Palliative Care Flashcards
What are the expected physiological changes in the dying patient?
Changes in obs - low BP, low HR, low RR
Weakness and fatigue (no organic cause)
Decreased oral intake and swallow reflex
Decreased blood perfusion
Renal failure
Incontinence/retention of urine
Changes in mental state - confusion, disorientation, delirium
What are the keys to success in palliative care?
- MDT team work and communication
- Good communication with family and other HCP
- Seek advice or refer early to specialist palliative services.
- Anticipate problems so immediate response can be made
What route for medication administration is common in palliative care?
If appropriate and needed oral medication may be stopped
Lots = subcutaneous
May also use = buccal, rectal, topical
Should avoid IM as painful.
What are the transitioning or early phases of death?
Bedbound
Incontinent
Decrease in ability/interest to eat or drink
Congitive changes - social withdrawal, decreased interest in world, disorientation
What are the features of the middle phase of death?
Tracheal congestion
Further cognitive changes - slow to arouse, brief wakefulness/responsiveness
No oral intake - assist family to find alternative ways to care.
How to communicate with the conscious patient?
Can be distressing to family
Awareness > ability to respond
Assume patient hears everything
Create familiar environment
Include in conversations
Touch
What are the late phase patterns of imminent death?
Comatose
Temperature instability
Altered respiratory pattern
Mottling and cool extremities
Absence of peripheral pulses
What is the general approach to care of a dying patient?
Transition to comfort care if not already in progress
Stop interventions and monitoring
Treat symptoms and educate as issues arise
Provide excellent oral and skin care
Be honest and present with family concerns/conflict
Attend to own emotional responses and support.
What are some good ways of managing deaths in institutions?
Home like environment - privacy, intimacy, personal items, photos, remove monitors and unnecessary equipment
Continuity of care plans
Avoid abrupt changes of settings
Consider a specialized unit.
What is the key components of spiritual care in palliative services?
Deeply personal
Life meaning and purpose
Religion/GOd
Often memory boxes, keepsakes, legacies etc
What physical presentations have guidlines for dealing with in palliative care?
Respiratory tract secretions
Restlessness/agitation
Breathlessness
Nausea/vomiting
Pain
What is the typical treatment for respiratory tract secretions at end of life?
Treat promptly
Educate family
Changing position of patient
Don’t over hydrate - reduce or stop parenteral hydration
Suctioning - rarely, carefully, gently
Cover or mask = music.
What are considerable reversible causes of restlessness/agitation in palliative care?
Pain, positioning, breathlessness, nausea
Urinary retention/bladder spasm
Constipation
Severe anxiety, fear and unexpressed concerns
Drug/alcohol/tobacco withdrawal
Medication adverse effects
Psychological:
Permission to die
Reassurance of survivors well being
How is nausea/vomiting treated in palliative care medically?
Injection formulation by syringe driver = metoclopramide, haloperidol, cyclizine, levomepromazine
What is the typical treatment for breathlessness at the end of life?
Morphine
What is the typical treatment for pain in palliative care?
Morphine
Not morphin if renal failure = oxycodone or alfentanyl.
What is an emergency in palliative care?
An unexpected change in the condition of or the symptoms/circumstances in a patient with a life-limiting illness
What are the different categories of palliative care emergencies?
Physical
Social
Spiritual
Psychological
What are some key physical palliative care emergencies?
Bone - pathological/crush fracture/mets
Hypercalcaemia
SVC obstruction
Spinal cord compression
MI
DVT/PE
Gastric/duodenal ulcer
Infection/neutropenic sepsis
Haemorrhage
Seizures
What is involved in planning for emergencies in palliative care?
Counselling - signs and symptoms
Planning - hospital, who to contact
Appropriate support
Emergency medications at home
Provision of a plan with patients wishes
What is the relevant epidemiology of spinal cord compression?
3 to 5% of cancer patients
10% patients with spinal mets
more common in some cancers - bowel, prostate
What are the causes of spinal cord compression?
Typically extradural compression from a bony tumour in the vertebral body
80% of which are mets
+/- vertebral collapse
Most common site of compression = thoracic, lumbosacral, cervical or multiple.
What is the common presentation of spinal cord compression?
Pain - back+nerve root, worse on movement, coughing, lying flat, can proceed by 6w.
Sensory disturance
Leg weakness = late signs, below level of lesion, stiffness/falls/gait disturbance
Sphincter problems - late sign and poor prognosis
What are the key clinical features of spinal cord compression?
