Palliative Care Flashcards
What is palliative care?
- Holistic care of patients with advanced progressive illness
What does palliative care involve?
- Pain management
- Management of other symptoms
- Psychological, social and spiritual support
Goal of palliative care
Achieve best QoL for patients and their families
Conditions you would expect to see in palliative care
- Cancer
- Respiratory diseases
- Organ failure
- HIV/AIDs
- Neurological conditions e.g. MS, PD, AD, MND
- Frailty
Individuals involved in palliative care
- Nurse specialists
- Pharmacists
- Psychologists
- OT
- Physio
- Social worker
- Medical staff
- Volunteers
How is palliative care delivered
- Outpatient/inpatient units
- Day Hospice
- Hospice at home
- Charities
Role of pallative care team in supporting carers
- Juggling responsibilities, respite
- Emotional support
- Financial support
- Making difficult decision, legal issues, planning ahead
- Bereavement: death certificate, notifying people, probate, funeral arrangements
Role of pallative care team in supporting patients
- 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
Pharmacist role in palliative care
- 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
What is the pharmacist’s role in concordance?
- Emphasise adherence - large numbers of medications, complex regimes
- Discuss alternative formulation/treatments
What is the pharmacists role in patients beliefs about medication
- Use of opioids
- Fear of dependence, tolerance
- Alternative treatments
Key symptoms in palliative care
- 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
Common SE of analgesia
- Constipation
- Drowsiness
- Confusion
- Xerostomia
- Fatigue
- Hypotension
- Hallucinations
- N + V
Pain
- 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
Principles of pain management
- Understand cause to optimize treatment
- Appropriate level of WHO ladder
- Use adjuvants where necessary
- Use oral where possible
- Assess regularly
- Encourage patients to take an active role in the management of their pain
Causes of pain
- Nociceptive
- Somatic
- Visceral
- Neuropathic
Opioids for pain management
- 1st line = morphine
- Background and breakthrough
Breakthrough pain management
- Regular opioid + Breakthrough opioid
- Regular opioid = typically long acting 12 or 24 hour preparations.
- Breakthrough = immediate release preparations, given PRN when pain worsens.
Monitoring
- Pain charts
- Individual dose titration
Syringe drivers
- SC
- Steady plasma conc. of drug
- Dose reviewed every 24 hours, titrated up/down as needed - dependent on symptoms/side effects.
- May still require breakthrough doses
When are syringe drivers useful?
- Intractable pain
- Vomiting
- Severe dysphagia (patient too weak to swallow or unconscious)
- Several drugs can be combined into one syringe - management of multiple symptoms.
Compatibility charts
- For syringe drivers
- Summarises compatibility information available for drug combinations
- Determines if drugs can be mixed or if they will precipitate
- Maximum concentrations
3 examples of palliative care emergencies
- Malignant hypoercalcaemia
- Neutropenic sepsis
- Malignant spinal cord compression (MSCC)
Malignant hypercalcaemia
- Palliative care emergency
- Sign that disease has significantly progressed (most paitnets with this die within a year)
- Ca> 2.6mmol/Lt
Malignant hypercalcaemia - treatment
- Fluid replacement (1-2L NaCl 0.9% over 24h)
- Given before bisphosphonates as nephrotoxic.
- Bisphosphonates: zolendronate or pamidronate
- Treatment effective for 2-4 weeks in 70-80% of pt
- Reduce dose in renal impairment
- Ca2+ levels fall after 48h and continue to decrease for 6/7 days
- Monitor
Zolendronate
4mg/100ml in normal saline for 15 mins
Pamidronate
- <3.5mmol/L = 60 mg
- > 3.5 mmol/L = 90 mg
- BOTH in normal saline over 2-4 hours
Malignant hypercalcaemia - MoA
- Due to parathyroid hormone-related protein
- Normally expressed in cells but also secreted by tumour cells
- PTHrP stimulates bone resorption, increasing osteoclast activity (breaks down old bones, releases calcium)
- Also increases calcium reabsorption so decreases urinary excretion of calcium
- Higher serum calcium
Malignant hypercalcaemia - Symptoms
- 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
Malignant hypercalcaemia - medical emergency
- > 4mmol/L
- Seizures
- Arrhythmias
- Untreated will die in a few days
Malignant spinal cord compression
- Palliative care emergency - urgent referral for MRI
- Complications of cancer where metastases in spine
MSCS - Symptoms
- Pain
- Motor deficits
- Autonomic deficits
- Sensory deficits
MSCC - Treatment
- Dexamethasone 16mg OD ASAP
- Analgesia
- Radiotherapy
- Surgery
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.
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
Spinal cord compression - treatment
- Dexamethasone
- Reduces oedema
- Inhibits inflammatory response
- Delays onset of neurological symptoms
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
Treatment of neutropenic sepsis
Broad spectrum abx IV within one hour
e.g. tazocin 4.5g TDS + gentamicin 5mg/kg OD
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
Late signs a patient is dying
- Agitation
- Decreased consciousness
- Mottled skin
- Cheyne-stokes breathing (very fast followed by quieter and slower breathing in a cycle)
- Noisy respiratory secretions
Early signs a patient is dying
- Fatigue
- Weight loss/loss of appetite
- Decreased mobility and performance
- Social withdrawal
- Changes in communication
Aim when a patient is dying
- Comfort and symptom management
- Stop unnecessary investigations, observations and medication
Common symptoms at end of life
- Pain
- Anxiety, agitation, delirium
- N+V
- Respiratory secretions
Malignant bone pain
- Localised, aching pain
- Secondary bone cancer:
- Osteoclasts break down too much bone
- Increased risk of fractures
- Causes malignant bone pain
Osteoblasts
Help build up new bone
Osteoclasts
Break down old bone
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
N+V and management
- Determine root cause
- Look at neuronal pathways, find trigger
N + V caused by higher cortical centres
Benzodiazepines
- Stomach or small intestine: 5-HT3 antagonist
N + V caused by chemoreceptor trigger zone
- Histamine antagonist
- Muscarinic antagonist
- Dopamine antagonist
- Cannabinoids
What to give in n+v caused by cancer chemo or radiotherapy
- 1st line: ondan, dex
- Need to follow cancer guidelines
What antiemetic to give when N+V has uncertain cause
1st line: haloperidol and/or cyclizine
2nd line: levomepromazine
What to give in n+v caused by drugs/biochemical
1st line haloperidol
2nd line levomepromazine
Neuropathic pain
- Shooting, stabbing, electric shock-like sensation
- Occurs due to nerve damage caused by cancer
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
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
A2D1
Potentiates pre and post-synaptic NMDA-R activity of the spinal dorsal horn neurones.
Causes pain and hypersensitivity
Constipation
- Mild to very severe
- ## Very severe = faecal impaction or partial bowel obstruction
- Risk of intestinal obstruction
- Causes Pain
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
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
Are bulk forming laxatives e.g. magrogol given in opioid induced constipation
No
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
Treatment of confusion/agitation
- Consider reversible/ underlying cause
- Treat as for delirium:
- Benzodiazepines: midazolam, lorazepam
- Antipsychotics: low dose, e.g. haloperidol
Role of pharmacist in palliative care emergencies
- Early spotting of symptoms can improve outcomes
- Advice on dosing of medications and monitoring
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
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
