Palliative care Flashcards
What is the WHO definition of palliative care?
Palliative care is an approach that improves the quality of life of patients and their families facing life-threatening illness by preventing and relieving suffering through early identification, impeccable assessment, and treatment of pain and other physical, psychosocial, and spiritual problems
What aspects does palliative care focus on according to WHO?
Palliative care focuses on the physical, psychosocial, and spiritual aspects of patient care.
What is the first step in the WHO analgesic ladder for pain management?
The first step involves the use of non-opioid analgesics like paracetamol or NSAIDs for mild pain, with or without adjuvant drugs.
What is the second step in the WHO analgesic ladder?
The second step involves the use of mild opioids, such as codeine, for moderate pain, in combination with non-opioids and adjuvant drugs as needed.
What is the third step in the WHO analgesic ladder?
The third step involves the use of strong opioids, such as morphine, for moderate to severe pain, with non-opioids and adjuvant drugs.
What is the typical dosage of paracetamol in palliative care?
Paracetamol is typically dosed at 500mg to 1g, four times a day (q.d.s.), with a duration of action of 4-6 hours.
What is the recommended dosage for aspirin in palliative care?
Aspirin is dosed at 300-600mg, four times a day (q.d.s.), with a duration of action of 6 hours.
How is ibuprofen dosed in palliative care?
Ibuprofen is typically dosed at 200-400mg, four times a day (q.d.s.), with a duration of action of 6-8 hours.
What is the dosage for diclofenac in palliative care?
Diclofenac is dosed at 50mg, three times a day (t.d.s.), with a duration of action of 8 hours
What is the typical dosage of codeine in palliative care?
Codeine is dosed at 30-60mg, four times a day (q.d.s.), with a duration of action of 4-6 hours .
What is the recommended dosage for tramadol in palliative care?
Tramadol is dosed at 50-100mg, four times a day (q.d.s.), with a duration of action of 6 hours .
How is normal release (NR) morphine dosed in palliative care?
Normal release (NR) morphine is typically started at 2.5-5mg every four hours, with the dosage adjusted based on patient response. A double dose may be taken at bedtime to avoid nighttime dosing .
What is the dosage for modified release (MR) morphine in palliative care?
Modified release (MR) morphine is typically dosed at 10-20mg every 12 hours. The exact dosage is calculated based on the total daily dose of NR morphine taken in the previous 24 hours .
What is an important step when converting a patient from oral morphine to another route of administration?
When converting from oral to intravenous (IV) or subcutaneous (SC) morphine, the oral dose should be divided by 2-3 to account for the higher bioavailability of parenteral routes.
What symptoms should be monitored for when tapering off morphine?
Monitor for symptoms of opioid withdrawal, such as anxiety, agitation, sweating, nausea, and muscle aches.
What should be done if withdrawal symptoms occur while tapering morphine?
If withdrawal symptoms occur, the tapering process should be slowed down, or the dose temporarily increased before attempting further reduction.
What is the most common side effect of opioid drugs?
Constipation is the most common side effect, occurring in nearly all patients on long-term opioid therapy.
How do opioids affect the gastrointestinal system apart from constipation?
Opioids can cause nausea and vomiting, especially when initiating therapy or increasing doses.
What are the common neurological side effects of opioids?
Drowsiness, sedation, and dizziness are common neurological side effects, particularly when starting treatment.
What are common signs of opioid toxicity?
Signs of opioid toxicity include drowsiness that does not improve, confusion, hallucinations, myoclonus (sudden jerking of the limbs), and respiratory depression (slowed breathing).
How can dehydration or renal failure contribute to opioid toxicity?
Dehydration or renal failure can cause morphine to accumulate in the body, increasing the risk of toxicity.
What is the recommended action if a patient shows signs of opioid toxicity?
If opioid toxicity is suspected, reduce the morphine dose by 50%. If the toxicity is severe, stop the morphine altogether.
Which medication can help manage hallucinations and confusion caused by morphine toxicity?
Haloperidol 1.5-5mg at night may help manage hallucinations and confusion caused by morphine toxicity.
What is a serious side effect of opioid overdose that requires immediate attention?
Respiratory depression, which can be life-threatening, is a serious side effect of opioid overdose.
Which medication is recommended for managing pain from severe swelling or inflammation in palliative care?
High-dose corticosteroids, such as dexamethasone, are recommended for managing pain from severe swelling or inflammation.
What is the typical dose of dexamethasone for raised intracranial pressure or spinal cord compression?
Dexamethasone is typically prescribed at 16 mg/day for raised intracranial pressure or spinal cord compression.
What dose of dexamethasone is recommended for all other severe swelling or inflammation?
For all other severe swelling or inflammation, dexamethasone is recommended at 8-12 mg/day.
How should the dose of dexamethasone be adjusted if there is no improvement after one week?
If there is no improvement after one week, the dose should be reduced by 2 mg/week until the lowest effective dose is found, and then maintained at that dose
What are common causes of neuropathic pain in palliative care?
europathic pain can be caused by nerve compression from cancer, viral damage such as Herpes Zoster (shingles) or HIV, nerve damage from certain drugs, and severe diabetes leading to neuropathy in the hands and feet.
