Palliative Care

Question 1

What is breathlessness?

Answer 1

-A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity’
-The experience of dyspnoea derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioural responses’

Question 2

Describe the breathing thinking functioning model

Answer 2

-Breathing
=Inefficient breathing, increased work of breathing
=Increased respiratory rate, use of accessory muscles, dynamic hyperinflation

-Thinking
=Thoughts about dying, misconceptions, attention to the sensation, memories, past experiences
=Anxiety, distress, feelings of panic

-Functioning
=Deconditioning of limb, chest wall and accessory muscles
=Reduced activity, tendency to self-isolate, more help from others

Question 3

Assessment of breathlessness

Answer 3

/

Question 4

Non-pharmacological management of breathlessness

Answer 4

-Breathing:
=Recovery breathing, Square breathing
=Fan
=Positioning
-Thinking:
=Relaxation, distraction
-Functioning
=Pacing

-Setting expectations – management rather than cure
-Self management plan
-Sources of support – local palliative care team, helpful information for patients (Marie Curie, Macmillan)

Question 5

Pharmacological management of breathlessness

Answer 5

-Disease modifying treatments – where appropriate
-Opioids
-Steroids
-Oxygen
-Benzodiazepines

Question 6

Describe cough in palliative care

Answer 6

-Impact on QoL – sleep, continence, social functioning, anxiety &depression
-May be under-reported in presence of other symptoms
-Holistic assessment and management

Question 7

Causes of cough unrelated to cancer

Answer 7

-Neuromuscular disease
-HF
-Respiratory failure
-Renal failure
-Asthma
-COPD
-GORD
-ACEi
-Autoimmune disease
-Infection

Question 8

Causes of cough directly related to cancer

Answer 8

-Pulmonary parenchymal disease
-Lymphangitis
-Pleural effusion
-Superior vena cava obstruction
-Tumour microemboli

Question 9

Causes of cough indirectly related to cancer

Answer 9

-Immunotherapy induced pneumonitis
-Aspiration
-PE
-Paraneoplastic syndrome
-Radiotherapy sequelae
-Chemotherapy-induced fibrosis

Question 10

Management of cough

Answer 10

-Non-pharmacological
=Simple advice for dry cough, smoking cessation, improved ventilation
=Special Mechanical aids for neuromuscular disease (cough assist machine)

-Pharmacological – evidence is poor
=DRY COUGH - Antitussive therapy for dry cough – simple linctus, morphine 2mg PRN 4-6 hourly in opioid naïve. methadone linctus (specialist advice only)
=WET COUGH - Protussive therapy to aid expectoration of wet cough –saline nebs

Question 11

Describe respiratory secretions at End of Life, and causes

Answer 11

-Retained respiratory secretions can develop towards EoL
-Onset generally occurs 60-70 hours before death
-How common - Noted in 23-92% of dying patients in PCUs
-Potential risk factors – artificial hydration, cerebral malignancies, lung pathology, Neuromuscular disorders
-Causes
=Inability to cough or swallow
=Partial airway obstruction
=Further production of respiratory secretions

Question 12

Assessment of respiratory secretions at EoL

Answer 12

-Carefully consider likely prognosis
-Are there signs of global deterioration – reduced consciousness, reduced mobility, reduced oral intake?

Question 13

Management of respiratory secretions at EoL

Answer 13

-Careful explanation to family – very important, likely not troubled by secretions
-Non-pharmacological
=Positioning
=Suctioning
=Consider stopping parenteral fluids: avoid fluid overload, stop IV or subcutaneous fluids
-Pharmacological
=1st line: Hyoscine Butylbromide s/c 20mg hourly (max120mg/24hours)PRN
=2nd line: Glycopyrronium s/c 200micrograms, 6-8 hourly PRN
=Opioids and midazolam for associated respiratory distress

Question 14

Why is N&V important in cancer patients?

