Palliative care Flashcards
what is the goal of palliative care
control symptoms and enhance QoL
what is palliative and end of life care
care provided to any pt for whom cure is not achievable, including those who may survive with progressive disease for many mths or years
when is a referral for specialist care done
multiple co-morbidities
disease burden
life limiting disease
high levels of planned hospital use
high level of planning ahead
symptom management not responding >48hrs after trt
complexity in one or more aspects of care
what is a holistic needs assessment
a questionaire that the pt fills out at any part of the pathway
why is a HNA good
develop a personalised care + support plan
starts a convo on needs
identifies pt concerns
sign post to relevant services
share the right info at the right time
what is the palliative care approach
not disease specific
relieves symptoms i.e pain and fatigue
affirms life
regards dying as normal
integrates spiritual and psychological aspects into pt care
support system to help pt live actively until death
support system to help family live with illness and bereavement
team approach to address pt needs and their families
enhance QoL and influence course of illness
what is the role of RT
managing terminally ill pts
what are the general indicators of decline
decreased activity and function
increasing dependence in ADL
advanced disease - complex symptom burden
decreasing response
no further choice for active trt
progressive weightloss
repeated unplanned admissions
serum albumin <25g/l
how many pt are managed with a palliative intent
50%
whats the purpose of palliative care
symptom control
patient management
trt specific guidelines
pt and family have a shared understanding of aims
what does best interest mean
acting on behalf of someone who lacks capacity when making a decision based on past, present wishes, feelings, valued and consulting with others involved in their care
what is a declaration
formal statement by making a decision for someone else under MCA they have a duty to consider the best interests
what does declared to the family mean
advanced directive family is informed that the person lacks capacity
what is capacity
to make the right decision for themselves
what stage is palliative care appropriate for
any stage
what does palliative care focus on
relieving pain
reducing illness
related complications
enhancing QoL
prolonging life with trt like chemo and radiotherapy
what does palliative provide
medical supplies and other needed equipment, which is covered by medical insurance
what needs does palliative care meet
psychological and spiritual needs
what test can be done to see if there are brain meta
plain xray or MRI
what test can be done for hypercalcaemia
blood test
what are the implications for brain mets
intent becomes life limiting
primary disease management could change
serious change in prognosis
implications for hypercalcaemia
may be a result from bone mets
what do biphosphonates do
prevent osteoclasts from breaking down bone and releasing calcium into the blood
what does calcitonin do
stops the breakdown of bone and absorption in the blood
what are brain met symptoms
persistent headache
vomiting
seizures
confusion
personality changes
numbness in arms/legs
speech difficulties
bone met symptoms
depression
confusion
memory loss
fatigue/lethargy
muscle weakness
bone pain
what % of pt with advanced cancer experience pain
80
2/3 due to cancer
1/3 due to other causes
what is the RT for cranium
short fractionated dose
dexamethasone = long course, high dose steroids
when should steroids be taken
in the morning to not impact sleep
corticosteroids SE
sleep issues
mood changes
indigestion
weight gain
thinning skin
what is classed as long term steroid use
> 3 months
might carry a red steroid card around
what is a high dose of steroids
> 6mg a day
carry a blue steroid card
example of corticosteroids
dexamethasone
what can pain be classified as
acute
chronic
what is pain
unpleasant sensory and emotional experience associated with actual or potential tissue damage
what should happen regarding pain before trt
pt should be informed on the need for analgesia, which is administrated based off the WHO pain ladder
what are the pain SE
nausea
vomiting
constipation
pruritis (itching)
dizziness
dry mouth
sedation
what is the pain associated with bone mets
some get relief 24hrs after trt (cytotoxic effect prevents the release of chemical medications of pain from normal cells)
some experience a flare at 24 hrs
how long does RT pain control last