How is neuropathic pain typically described by patients?
Patients often describe neuropathic pain as burning, shooting, electric shocks, or other unusual sensations. They may also report areas of skin near the pain that are either numb or extremely sensitive.
Which adjuvant analgesics are commonly used to manage neuropathic pain?
Tricyclic antidepressants (e.g., amitriptyline) and anticonvulsants (e.g., valproate, gabapentin, carbamazepine) are commonly used to manage neuropathic pain. These medications help to modulate nerve pain and are often started at lower doses than used for their primary indications.
What should be the initial dosing of amitriptyline for neuropathic pain?
Amitriptyline is usually started at 12.5-25 mg at night, and the dose can be increased to 50-75 mg if tolerated by the patient
Which anticonvulsants are commonly used to manage neuropathic pain in palliative care?
Common anticonvulsants used for neuropathic pain include gabapentin, carbamazepine, and valproate.
How does gabapentin help in managing neuropathic pain?
Gabapentin helps manage neuropathic pain by modulating calcium channels, reducing the release of excitatory neurotransmitters, and decreasing the abnormal electrical activity in the nervous system.
What is the starting dose of gabapentin for neuropathic pain?
The starting dose of gabapentin is typically 300 mg at night, which can be gradually increased to a maximum of 3600 mg per day, depending on the patient’s response and tolerance.
How is carbamazepine dosed for neuropathic pain?
Carbamazepine is usually started at 100-200 mg twice a day, with the dose gradually increased based on patient response, typically up to 600-800 mg per day.
What role does valproate play in managing neuropathic pain?
Valproate, another anticonvulsant, may be used for neuropathic pain, particularly in cases where other anticonvulsants are ineffective or not tolerated.
What are common side effects of anticonvulsants used in neuropathic pain management?
Common side effects of anticonvulsants include dizziness, drowsiness, gastrointestinal disturbances, and in some cases, mood changes or weight gain
What is a common cause of muscle spasms in palliative care patients?
Muscle spasms in palliative care patients can be caused by conditions such as nerve damage, spinal cord compression, or other neurological disorders.
Which class of drugs is commonly used to treat muscle spasms?
Muscle relaxants, such as baclofen or diazepam, are commonly used to treat muscle spasms.
What is the typical starting dose of baclofen for managing muscle spasms?
The typical starting dose of baclofen is 5 mg three times a day, with gradual increases every three days based on patient response, up to a maximum of 80 mg per day.
How is diazepam used in the management of muscle spasms?
Diazepam is usually prescribed at a dose of 2-10 mg up to four times a day, depending on the severity of the spasms and patient tolerance.
What are some common side effects of muscle relaxants used for muscle spasms?
Common side effects of muscle relaxants include drowsiness, dizziness, weakness, and in some cases, dependence (especially with diazepam).
How should muscle relaxants be tapered when discontinuing therapy?
Muscle relaxants should be tapered gradually to avoid withdrawal symptoms, particularly with diazepam due to the risk of dependence
What medication is recommended for managing abdominal cramp and colic in palliative care?
Anticholinergic drugs, such as hyoscine butylbromide (Buscopan) 20mg four times a day (q.d.s.), are recommended for managing abdominal cramp and colic.
What is the first step in managing fever in palliative care?
The first step is to look for and treat any underlying infections that may be causing the fever.
What is the first-line treatment to stop a seizure lasting more than five minutes?
Administer diazepam 10 mg rectally or intramuscularly (PR or IM), and repeat if necessary after 10 minutes.
What alternative medications can be used if diazepam is unavailable or ineffective?
Alternatives include midazolam 5 mg subcutaneously (SC) or buccally, paraldehyde 5-10 ml rectally, and phenobarbital 200 mg intramuscularly (IM) for seizures not responding to diazepam.
What medications can be prescribed if a patient with confusion is very agitated or aggressive?
Haloperidol (1.5-5 mg up to three times a day) or chlorpromazine (25-50 mg up to three times a day) can be prescribed until the patient is settled. Diazepam (5-10 mg at night) may be added if necessary, but only in combination with haloperidol or chlorpromazine.
hat is a last-resort treatment for severe cases of confusion that do not respond to other drugs?
Phenobarbital (200 mg subcutaneously four times a day) can be considered in severe cases .
What medication can be prescribed for anxiety in palliative care if counseling is not enough?
Diazepam 2.5-10 mg at night, but it should be used cautiously and not for more than a week unless the patient is terminally ill.
What medication can be used specifically for sleeplessness in palliative care patients?
Temazepam 10-20 mg at night, which acts for eight hours and is useful for sleeplessness
What symptoms can help diagnose depressive illness in someone with an incurable disease?
Symptoms include low mood for more than 50% of each day, loss of enjoyment or interest, excessive or inappropriate guilt, and thoughts of suicide.
What should be treated alongside depression in palliative care?
Anxiety and unrelieved chronic pain should be treated as they are major contributors to depression in patients with incurable illness.
