Palliative Care Flashcards
how would you manage agitation / confusion in a palliative patient?
- look for causes
- eg hypercalcaemia, infection, urinary retention, medications
Mx
- haloperidol
- chlorpromazine, levomepromazine
- terminal - midazolam
management of hiccups in a palliative patient?
Mx
- chlorpromazine
- haloperidol / gabapentin
- dexamethasone if hepatic lesions
management of secretions in a palliative patient?
Conservative
- avoid fluid overload - stop IV/SC fluids
- pt not likely troubled by secretions
Medical
- hyoscine butylbromide (buscopan)
- glycopyrronium bromide
managing pain in a palliative patient/
- regular oral MR / IR morphine, with oral IR morphine for breakthrough
- no comorbidities - 20-30mg MR per day + 5mg morphine breakthrough
- breakthrough 1/6 daily morphine dose
- prescribe laxatives, antiemetics
- CKD - oxycodone over morphine, or if severe then alfentanil, buprenorphine, fentanyl
- metastatic bone pain - strong opioids, bisphosphonates, radiotherapy, denosumab
S/E of opioids?
nausea, drowsiness, constipation
what are the opioid conversion rates?
Oral codeine ->oral morphine
- Divide by 10
Oral tramadol -> oral morphine
- Divide by 10
Oral morphine -> oral oxycodone
- Divide by 1.5/2
Transdermal fentanyl 12mcg patch = 30mg morphine daily
Transdermal buprenorphine 10mcg patch = 24mg oral morphine daily
Oral morphine -> SC morphine
- Divide by 2
Oral morphine -> SC diamorphine
- Divide by 3
Oral oxycodone -> SC diamorphine
- Divide by 1.5
describe the WHO pain ladder
Step 1
- paracetamol, NSAIDs
- adjuvants
Step 2
- codeine
- step 1
- adjuvants
Step 3
- morphine
- step 1
- adjuvants
what are some adjuvant analgesics that could be used in palliative care?
- Amitriptyline, carbamazepine, gabapentin, pregabalin, clonazepam, duloxetine, oxcarbazepine
- Local anaesthetics, baclofen, diazepam, antidepressants, corticosteroids, bisphosphonates
6 types of n+v syndromes in palliative care?
Reduced gastric motility
- May be opioid related – most frequent in palliative care
- Related to serotonin (5HT4) and dopamine (D2) receptors
Chemically mediated
- From hypercalcaemia, opioids, chemo
Visceral / serosal
- Due to constipation
- Oral candidiasis
Raised ICP
- Eg cerebral metastases
Vestibular
- ACh and histamine (H1) receptors
- Motion related, or due to basal skull tumours
Cortical
- Anxiety, pain, fear, anticipatory nausea
- Related to GABA and histamine (H1) receptors in cerebral cortex
non pharmalogical tx of n+v in palliative care
- Control odours from colostomy / wounds / fumigating tumours
- Minimise sight/smell of food
- Give small snacks, not large meals
- Try acupressure wrist bands
how to manage n+v due to reduced gastric motility?
- metoclopramide (CI - obstruction, Parkinson’s - both)
- domperidone
how to manage chemically mediated n+v?
- correct chemical imbalances
- ondansetron (also post-op)
- haloperidol
- levomepromazine
managing visceral / serosal n+v?
- cyclizine
- levomepromazine
- hyoscine
managing n+v related to raised ICP?
- cyclizine
- dexamethasone
- radiotherapy
managing vestibular n+v?
- cyclizine
- metoclopramide / prochlorperazine
- maybe olanzapine / risperidone
managing cortical n+v?
- lorazepam
- cyclizine
- potentially ondansetron / metoclopramide
managing breathlessness in palliative care?
- Morphine
- Tx cause
- Anxiolytic may help - eg diazepam / lorazepam
- Salbutamol / terbutaline
- Ipratropium
- Dexamethasone
- O2 / LTOT
when might you consider using a syringe driver?
- Consider use when patient unable to take medication orally – due to nausea, dysphagia, intestinal obstruction, weakness, coma
- Majority of drugs compatible with water for injection. Use NaCl 0.9% with - granisetron, ketamine, ketorolac, octreotide, ondansetron
commonly use drugs in syringe drivers?
N+V – cyclizine, levomepromazine, haloperidol, metoclopramide
Resp secretions / bowel colic – hyoscine hydrobromide/butylbromide, glycopyrronium bromide
Agitation / restlessness – midazolam, haloperidol, levomepromazine
Pain – diamorphine
Metastatic spinal cord compression (MSCC)
- cancerous tumour damages / presses on spinal cord
- most common with multiple myeloma, breast, lung, prostate, kidney, thyroid
- 10-20% of pts with spinal mets get this
MSCC Px?