Answer 14

-Prevalence …. in cancer patients
=Up to 68% of cancer patients suffer from nausea/vomiting
=80% of those receiving cancer chemotherapy

-Prevalence … in other advanced disease
=17-48% patients with heart failure had nausea
=33% patients with end stage renal failure had nausea/vomiting

Question 15

Complications of N&V

Answer 15

-Dehydration
-Electrolyte imbalance
-Hypoglycaemia
-Malnutrition
-Aspiration risk
-Mallory Weiss tears
-Anticipatory and refractory N/V
-Depression
-Poor symptom control
-Poor quality of life

Question 16

How does N&V occur?

Answer 16

-Vomiting centre

-Emotions, fear, pain, memory
-Vestibular and raised ICP
-Chemoreceptor trigger zone outside BBB: drugs, metabolic, toxins
-GI tract/ viscera (vagus nerve): gastric paresis, visceral stretch, bowel obstruction

Question 17

Assessment of N&V

Answer 17

-History
=Pattern recognition – emesis pathways
-Consider nausea and vomiting separately
-Explore timing, appearance, what’s helped
-Consequences
=Dehydration
=pain relief
=diabetic Rx
=Meds eg cardiac, anti-epileptics
-Reversible factors
=Medication, Infection, Biochemical
-Contributing factors
=Constipation, Anxiety, Pain
-Examination
=Obs, fluid status
-Investigations (as appropriate)
=Blood tests incl FBC, U&E, LFTs, Ca, Mg
=Imaging
=Microbiology-stool, MSU

Question 18

Causes of N&V

Answer 18

-Vestibular
-Obstruction
-Motility
-Infection
-Toxins
-Stress

-Reduced gastric motility
=May be opioid related
=Related to serotonin (5HT4) and dopamine (D2) receptors

-Chemically mediated
=Secondary to hypercalcaemia, opioids, or chemotherapy

-Visceral/serosal
=Due to constipation
=Oral candidiasis

-Raised intra-cranial pressure
=Usually in context of cerebral metastases

-Vestibular
=Related to activation of acetylcholine and histamine (H1) receptors
=Most frequently in palliative care is opioid related
=Can be motion related, or due to base of skull tumours

-Cortical
=May be due to anxiety, pain, fear and/or anticipatory nausea
=Related to GABA and histamine (H1) receptors in the cerebral cortex

Question 19

Approach to reduced gastric motility

Answer 19

-Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis
-According to NICE CKS and BMJ best practice, first-line medications include metoclopramide and domperidone
-However, NICE CKS indicate that metoclopramide should not be used when pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery

Question 20

Approach to chemically mediated N&V

Answer 20

-If possible, the chemical disturbance should be corrected first
-In the context of other chemically mediated syndromes, for example due to opioid medications, there are a number of suggested medications
-Key treatment options include ondansetron, haloperidol and levomepromazine

Question 21

Approach to visceral/ serosal causes

Answer 21

-Cyclizine and levomepromazine are first-line
-Anti-cholinergics such as hyoscine can be useful

Question 22

Approach to raised intra-cranial pressure

Answer 22

-The NICE CKS guidelines recommend using cyclizine for nausea and vomiting due to intracranial disease
-Dexamethasone can also be used
-Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours

Question 23

Approach to vestibular N&V

Answer 23

-NICE CKS and BMJ best practice recommends use of cyclizine as a first-line treatment in disorders due to the vestibular system
-Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine
-Atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases according to UptoDate

Question 24

Approach to cortical N&V

Answer 24

-If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful
-If benzodiazepines are not ideal, BMJ best practice recommends use of cyclizine
-Ondansetron and metoclopramide can also be trialled

Question 25

Approach to management of N&V

Answer 25

-Treat reversible causes
-Non-pharmacological strategies
=Oral care
=Small portions
=Avoid food prep
=Environment
=Acupuncture
-Anti-emetic

Question 26

Overview of metoclopramide

Answer 26

-Pro-kinetic class
-SE
=Colic, oesophageal spasm, EPSE’s (extra-pyramidal side-effects)

10mg oral TDS or 30mg-80mg over 24h via syringe driver (CSCI)

Question 27

Overview of Domperidone

Answer 27

-Pro-kinetic
-SE
=Colic, oesophageal spasm, EPSE’s (rare)

