycle)
  • Noisy respiratory secretions
42
Q

Early signs a patient is dying

A
  • Fatigue
  • Weight loss/loss of appetite
  • Decreased mobility and performance
  • Social withdrawal
  • Changes in communication
43
Q

Aim when a patient is dying

A
  • Comfort and symptom management
  • Stop unnecessary investigations, observations and medication
44
Q

Common symptoms at end of life

A
  • Pain
  • Anxiety, agitation, delirium
  • N+V
  • Respiratory secretions
45
Q

Malignant bone pain

A
  • Localised, aching pain
  • Secondary bone cancer:
    • Osteoclasts break down too much bone
    • Increased risk of fractures
    • Causes malignant bone pain
46
Q

Osteoblasts

A

Help build up new bone

47
Q

Osteoclasts

A

Break down old bone

48
Q

Treatment of malignant bone pain

A
  • 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
Q

N+V and management

A
  • Determine root cause
  • Look at neuronal pathways, find trigger
50
Q

N + V caused by higher cortical centres

A

Benzodiazepines
- Stomach or small intestine: 5-HT3 antagonist

51
Q

N + V caused by chemoreceptor trigger zone

A
  • Histamine antagonist
  • Muscarinic antagonist
  • Dopamine antagonist
  • Cannabinoids
52
Q

What to give in n+v caused by cancer chemo or radiotherapy

A
  • 1st line: ondan, dex
  • Need to follow cancer guidelines
53
Q

What antiemetic to give when N+V has uncertain cause

A

1st line: haloperidol and/or cyclziine
2nd line: levomepromazine

54
Q

What to give in n+v caused by drugs/biochemical

A

1st line haloperidol
2nd line levomepromazine

55
Q

Neuropathic pain

A
  • Shooting, stabbing, electric shock-like sensation
  • Occurs due to nerve damage caused by cancer
56
Q

Neuropathic pain - amitriptyline

A
  • 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
Q

Neuropathic pain - gabapentin

A
  • 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
Q

A2D1

A

Potentiates pre and post-synaptic NMDA-R activity of the spinal dorsal horn neurones.
Causes pain and hypersensitivity

59
Q

Constipation

A
  • Mild to very severe
  • ## Very severe = faecal impaction or partial bowel obstruction
    • Risk of intestinal obstruction
    • Causes Pain
60
Q

Causes of constipation

A
  • 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
Q

Management of constipation

A

○ 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
Q

Are bulk forming laxatives e.g. magrogol given in opioid induced constipation

A

No

63
Q

Confusion/agitation & causes

A
  • 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
Q

Treatment of confusion/agitation

A
  • Consider reversible/ underlying cause
  • Treat as for delirium:
  • Benzodiazepines: midazolam, lorazepam
  • Antipsychotics: low dose, e.g. haloperidol
65
Q

Role of pharmacist in palliative care emergencies

A
  • Early spotting of symptoms can improve outcomes
  • Advice on dosing of medications and monitoring
66
Q

What does the MDT do when a pt admitted to pallaitve care

A
  • Medicine - remove uncessary meds/make switches
  • Review pain levels
  • Home situation:
    • Hospice or home?
    • If at home, provide appropriate bed/carer
67
Q

Common symptoms and treatments for it at EoL

A

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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