What care steps should be taken for a patient overwhelmed by depression?
Ensure the patient is comfortable and not in pain, encourage small steps to address problems, and set aside time each day to discuss worries.
What role does a patient’s religious faith play in managing depression?
Visits from the patient’s faith group can be helpful if the patient has a religious faith.
How should suicidal thoughts be addressed in palliative care?
Do not be afraid to ask about suicidal thoughts, provide supervision if needed, and encourage carers to seek help quickly if they are concerned.
What antidepressant medication can be prescribed for depressive illness not responsive to counseling?
Amitriptyline, starting at 25 mg at night and increasing gradually to 75-150 mg, may be prescribed. Alternatives include imipramine and dosulepin (dothiepin) .
What types of food are recommended for patients with poor appetite?
High-calorie, high-protein foods, such as milk or yogurt, are recommended if available.
How can metoclopramide be used in patients with poor appetite?
Metoclopramide 10-20 mg can be taken half an hour before meals up to three times a day to help the stomach empty more quickly, but it should be stopped if there is no benefit.
Which steroids might be prescribed to improve appetite, and when should they be used?
Dexamethasone (2-4 mg in the morning) or prednisolone (15-30 mg in the morning) may be prescribed to improve appetite. If effective after a one-week trial, the dose should be reduced to the lowest effective dose. Steroids are best used when the patient has a life expectancy of a few months or less due to long-term side effects
What non-pharmacological care can help manage nausea and vomiting?
Non-pharmacological care includes offering cold drinks and cold food, encouraging small, frequent meals, preparing food away from the patient, and encouraging fluid intake with small, frequent sips.
What is the recommended treatment for nausea due to poor stomach emptying?
Metoclopramide (10-20 mg before meals) or domperidone (20-30 mg twice daily) is recommended for nausea due to poor stomach emptying.
How should nausea from blood chemistry disturbances be managed?
Haloperidol (1-5 mg at night) or prochlorperazine (5-10 mg three times daily)
What medications are suggested for managing nausea caused by inflammation or swelling in the head?
Cyclizine (25-50 mg three times daily) or promethazine (25 mg three times daily)
what medication would you suggest for vomiting with diarrhoea?
Cyclizine 25-50mg t.d.s or Promethazine 25mg t.d.s
what medication would you suggest for a patient with nausea and vomiting due to partial bowel obstruction
Metoclopromide 20mg SC q.d.s
What medication would you suggest for a patient with nausea and vomiting due to complete bowel obstruction?
Promethazine 25mg SC t.d.s or Cyclizine SC 50mg t.d.s or Chlorpromazine SC 10 -25mg t.d.s or Hyoscine butylbromide SC 20-40mg q.d.s
What are common causes of indigestion in palliative care patients?
Indigestion is common when there is pressure on the diaphragm from an abdominal tumor or ascites, and in neurological diseases.
What initial treatment should be considered for indigestion in palliative care?
Consider stopping NSAIDs or aspirin if they could be the cause of indigestion.
What care measures can help alleviate indigestion symptoms?
Nurse the patient in a sitting position, give drugs after food, and try giving milk.
What medications are prescribed for indigestion in palliative care?
Antacid: Magnesium trisilicate suspension, 10ml three times daily.
If persistent: Cimetidine 200mg twice daily, or ranitidine 300mg twice daily, or omeprazole 20-40mg once daily .
What are common causes of hiccups in palliative care?
Hiccups are usually caused by distension of the stomach but may also result from anything pressing on the diaphragm or from renal failure.
How can hiccups be managed with non-drug interventions?
To stop hiccups, get the patient to swallow dry bread or crushed ice, breathe from a paper bag, or quickly swallow two large teaspoons of sugar. Nursing the patient sitting up can also help.
What medications can be prescribed if hiccups do not resolve?
If hiccups persist, prescribe metoclopramide 10-20mg t.d.s., haloperidol 3mg at night, chlorpromazine 25-50mg at night, or baclofen 5-10mg t.d.s. (may help hiccups not responding to the above
What medications can be prescribed to manage breathlessness?
Morphine (2.5-5mg every four hours) can be used to relieve breathlessness. If the patient has COPD, a bronchodilator such as salbutamol may also be prescribed
What are the recommended drugs for managing persistent diarrhea not helped by dietary measures?
Loperamide 2mg three times daily (t.d.s.) and after each loose stool, up to 16mg/day, or codeine 10mg three times daily (t.d.s.), with an increase to 30mg four hourly if necessary
What should always be prescribed when giving opioids to prevent constipation?
Always prescribe a laxative when giving opioids (e.g., morphine or codeine) to prevent constipation.
What medications can be prescribed for constipation in palliative care?
Bisacodyl 5 mg at night (increasing to 15 mg if needed) or senna (one to two tablets at night, increasing if necessary) can be prescribed for constipation. Glycerol or bisacodyl suppositories can also be helpful
what medication would you suggest for respiratory secretions in palliative care
hyoscine butyl bromide is useful in reducing
excess respiratory secretions.