10mg oral TDS

Question 28

Overview of Cyclizine

Answer 28

-Anti-histamine, anti-cholinergic
-SE: sedation, dry mouth, blurred vision, constipation

50mg oral TDS or 150mg over 24h via CSCI

Question 29

Overview of Haloperidol

Answer 29

-Anti-psychotic (strong D2 antagonist)
-ESPE SE

Oral 0.5mg-1mg s/cut or oral BD (starting doses)

Question 30

Overview of Levomepromazine

Answer 30

-Anti-psychotic (broad-spectrum)
-SE: ESPE’s sedation, hypotension

2.5mg-5mg s/c BD

Question 31

Overview of Ondansetron

Answer 31

-5HT3 antagonist
-SE: constipation, dizziness, headache

Question 32

Overview of Prochlorperazine

Answer 32

-Anti-psychotic
-ESPEs, sedation

3mg BD buccal or 5-10mg oral TDS

Question 33

Management of N&V when caused by higher neurological centres (raised intracranial pressure due to cancer)

Answer 33

-Clinical picture
=Worse in the morning
=Headache
=Neurology

-Treatment
=Cyclizine
=?? Trial Dexamethasone 8mg to reduce oedema
=Second line Levomepromazine, Prochlorperazine

Question 34

Management of N&V when caused by vestibular dysfunction (movement related nausea)

Answer 34

-Clinical picture
=Vertigo – dizziness with nausea
=Movement related nausea

-Treatment
=Cyclizine
=Cinnarizine
=Prochlorperazine

Question 35

Chemical/ metabolic causes of N&V

Answer 35

-Causes:
=Drugs
=Extensive cancer
=Sepsis
=Renal/liver failure
=Biochemical causes
=Chemotherapy/radiotherapy induced

-Clinical history: persistent often severe vomiting, little relief from vomiting

-Causes: chemical stimulation via CTZ

-Treatment
=Treat metabolic imbalance / Address cause
=Metoclopramide or domperidone OR
=Haloperidol OR
=levomepromazine s/c
=For cytotoxic/chemo related – check local policy

Question 36

Describe N&V caused by motility disorder

Answer 36

-Clinical history
=Intermittent vomits.
=Nausea often relieved by vomiting
=Early satiety, reflux, hiccups
=Often little nausea until immed prior to vomit

-Causes
=Gastric stasis
=Gastric outlet obstruction - pseudo obstruction - intestinal
By
=Autonomic neuropathy (paraneoplastic)
=Drugs
=Mechanical obstruction, tumour, nodes, enlarged liver leading to squashed stomach
=Metabolic (hypercalcaemia)

Question 37

Treatment of motility disorder

Answer 37

-Metoclopramide
-Domperidone (if elderly/higher risk of EPSEs)
-Consider trial of dex if external compression (trial 3/7, aim to reduce/stop)
+/- stent if appropriate

NB prokinetics may cause oesopheal spasm

Question 38

Treatment of multifactorial/ unknown/ refractory

Answer 38

-Consider route
-Metoclopramide
-Levomepromazine
-Trial of dexamethasone
-Consider higher centres eg pain, anxiety – offer psychological input/medication

Question 39

Describe bowel obstruction history/ exam

Answer 39

Due to mechanical obstruction (partial/ complete) and/or peristalsis failure

-Constipation / faecal incontinence
-Complete bowel obstruction – no flatus PR
-Intermittent nausea , often relieved by vomiting
-Worsening nausea / faeculent vomiting as obstruction progresses(small bowel contents become colonised by colonic bacteria)
-Continuous pain / colic
-Altered bowels sounds
-Abdo distension

Question 40

Management of bowel obstruction

Answer 40

-Multidisciplinary approach (surgical, oncological, palliative care)
-Assess on clinical condition, likely benefits/risks, patient preference
-Exclude faecal impaction (can complicate/mimic BO)
-Consider surgery if localised obstruction
-Other interventional palliative treatments:
=Stenting (gastric outlet, proximal small bowel, colon) or laser Rx
=Venting gastrostomy (Gastro-duodenal or jejunal obstrn)

