Palliative Care

Question 1

Define what palliative care is and give cases of where it might be available

Answer 1

The active holistic care of patients with advanced progressive illness

Management of pain, and other symptoms and provision of psychological, social and spiritual support is paramount

Goal of palliative care is achievement of the best quality of life for patients and their families

Available in patients with COPD, heart failure, HIV
Making quality of life best they can
Supporting family to get the best quality of life with limited amount of time

Question 2

How is palliative care normally delivered by who?

Answer 2

Nurse specialists

Day hospice

Hospice at home

Out patients

Inpatient units/SPCUs

Multidisciplinary Team pharmacists, psychologists, occupational therapist, physiotherapist, chaplain, social workers, nursing staff, medical staff, complimentary therapists, volunteers

Question 3

How do you symptomatically manage pain

Answer 3

Pain WHO pain ladder

Paracetamol and opioids

Malignant bone pain (bisphosphonates- prevent bone breakdown which may cause pain, denosumab)

Neuropathic pain- anti-epileptics (gabapentin and pregabalin), anti-depressants

Skeletal muscle spasm (baclofen, benzodiazepines- watch out for addictive effect)

Question 4

How do you symptomatically manage nausea

Answer 4

Haloperidol- affects area posterma, then vomiting centre, then stomach gastric stasis (can be used for opioid sickness)

Cyclizine- affects vomiting centre, then stomach gastric stasis

Pro kinetics like metoclopramide, domperidone- affects stomach gastric stasis (constipation sickness)

Laxative can be used to deal with constipation too

Question 5

Describe why we use syringe drivers in the first place and what they are

Answer 5

Patient is unable to use oral route- oral cancer or reduced absorption

Better control of symptoms- constant blood levels over 24 hours

End of life patient

Consider compatibilities, diluent- syringe driver, PCF, unlicensed medications made

A continuous subcutaneous infusion in palliative care

Question 6

Why do syringe drivers need to be at a specific concentration like 0.95mg/mL

Answer 6

To make sure it doesn’t precipitate to cause chemical non-compatibility

Question 7

What is the role of the pharmacist in palliative care

Answer 7

Polypharmacy- try to avoid for as long as possible

• Interactions
• Drug induced vs disease induced symptoms
• Drug handling- co-morbidities
• Review of long term medications

Patients beliefs about medication

• Use of opioids
• Dependence (opioids), tolerance
• Might not work if used too early
• Alternative treatments- herbal, chinese, homeopathic
• Patient counselling

Concordance

• Large number of medications
• Complex regimes- try to keep it simple for patient
• Formulations- liquids, crush tablets (becomes unlicensed) and medicines enter down enteral tube

Supplying end of life medication for patients at home

• Available in community
• Morphine, modazolam, haloperidol

Provide information to
Drs, nurses, other pharmacists
Use of medication via subcutaneous route like sodium valproate
Policies, guidelines, medicines management group

More symptoms experienced as they become unwell
Could be on drugs like: Opioids, laxatives, Amitriptyline, cyclizine

Question 8

What are unlicensed drugs and uses of them

Answer 8

Routes-
subcutaneous haloperidol
Sublingual modazolam to calm patient down

Uses- lidocaine patches, cutting fentanyl patches

Drug- ketamine oral solution

Combining medicines in syringe drivers- mixing together is outside product license

Question 9

When do controlled drug regulations apply

Answer 9

Use in hospice and hospital

Accountable officer

CD prescribing

Question 10

What do macmillan offer

Answer 10

Provision of information

Offer support, listening ear and friendly face

Living with and beyond cancer information day

Signposting
CAB, relationship counselling, physical activity, psychological support

Decision making
Choice between chemo or radiotherapy

Dietary advice based on culture

Money for patients

Question 11

What are the complementary therapy offered to support patients with cancer

Answer 11

Acupuncture- helps with induced nausea and vomiting, anxiety, fatigue, dry mouth, depression, stress, increased quality of life, decrease fatigue

Taichi- gentle exercises, movement, reduce inflammation and pain management

Mindfulness of medication

Reduces stress, anxiety, depression

Question 12

What is the look good feel better campaign

Answer 12

Helps women and teenagers with 2 hour workshops on how to draw back on eyebrows and it is a support group

Question 13

What is the pharmacists role in palliative care emergency

Answer 13

Advise and/or prescribe medication to manage symptoms

Have awareness of diagnostic signs and symptoms of incipient palliative care emergencies

Advise on anticipatory prescribing for patients discharged to community setting

Question 14

Describe what malignant spinal cord compression is

Answer 14

A cancerous vertebrate pushing on spinal cord suppressing it

Bone metastases pushing on spinal cord on epidural space

Affects 5% of cancers in final 2 years of life

Impacts patients quality of life and survival

Involves rapid referral and quick medical review

Symptoms: Severe back pain, nerve pain, pain worst when laying down when they do straight leg raises

Question 15

What are the clinical features of malignant spinal cord compression

Answer 15

Pain

Motor deficits

Sensory deficits loss of touch, movement, general body awareness and less aware of their surrounding

Automatic deficits urinary retention

Investigate via MRI

Question 16

How do you treat malignant spinal cord compression?

Answer 16

Corticosteroids: 
Dexamethasone 16mg daily as soon as suspected MSCC
2mg Dexamethasone = 15mg prednisolone
- Need to see if PPI needed
- Reduced oedema
- Inhibit inflammatory response
- Stabilise vascular membranes 
- Delay onset of neurological dysfunction 

Analgesia
WHO ladder
Optimise opioids +/- NSAIDs +/- neuropathic agents

Radiotherapy used until tumour becomes sensitive to it

Surgery

Question 17

What is malignant hypercalcaemia and the symptoms

Answer 17

Adjusted serum calcium >2.6mmol/L
Incidence: 10-20% of all cancer patients
Indicate disseminated disease
Poor prognosis- 4 to 5 die within 1 year

Symptoms:

• Anorexia
• N and V
• Constipation
• Fatigue
• Polyuria
• Pain escalation, mood disturbance, delirium, coma/death

Adjusted calcium of >4mmol/L is a clinical emergency and may result in seizures or arrhythmias

Question 18

How do you manage malignant hypercalcaemia

Answer 18

Review medication- high calcium and still taking adcal D3?
Thyroxine, lithium and gaviscon

Alleviate symptoms

Assess fluid status and renal function

Pre hydration

IV bisphosphonates- zoledronic acid 4mg- takes 3 days to have an effect and lasts 4 weeks

Disodium Pamidronate (30, 60, 90mg) depends on calcium level- it is nephrotoxic so need to assess renal function or we would give it slower to them (pre hydration to protect kidneys)

Question 19

What is neutropenic sepsis

Answer 19

When neutrophil count is less than 0.5 x 109/L and temperature of 38 degrees- result of chemotherapy- must monitor white cell count and platelets and 38 degrees= organ failure

Medical emergency- can occur in any patient who has received chemotherapy within last 4 weeks

Symptoms can progress rapidly to shock and death- rapid referral necessary

Question 20

How do you manage neutropenic sepsis (treatment) and monitoring

Answer 20

Broad spectrum of antibiotic IV within one hour
- Tazocin 4.5g TDS + Gentamicin 5mg/kg OD

Monitor: 
Urea and electrolytes
Full blood count
Liver function tests
CRP 
Blood cultures- see what antibiotics are more sensitive 
Urine and sputum cultures 
Chest X ray 
Look for infection focus- is it fungal infection?