2-8 weeks as destroys some tumour cells at the deposit site
DONT GIVE RT IF THEY WONT SURVIVE 2–8 WKS
what are the type of antiemetics
ondanestron
levomepromazine
metoclopramide
what are the side effects of ondansetron
constipation
what is the side effects of metoclopramide
colic
diarrhoea
what line is levomepromazine
second line
side effects of levomepromazine
sedation, constipation, hypotension
what can we do to help with sickness
control malodour e.g colonstomy, fungating wound
fresh air
good oropharyngeal hygiene
avoid emetogenic smells and foods
avoid situations where nausea and vomiting responses are conditioned
management advice for constipation
fibre
increased fluid intake
exercise
laxatives
what is constipation common with
opiates
what are the different types of laxatives
osmotic
stimulant
what are osmotic laxatives
increases fluid in bowels softens stills and stimulates body to pass them
examples of osmotic laxatives
lactulose and macro gels
what are stimulant laxatives
stimulates muscles within the digestive tract lining
examples of stimulant laxatives
senna
bisacodyl
sodium picosulphate
what are the surgical procedures which can be carried out
pinning of pathological fractures
toilet mastectomy
debulking of lesions
what is debulking lesions for
ovarian cancer seedlings
brain mets
who is toilet mastectomy for
locally advanced or met breast cancer
why is a toilet mastectomy done
to provide satisfactory relief from complications
some symptoms might be distressing for the pt:
- bleeding and secondary infections
what needs to be assessed for a toilet mastectomy
skin closure to see if a WLE is possible
what surgery should be avoided during a toilet mastectomy
axilla
due to the lymphatics and brachial plexus present
what is a pathological fracture
a fracture caused by the disease itself
why does a fracture result in pain
the fracture reaches the perisoteum (outer bone edge, which means it’s hit a wall of nerves)
where is a pathological likely to be found
head/neck of femur
long bone
what cancers are likely to result in bone mets
breast
prostate
lung
colorectal
what is the appearance of a pathological fracture
moth eaten appearance
s-shape tearing type stress fracture
dark ring (radiolucent), lost bone density bone is all hollowed out
what is the aim of debulking lesions
to remove as much tumour as possible
removal of cancer in specific locations i.e causing bowel obstruction improves patient nutritional and immunological needs
why is it good debulking lesions
removing large necrotic masses promotes drug delivery to smaller tumours with a good blood supply
smaller tumours have a high growth fraction that should be more chemo sensitive
what is the % of ovarian cancer which presents at III or VI
60-70%
where does ovarian cancer spread..
throughout the abdomen
what is the aim of debulking ovarian cancer
leave no tumours behind no larger than 1cm = optimally debulked
what is a sub optimal debulk
when tumours are left which are greater than 1cm
what can ovarian seedlings lead to
ascites
(fluid caused by the immune response)
what is a craniotomy
removal of portion of the skull
what is brain met surgery best for
single met lesion in a well controlled systemic cancer
what are surgical risks for brain mets
neurological deficits
infections
bleeding
surgery near the optic nerve causes vision loss
what is hormone therapy mainly for
breast and prostate
what is given for hormone therapy
corticosteroids
examples of corticosteroids
dexamethasone, prednisone, prednisolone, hydrocortisone
what are the acute risks of corticosteroids
dyspepsia
peptic ulcer disease
insomnia
oral + vaginal candidiasis
anxiety
glucose intolerance
what are the chronic risks of corticosteroids
develop cushingoid appearance
weight gain
oedema
cataracts
osteoporosis
proximal myopathy
skin thinning
infection
impaired wound healing
neuropsychiatric changes: depression, agitation, delirium
when is hormone therapy most beneficial for breast pts
post menopausal, disease free for 2 years
what is tamoxifen
anti oestrogen (antagonist)
similar properties to oestrogen
how does tamoxifen work
prevents hormone receptors from being activated
what is breast cancer stimulated by
circulating oestrogens
side effects of tamoxifen
hot flushes: airy clothes
feeling sick/vomiting: simple and bland foods
headache: pain killers
light headed/dizzy: don’t drive or use machinery
genital itching, menstrual changes, pain
what are the two types of aromatase inhibitors
anastazole
letrazole
what does anastazole do