-Medical management
=Frequent mouth care
=In acute phase (2-3 days) – conservative management may be appropriate (rest bowel, NBM +/- NG tube)
=Low fibre diet,
=Consider additional hydration
=Exclude / treat constipation
=Most will need SC infusion of medication

-Peristalsis failure
=N&V: prokinetic metoclopramide (stop if colic)
=Pain: opioid

-Mechanical obstruction
=Nausea: Cyclizine or buscopan +/ Haloperidol, or levomep
-Dexamethasone: 8mg subcut 4-7 days may relieve partial obstruction, reduce gut wall oedema
=Pain: opioid
=Colic: Buscopan
=Vomiting: Buscopan or Octreotide (reduces volume of vomit)

Question 41

Pain assessment

Answer 41

-If the pain is severe and overwhelming immediate treatment may be required before further assessment (adjust dose according to current analgesic use and seek specialist advice)
-Breakthrough and incident pain: a transient exacerbation of pain which occurs either spontaneously (breakthrough) or in relation to a trigger (incident pain) in someone who has mainly stable or adequately relieved background pain

-History
-Structured pain assessment tool, pain intensity scores
-Examination: tender hepatomegaly, abnormal sensation
-Impact of pain on: function, sleep, mood, patient, family
-Consider reversible causes

Question 42

Causes of pain in palliative care

Answer 42

-Disease related - direct invasion by cancer, distension of an organ, pressure on surrounding structures:
=bone pain: worse on pressure or stressing bone or weight bearing
=nerve pain: burning, shooting, tingling, jagging, altered sensation, dermatomal distribution - consider spinal cord compression
=liver pain: hepatomegaly, right upper quadrant tenderness, referred pain shoulder tip
=raised intracranial pressure: headache, nausea or both, often worse in the morning or with lying down
=colic: intermittent cramping pain. Consider bowel obstruction, bladder spasm. Consider adjuvant therapies (refer to Pain management guideline).
-Treatment-related pain: chemotherapy neuropathy, constipation due to opioids, radiation-induced mucositis.
-Debility: pressure sores, severe cachexia, oral candidiasis.
-Other unrelated illnesses: arthritis, osteoporosis, vascular disease, gastritis

Question 43

Palliative pain management steps

Answer 43

-Agree a pain management plan, including goals of treatment, in conjunction with the patient and family.
-Agree arrangements for regular review

1. Mild intensity:
   =Paracetamol 1g x4 a day
   =NSAID
   =+/- Other adjuvant
2. Mild to moderate
   =Weak opioid (codeine 30mg to 60mg x4 daily or dihydrocodeine 30mg to 60mg x4)
   =Alternatively: combined paracetamol codeine prep like co-codamol 30/500, 2 tablets x4 daily
   =Laxative and consider anti-emetic
3. Mod to severe
   =Strong opioid: If titrating with immediate release oral morphine prescribe 5mg, 4 hourly and as required for breakthrough pain/ If starting with modified release oral morphine prescribe 10mg to 15mg,
   12 hourly and immediate release morphine 5mg as required for breakthrough pain
   =Stop any step 2 opioid (Codeine or dihydrocodeine 60mg 4 times daily≈24mg oral morphine in 24 hours)
   =Seek advice if severe pain not responding to treatment (unacceptable side effects or toxicity)
   =Use lower doses and increase dose more slowly if patient is frail, elderly or has renal impairment. In severe renal impairment, an alternative opioid may be needed

Question 44

Caution with paracetamol

Answer 44

Consider reducing paracetamol dose to 500mg four times daily when poor nutritional status, low body weight (<50kg), hepatic impairment and/or chronic alcohol abuse (check local policy for paracetamol and NSAIDs if patient receiving chemotherapy)

Question 45

Dose titration for step 3

Answer 45

-Increase regular oral morphine dose each day in steps of about 30% (or according to breakthrough doses used) until pain is controlled or side effects develop.
-Increase laxative dose as needed.
-Convert to modified release morphine when stable.
=Divide 24 hour dose of immediate release morphine by 2.
=Prescribe as modified release morphine, 12 hourly.
=Prescribe breakthrough analgesia at correct dose (1/6th to 1/10th of 24 hour morphine dose up to a maximum of 6 doses in 24 hours)