Back pain +/- tender vertebrae on percussion
Leg weakness/altered gait
Lesions above L1 = UMN signs and sensory level
Lesion below L1 = LMN signs and peri-anal numbness (Cauda equina syndrome)
What is the investigation of choice for spinal cord compression?
MRI - for compression
Other:
X-ray 80%
Bone scan = mets but not compression
What is the management for spinal cord compression?
May require oncology referall
Steroids ASAP = dexamethasone 16mg
Analgesia
Radiotherapy
Urgent surgical debulking
Urinary catheter/bowel regime
What are the typical outcomes of spinal cord compression?
Prognosis = degree of deficit at diagnosis
Most walking on admission - leave walking
Is function lost may permanently lose ability to walk.
What is considered malignant hypercalcaemia threshold?
Corrected serum calcium conc above 2.65mmmol/L
What is the relevant epidemiology of malignant hypercalcemia?
10% of all cancer patients
Up to 20% without bone mets
Most have disseminated disease
Poor prognosis: median survival 3-4 months
Less than 80% 1yr survival
What is the relevant pathogenesis of hypercalcaemia?
Osteolytic hypercalcaemia - inc osteoclastic bone resoprtion
Humoural - systemic release of PTH, prostaglandins, cytokines and TNF
Reduced renal clearance
1,25-dihydroxy vitamin D secretion (some lymphomas)
Ectopic secretion of authentic PTH (very rare)
What are the common symptoms of malignant hypercalcemia?
Dehydration (thirst/polydypsia)
Pruritis
Anorexia/weight loss
N&V
Constipation/ileus
Fatigue
Confusion/delirium, seizures, psychosis, coma
Bradycardia, atrial arrhythmias, prolonged PR internal, Reduced QT internal, wide T waves.
What is the management of malignant hypercalcaemia?
Rehydration: 2-3L 0.9% saline/24hrs
Calcium lowering agents - bisphosphonates
Withdrawl hyperCa2+ promoting drugs - thiazide diuretics, Vit A/D
How are bisphosphonates used for malignant hypercalcaemia?
Example - zolendronic acid,
Reduce bone resorption (osteoclasts)
Dose adjust if renal impairment
Works in up to 80%
Side effects = flu-like symptoms/pyrexia, rare osteonecrosis
Recheck: 5-7days after treatment
What is the typical treatment for neutropenic sepsis?
Tazocin +/- gentamycin
How common is haemorrhage in palliative care?
Affects 20% patietns with advanced cancer
COntributes to death in 5%
Catastrophic external haemorrhage is less common than internal hidden haemorrhage
What is the relevant aetiology of haemorrhage?
Direct - related to tumour itself e.g local bleeding from fungating tumours, erosion of vessels
Indirect - haematemesis, melanea, haemoptysis, Drugs (Steroids, NSAIDs, warfarin), low platelet.
What is the typical management of haemorrhage?
Anticipate - often preceded by smaller bleeds, DNAR, counselling patients
Establish support at home
Dark tiles and dark towels
PRN benzodiazepines /sedation
What medication may be given for non-acute haemorrhage management?
Topical - adrenaline or tranexamic-soaked gauze, silver nitrate, haemostatic dressings
Systemic-antifibrinolytics (tranexamic acid and haemostatic agents (etamsylate)
Other - embolisation, diathermy, radiotherapy.
What is the aim of treatment if an acute massive haemorrhage is not immediately fatal?
Local control if possible
Sedation of a shocked, frightened patient - midazolam 10mg SC/IM/IV or buccaly
Dark towels
Reassurance
Follow-up support for family and staff
Define SVC obstruction
External compression of and/or thrombosis of SVC by mediastrinal lymph nodes or tumour in region of right main bronchus
Mainly caused by lung cancer, lymphoma
What are the signs of SVC obstruction?
Venous hypertension
Headache
Visual changes
Dizziness
Swelling of face/neck/arms
What are the signs of SVC obstruction?
Engorged conjunctivae
Periorbital oedema
Non-pulsatile dilated neck veins
What is the management of SVC obstruction near to death?
Opioid
Oxygen
Keep bed at 30 degrees
Dexamethasone
Furosemide 40mg PO/IV
Treatment for anxiety or seizures
Crisis medications
What investigation and management may be done for SVC obstruction with a better prognosis?
CXR
Chest CT
Stent for extrinsic compression
Stent and thombus for obstruction
Anticoagulant for thrombus associated SVCO
What is the typical prognosis of SVC obstruction?
Typically a few days without treatment
Measured hours to days prior to onset.
What is a social crisis in palliative care?
Very common - carer fatigue, difficult symptoms, psychological distress
Important to plan and predict in advance
Can happen at the end of life
