Palliative care Flashcards
Who are palliative care patients?
People who have a progressive, life threatening illness and are confronting death in the foreseeable future
What does PQRST stand for?
Provokes Quality Radiates Severity Time
What are 2 types of nociceptive pain?
Somatic- constant and well localised, variation in intensity related to body position
Visceral- dull ache, ‘deep’ or a pressure
What are 2 types of non- nociceptive pain?
Neuropathic- typically burning or stabbing pain
Psychogenic- central pain without obvious somatic source
What are some non pharmacological ways to manage pain?
Physical- physiotherapy, RICE therapy, acupuncture, TENS, muscle relaxation
Psychological- CBT, education, family therapy, hypnosis, art and music therapy
Which opioid is used as first line treatment in palliative pain?
Morphine
Which opioids are weak and should not be used in palliative pain?
Tramadol
Dextropropoxyphene
Codeine
Also not recommended to use methadone or pethidine
6 step dose titration?
- Initial IR dose
- BT dose with initial IR dose
- Subsequent IR dose
- Subsequent daily IR doses
- Switch to CR prep
- Subsequent CR daily doses
What is the common dose of morphine in opioid naive patients?
Elderly, renal impairment: 2.5-5mg
Younger, larger patient: 5-10mg
EVERY FOUR HOURS
What factors affect oral administration of medication?
Inability to swallow Severe N+V or bowel obstruction Depressed conscious state Need for larger dose Need for rapid response Poor patient compliance
How many hours should a regular opioid be continued when a fentanyl patch is applied?
12-18 hours
Why is dose reduced when converting opioids?
To avoid risk of overdose due to incomplete cross tolerance in individuals, sensitivity different in different opioids
What are some symptoms of opioid overdose?
Depressed consciousness and respiratory state
A respiratory rate that has fallen significantly (or below 10)
Sedation that doesn’t respond to moderate voice and gentle movement
What can be used in opioid overdose?
Naloxone
very potent opioid reverse agent
What are some symptoms of opioid withdrawal? (list 6)
Anxiety Nervousness Chills/ flushes N+V Insomnia Abdominal cramps Rhinorrhoea Salivation Lacrimation
Opioids should be withdrawn slowly, decrease by 20-30% every 24 hours
Clonidine, BZD or b-blockers can be used to treat withdrawal symptoms
Which adjuvants are used for pain in palliative care? (list 6 classes)
- TCA
- Anti convulsants (Gabapentin, lyrica, epilim, tegretol)
- Systemic local anaesthetics (Flecainide, lignocaine)
- NMDA antagonists (Ketamine)
- Corticosteriods
- BZD
How should adjuvants be used?
- Titrate one at a time
- Continue titration until good pain relief, intolerable S/E, max acceptable dose
- Continue use if good pain relief, acceptable S/E
11 non pain palliative symptoms?
- Mouth care
- Anorexia
- N+V
- Constipation
- Dsypnoea
- Delirium
- Anxiety
- Depression
- Terminal restlessness
- Wounds
- Fatigue
What are some causes of anorexia?
Chronic pain
Mouth conditions
GI motility problems
Reflux
Natural process of dying, don’t force feed
Anorexia: non pharm management?
- Frequent small meals
- Small amounts of liquid with meals
- Sit upright to eat
- Avoid strong cooking smells
- Increase calories and protein in diet
- Soft, cool foods are better than hot food
- Caffeine beverages can stimulate appetite
Anorexia: Pharm management? (3)
- Prokinetic agents promote gastric emptying (metoclopramide/domperidone)
- Corticosteriods
- Progestational agents
N+V: non pharm management?
- Avoid strong cooking smells
- Improve food presentation
- Avoid fatty, fried, rich foods
- Try cool fizzy drinks
N+V: pharm management?
- Empirical- physician preference
2. Mechanistic approach- emetic pathway
What are some causes of constipation?
- Lack of fibre/ fluid in diet
- Abnormal peristalsis
- Lack of strength of abdominal and pelvic musculature
- Opioids, TCA, anticholinergics
Constipation: non pharm management?
Diet
Encourage fluid intake
Encourage mobility
Constipation: pharm management?
Introduce laxative with opioids TCA or anticholinergics are used
- Coloxyl and senna
- Movicol
Avoid bulk forming and stimulants without the use of a softener and enough water
What is methylnaltrexone used for?
Impacted/ ballooned rectum
Increases bowel movements without reversing analgesia
ONLY used for constipation caused by opioids
Dont used for than ONCE every 24 hours
Bowel movements can occur within 30 mins of injection
Common adverse effects include mild to moderate abdominal pain, nausea and flatulence
What are some causes of dyspnoea? (5)
- Extrinsic compression of airways
- Lung infiltration by tumor
- Pheumonitis
- PE
- Hypoventilation
Dyspnoea: non pharm management?
Bedside fans Adjustment of posture Cold face washers Open windows Physio advice on breathing techniques Meditation therapy Modify ways of life Home oxygen readily available
Dyspnoea: pharm management?
Morphine
Dose drawn up readily available to use immediately
How does morphine work to alleviate dyspnoea?
Alters perception of breathlessness and decreases anxiety.
This reduces oxygen consumption and improves oxygen supply
It also dilates pulmonary vessels which assists in relieving lung congestion
Relieves symptoms before causes sedation, then causing sedation before depression vital signs
What are some causes of delirium?
Underlying conditions (cns disorders, metabolic disorders, constipation) Medications
Delirium: non pharm management?
Quiet, familiar environment Presence of carer/family Night light Appropriate music Mattress on floor
Delirium: pharm management?
Sedation:
1. Typical/ Atypical neuroleptics (Haloperidol/ olanzapine)
- Morphine- fentanyl / oxycoodone
- Midazolam
What are some causes of Anxiety?
Psychological factors Panic disorder ADR Hypoxia Inadequate controlled pain Withdrawal status
Anxiety: non pharm management?
- Suppport
- Adequate explanation of current and future tx needs
- Address fears and concerns
- Relaxation techniques
Anxiety: pharm management?
BZD: oxazepam, clonazepam, midazolam
What are some causes of fatigue?
Physical stressors: disease (anaemia, dehydration, malnutrition) or treatment (chemo)
Psychological: anxiety, depression
Fatigue: non pharm management?
Educate patient and carer about causes
Give patient permission to rest
Provide nutritional advice
Distraction and stress management techniques
Fatigue: pharm management?
Corticosteriods
Psychostimulants
Antidepressants
What are the 4 parts of the aetiology approach to pain management
- Psychosocial assessment
- Decrease noxious stimuli
- Intro opioids
- Add adjuvants