Question 46

Starting pain treatment

Answer 46

-when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
-if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of -oral morphine solution as required
-oral modified-release morphine should be used in preference to transdermal patches
-laxatives should be prescribed for all patients initiating strong opioids
-patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
-drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

Question 47

Types of anti-emetics and laxatives

Answer 47

-QT Metoclopramide 10mg up to three times a day
-QT Haloperidol 500 micrograms to 1.5mg daily (prescribe as required for 5-10 days)

-Senna 2 tablets at night or Bisacodyl 5mg to 10mg at night plus docusate 100mg twice daily
-Macrogol 1 to 3 sachets per day

Question 48

Advice for Subcutaneous analgesia

Answer 48

-Usually given via a CME T34 syringe pump over 24 hours.
-Calculate the 24 hour dose of oral morphine.
-Convert this to SC morphine.
-Oral morphine 30mg≈SC morphine 15mg.
-When large doses of breakthrough SC analgesia are required consider SC diamorphine.
-Prescribe 1/6th to 1/10th of the 24 hour SC opioid dose as required, via SC route for breakthrough pain

Question 49

Advice for breakthrough pain

Answer 49

-Defined as a transient exacerbation of pain which occurs either spontaneously or in relation to a specific trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

-Prescribe immediate release morphine at 1/6th to 1/10th of the regular 24 hour dose, as required up to a maximum of 6 doses in 24 hours. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review.
-Assess 30 to 60 minutes after a breakthrough dose.
-If pain persists give a second dose as required.
-If pain is still not controlled seek advice.
-Change breakthrough dose if regular dose altered

Question 50

Management or incident related predictable pain

Answer 50

Can be difficult to manage; a dose of short-acting opioid before moving or when pain occurs may help. If pain is short-lived and the patient develops excessive drowsiness seek specialist advice

Question 51

Advice for opioid toxicity

Answer 51

-Can be precipitated by several factors including rapid dose escalation, renal impairment, sepsis, electrolyte abnormalities, drug interactions.
-Wide variation in the dose of opioid can cause symptoms of toxicity.
-Prompt recognition and treatment are needed. Symptoms include:
=persistent sedation (exclude other causes)
=vivid dreams, hallucinations, shadows at the edge of visual field
=delirium
=muscle twitching/myoclonus/jerking
=abnormal skin sensitivity to touch.
-If the pain is controlled reduce the opioid dose by a third. Ensure the patient is well hydrated. Seek advice.
-If patient still in pain consider reducing opioid dose by a third. Consider adjuvant analgesics, alternative opioids or both (refer to Choosing and changing opioids guideline). Seek advice.
-Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression (refer to Naloxone guideline).

Question 52

Adjuvant therapies for pain management

Answer 52

-NSAID: for bone pain, liver pain, soft tissue infiltration, or inflammatory pain (side effects: gastrointestinal ulceration or bleeding [consider proton pump inhibitor (PPI)], renal impairment, fluid retention, adverse cardiac events).
-Other analgesics: Nefopam is a non-opioid, non-NSAID analgesic occasionally preferred where alternatives are contraindicated or ineffective, or used as add-on therapy when pain is inadequately controlled. There is limited evidence regarding dose conversions. Seek specialist advice if considering prescribing.
-Antidepressant or anticonvulsant: for nerve pain. Start at low dose: titrate slowly (refer to Neuropathic pain guideline). No clear difference in efficacy between the two types of medicine for this indication.
=amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
=gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
=amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
=gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).

-Corticosteroids: †dexamethasone
=8mg to 16mg daily for raised intracranial pressure.
=4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
=Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
=8mg to 16mg daily for raised intracranial pressure.
=4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
=Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.

-TENS, nerve block, radiotherapy, surgery, bisphosphonates, ketamine (specialist use) and skeletal or smooth muscle relaxants