Palliative Care Flashcards
What symptoms are common at the end of life
Pain
Breathlessness
Constipation
Nausea and vomiting
Agitation and restlessness
Management for hiccups
First line: Chlorpromazine
Second line: haloperidol, gabapentin
Hepatic: dexamethasone
How is pain managed in palliative care
Start analgesia (± PPI, laxative)
1. Paracetamol, NSAIDs
2. Weak opioids: tramadol, codeine, dihydrocodeine
3. Strong opioids:
- Morphine
- oxycodone
- diamoprhine
- Fentanyl (if renal impairment)
- Alfentanil (if renal impairment)
Adjuncts: neuropathic, dexamethasone, NSAIDs
Consider syringe drivers if more than 2 PRN doses have been given
What are the conversion rates for opioid prescribing
PO morphine to:
PO tramadol - x10
PO codeine/dihydrocodeine - x10
SC morphine - /2
PO oxycodone - /2
PRN morphine - /6
What laxatives can be used for constipation in palliative care
Softening agents
e.g. docusate sodium, arachis oil, liquid paraffin (milpar)
Osmotic agents
e.g. lactulose, movicol, glycerine, phosphate, magnesium hydroxide (milpar), sodium salts
Stimulants
e.g. senna, bisacodyl, docusate
SE: cramps
CI: intestinal obstruction. colostomy
What may cause nausea in palliative care
Delayed gastric emptying: gastric paresis, obstruction, constipation
Damage to the bowel: surgery/radiotherapy to the bowel, infeciton/ischaemia/inflammation
CNS: raised ICP/SOL, infection, injury
Chemical disturbance: hypercalcaemia/hyponatraemia/ketoacidosis, renal/liver failure, necrosis/ischaemia, drugs
Labyrinth: motion sickness, infeciton/injury/surgery
Psychological factors: Stress, anticipation, pain
Management for nausea and vomiting caused by CNS lesions/central issues/labyrinthitis
Cyclizine
Management for nausea and vomiting caused by abdominal issues e.g. surgery/radio/chemotherapy
Ondansetron
Management for nausea and vomiting caused by chemical causes or renal failure
Haloperidol
Management for nausea and vomiting caused by delayed GIT transit or bowel obstruction
Metoclopramide
Side effects of anti-emetics in palliative care
Cyclizine: irritant SC, severe heart failure
Ondansetron: constipation, QT prolongation
Haloperidol: lower seizure threshold, parkinson’s
Metoclopramide/domperidone: BO with colic, Parkinson’s, cardiac conduction disorders, young women, causes movement disorders
Causes of breathlessness in palliative care
- Disease
- Pleural effusion → SOB
- Treatment of disease (or treatment of symptoms)
- Radiotherapy to chest → acute radiation pneumonitis → SOB
- Chemotherapy → cardiotoxicity → SOB
- Concurrent problem related to disease
- Pneumonia → SOB
- Pulmonary Embolus → SOB
- Concurrent problem unrelated to disease
GI bleed from stomach ulcer → anaemia → SOB
Management for breathlessness in palliative care
- Treat any reversible causes e.g. infection, anaemia, PE
- If hypoxic -> oxygen
Conservative:
- Reposition, sit up
- Fan to help with movement of air across the face
- Nebulisers and steroids
- Treat any reversible causes e.g. infection, anaemia, PE
- Hypoxia → oxygen supplementation
- Talking therapy, CBT, relaxation techniques, mindfulness
- Acu pressure points
Medical
- Opioids e.g. morphine sulfate immediate release 1mg PO PRN/sustained release 5mg BD
- Short acting benzodiazepine e.g. lorazepam 0.5mg PRN SL
- Anxiety: Midazolam
- Antidepressants
Management for respiratory secretions
- Reposition
- Glycopyrronium 200mcg SC up to every 6 hours
- If 2 or more doses have been given and are effective → syringe driver over 24h
Causes of agitation and restlessness in palliative care
confusion
uncontrolled pain
urinary retention
constipation
breathlessness
thirst
anxiety
fear