blocks aromatase enzymes which are involved in oestrogen production in the body. decreases tumour size or delays progression
what does letrazole do
inhibits the enzyme in the adrenal glands (aromatase) which produces oestrogen, oestrodiol and oestrone
what progesterone drug can be given
megestrol acetate
MEGACE = second line
normally if everything else has failed mostly benefits pt who’s post menopausal and disease free for two years
how does hormone therapy work for prostate cancer
stop testosterone from being produced, reaching prostate cells which rely on testosterone to grow
what does hormone therapy do for prostate cancer
causes the cancer cells to die or grow more slowly
side effects of HT for prostate cancer
loss of muscle mass
Increased body fat
Erectile dysfunction
Loss of sex drive
Bone thinning which leads to broken bones
Hot flushes
Fatigue
Behaviour changes
metabolism changes
decreased body hair, smaller genitalia, growth of breast tissue
where is testosterone produced
testes
adrenal glands
what do androgens do for men
control development and maintenance of male characteristics, promote growth of normal and cancerous cells by binding to and activating the androgen receptors
what happens when the androgen receptors are activated by proteins
stimulates the expression of specific genes which cause prostate cells to grow
what proteins stimulate the androgen receptors
testosterone
dihydrotestosterone
why is an orchidectomy good
reduces circulation of androgens by 90% as some is released in the adrenal glands
how many pt with advanced prostate cancer respond to surgical castration leading to reduced testosterone
80%
how long does the immediate effect last regarding an orchidectomy
up to 2 years
what is the median response for an orchidectomy
18-24 months
when is an orchidectomy done
for primary and met spread
what is a medical castration
LHRH agonists prevent pituitary gland from secreting LH, which is similar structurally to LHRH which binds to the receptor
describe what happens when androgen levels are low
when androgen levels are low the hypothalamus releases LHRH
stimulates the pituitary to produce LH which stimulates testicles to produce androgens
what happens when LHRH agonist is given
initially stimulates LH causing more testosterone to be produced after first injection - a flare
continued high levels of agonists causes pituitary gland to stop producing LH, testicles are not stimulated to produce androgens
what happens if they stop taking the agonist
production of LH resumes and androgens are produced
what are the agonists which can be taken
zoladex, prostap, lupron
injection or implanted under skin
what are the type of anti androgen tablets which can be taken
bicalutamide
cyproterone
flutamide
what do the anti androgen tablets do
stop testosterone from reaching the cancer cells, less likely to cause a sexual issue + bone thinning but more likely to cause breast swelling, tenderness and liver problems
what does the androgen deprivation therapy and docetaxel do
extends life (palliative care)
who receives ADT and docetaxel
pt with advanced disease and good condition
SE can be difficult to manage
what hormones do endometrial cancer tend to use
progesterone
progesterine
why is progesterone good for endometrial cancer
slow growth of endometrial cells
useful for pt that want to get pregnant
SE for progesterone/progesterine
hot flushes
weight gain (high fluid retention, increased appetite)
night sweats
worsening depression
increased blood sugar levels with diabetes
serious blood clots (rare)
what type of progesterone therapy can be given for endometrial
megestrol acetate (capsule or liquid)
medroxyprogesterone (pill or injection)
when are aromatase inhibitors given for endometrial pts
after ovaries removed or aren’t functioning
where is oestrogen made if not in ovaries
fat tissue
what do aromatase inhibitors do for endometrial cancer
stop oestrogen from being made
given if pts can’t have surgery
what are the type of aromatase inhibitors given for endometrial pts
letrazole
anastrozole
etremstane
what are the side effects to aromatase inhibitors for endometrial
headaches
joint pain
hot flushes
oestoporosis
when is tamoxifen given for endometrial cancer
advanced or recurrent
what is better tolerated for endo than progesterone alone
tamoxifen and progesterone alternate
what is the goal of tamoxifen
prevent oestrogen from encourage cell growth of cancer
SE of tamoxifen for endo
hot flushes
vaginal dryness
high risk of blood clots in legs
DOESNT CAUSE BONE LOSS