- back pain
- chest/abdo pain
- pain down to legs
- back pain worse at night / lying down / coughing / straining
- localised spinal tenderness
- leg weakness / difficulty standing/walking
- numbness/tingling in legs
- urinary incontinence / retention
- faecal incontinence / constipation
MSCC Ix?
- MRI
- CT +/- myelography
MSCC Mx?
- inform GP / hospital acute oncology team / palliative care team
- lie flat in bed
- pain relief
- bisphosphonates
- dexamethasone
- surgery
- radiotherapy
- OT/PT, psych support
SVC obstruction?
- SVC blocked/compressed by tumour
- lung cancer, also lymphoma, mets from breast, bowel etc
SVCO Px?
- headache, feel full in head, worse bending/lying down
- SOB
- swollen veins in neck/chest
- swelling of face, neck, arms, hands
- changes to vision
- dizziness
- red face, blue skin/lips/tongue
- engorged conjunctiva
- seizure/coma
SVCO Ix?
- CXR
- Doppler
- CT / MRI chest
SVCO Mx?
- loosen clothing, sit up,
- O2
- analgesia
- dexamethasone
- anticoagulants
- chemo/radio
- surgery - stent
Malignant hypercalcaemia
- caused by changes to bones in pts with cancer - even if not spread to bone
- advanced cancer, also multiple myeloma, breast, lung, kidney, thyroid
malignant hypercalcaemia Px?
- bones, stones, moans, groans
- malaise, weak, fatigued
- anorexia, N+V
- bone pain
- thirsty, polyuria
- constipation, confusion, drowsy, seizures, delirium
malignant hypercalcaemia Ix?
- bloods - Ca>2.6 corrected
malignant hypercalcaemia Mx?
- IV fluids
- bisphosphonates
- ?denosumab
neutropenia sepsis?
- Temp >38 / sx of sepsis in pt with neutrophils <0.5x10^9/L
- Coag-negative, G+ bacteria most commonly, particularly Staph epidermidis - probably due to indwelling lines
causes of neutropenia?
- Bone marrow disorders - aplastic anaemia, myelodysplastic syndromes
- Chemotherapy (10d period after when WCC very low)
- Immunosuppressants
- Stem cell transplantation
neutropenic sepsis Px?
- sepsis, unwell, flu, fever, shivering, agitation, oliguria, diarrhoea, change in behaviour
- pale, mottled skin, rash
neutropenic sepsis Ix?
FBC, U+E, LFT, albumin, CRP, lactate, cultures
neutropenic sepsis Mx?
- hospital admission - haematology/oncology
- GP OOH if not for hospital
- sepsis workup
- Abx - tazocin / meropenem
- if no response after 4-6d - Ix for fungal infections
- fluoroquinolone prophylaxis
major haemorrhage (palliative care context)
- loss of large volumes of blood
- advanced cancer
- can be from tumour itself / impaired clotting
- eg head/neck tumours, lung tumours, GI tumours
haemorrhage in palliative care Px?
- haemoptysis
- haematemesis
- melaena
- haematuria
- bleeding from ulcers, tumours, wounds on skin
palliative care: haemorrhage Mx?
- discuss plans in advance - respect form, living will, DNAR
- midazolam - IV/IM/sublingual
- dark coloured towels
- plastic aprons, gloves, waste bags
- pressure, celox etc
discuss stridor in context of palliative care?
- obstructed airway
- eg head/neck tumour, lung/upper GI tumour
Px
- noisy breathing on inspiration
- SOB - late sign
Ix
- clinical dx
- ENT / maxfax to dx
- CT
Mx
- O2 / heliox
- dexamethasone
- ENT / onc review
- tracheostomy
- stenting
- radiotherapy
opioid overdose in palliative care?
Px
- reduced GCS
- reduced RR
- pinpoint pupils
- myoclonic jerks
Mx
- naloxone
death verification process
- Introduce self to patient / family
- Explain / consent, WIPE etc
- Identify pt from wristband
- Assess voice response
- Assess pain response
- Feel carotid pulse, listen to chest sounds, heart sounds - for 5 full minutes
- Check pupils - fixed / dilated
- Can check corneal reflex
- Check for pacemaker - document presence / absence
- Document time of death - when examination is completed
when should deaths be reported to the coroner?
- Unknown cause of death
- Identity of deceased unknown
- Death occurred during / shortly after period of police custody
- No attending medical practitioner available to sign death certificate
- Death may be due to undergoing a medical tx / procedure
- Death may be attributable to person’s employment
- All deaths <24hrs of admission to hospital
- When not seen by medical practitioner in 28d prior to death
- Poisoning - deliberate / accidental
- Exposure to toxic substances - inc radioactive material
- Overdoses
- Death due to violence, trauma, injury
- Death due to self-harm / suicide
- Death may be due to neglect, self-neglect, or neglect on the behalf of others
- Death may be due to abortion
