Palliative Care Flashcards
______ applies not only to incurable malignant
disease and HIV/AIDS but also to several other
diseases, such as end-stage organ failure (heart
failure, kidney failure, respiratory failure and hepatic
failure) and degenerative neuromuscular diseases.
Palliative care
The GP is the ideal person to manage palliative care
for a variety of reasons—
1.
2
3
availability, knowledge of
the patient and family, and the relevant psychosocial
influences
_____________ is the best policy when discussing
the answers to these questions with the patient
and family.
Caring honesty
Patients must not be made to feel isolated or be
victims of the so-called _______in
which families collude with doctors to withhold
information from the patient
‘conspiracy of silence’
The worst feeling a dying patient can sense is one
of rejection and discomfort on the part of the
______
doctor.
The Gold Standards Framework (UK)
This framework, which provides an optimal model for
palliative care by the primary care team, focuses on
seven key tasks:
1 optimal quality of care 2 advanced planning (including out of hours) 3 teamwork 4 symptom control 5 patient support 6 carer support 7 staff support
_______ is the commonest, most feared, but generally
the most treatable symptom in advanced cancer
Pain
The
principles of relief of cancer pain are:
1 Treat the cancer.
2 Raise the pain threshold:
3 _______, for
example, opioids (if necessary).
Add analgesics according to level of pain
The
principles of relief of cancer pain are:
4 _______—not all pain
responds to analgesics (refer TABLE 11.2 ).
5 Set realistic goals.
6 Organise supervision of pain control.
Use specific drugs for specific pain
The right drug, in the right dose, given at the
right time relieves _______ of the pain. Reports of
the undertreatment of cancer pain persist.
80–90%
The World Health Organization (WHO) analgesic
ladder is an appropriate guide for the management of
cancer pain:
Step 1: Mild pain
Start with basic non-opioid analgesics:
1.
2.
aspirin 600–900 mg (o) 4 hourly (preferred)
or
paracetamol 1 g (o) 4 hourly ± NSAID
Use low dose or weak opioids (according to age
and condition) or in combination with non-opioid
analgesics (consider NSAIDs. What kind of pain?
Step 2: Moderate pain
Options for moderate pain
add ________ 5 to 10 mg (o) 4 hourly (2.5 mg
in elderly)
increase in increments of 30–50% up to
15–20 mg
or
\_\_\_\_\_\_\_\_ 2.5 mg (in elderly) up to 10 mg (o) 4 hourly or CR 10 mg (o) 12 hourly or oxycodone 30 mg,\_\_\_\_\_\_\_ 8 hourly
morphine
oxycodone
rectally,
Step 3: Severe pain
Maintain non-opioid analgesics. Larger doses of
opioids should be used and _______ is the drug of
choice
morphine
How to give Morphine in severe pain:
morphine 10–15 mg (o) 4 hourly, increasing to
________ if necessary
or
morphine CR/SR tabs or caps _______
30 mg
(o) 12 hourly or
once daily
Usual starting dose for morphine CR
The usual starting dose is 20–30 mg bd
To convert to morphine CR/SR, calculate the
daily oral dose of regular morphine and divide by
_______
2 to get the 12 hourly dose
How to give Morphine:
Starting doses are usually in the range of
_____
5–20 mg (average 10 mg)
How to give Morphine:
If analgesia is inadequate, the next dose should
be increased by ______until pain control is
achieved
50%
How to give Morphine:
____ is a problem, so treat
prophylactically with regular laxatives and
carefully monitor bowel function.
Constipation
How to give Morphine:
Order a ________ for
breakthrough pain or anticipated pain (e.g. going
to toilet
‘rescue dose’ (usually 5–10 mg)
How to give Morphine:
Order antiemetics ______
(e.g. haloperidol prn at first;
usually can discontinue in 1–2 weeks as tolerance
develops).
Using morphine as a mixture with other
substances _________has no
particular advantage
(e.g. Brompton’s cocktail)
How to give Morphine:
______ is not recommended (short half-life,
toxic metabolites) and codeine and IM morphine
should be avoided
Pethidine
______is a potent synthetic opioid which is
available as a transdermal system. Effective and
good for compliance. It is the least constipating
opioid and can be used in ______
Fentanyl
kidney failure
_____ is a potent analgesic available
as oral liquid, tablets and injection and is now
widely used in palliative care.
Hydromorphone
Hydromorphone:
It facilitates oral
dosing when a high opioid dose is required and
because of its ______ may reduce
the incidence of side effects in the frail and
elderly but like oxycodone may need to be given
_______
short half-life (2–3 h)
4 hourly if used alone.
This practice involves changing from one strong
opioid to another in patients with dose-limiting side
effects. Different opioids have differences in opioid
receptor binding
Opioid rotation
How to convert PO to SC
• Divide oral dose morphine by 3 for equivalent
SC dose 9
e.g. 30 mg oral morphine = 10 mg SC
• 10 mg morphine SC = 150 mcg fentanyl SC or
2–3 mg hydromorphone SC
Indications for IV Morphine
- unable to swallow (e.g. severe oral mucositis;
dysphagia; oesophageal obstruction) - bowel obstruction
- severe nausea and vomiting
- at high oral dose (i.e. above 100–200 mg dose)
there appears to be no additional benefit from
further dose increments
When the oral and/or rectal routes are not possible
or are ineffective, a subcutaneous infusion with a
_______ can be used
syringe driver (pump)
SQ Morphine advantages:
It may avoid bolus peak effects
________ or trough effects
________ with intermittent parenteral
morphine injections.
(sedation, nausea or vomiting)
breakthrough pain
_______ is sometimes
indicated for pain below the head and neck, where
oral or parenteral opioids have been ineffective
Epidural or intrathecal morphine
Sx control: anorexia
1.
2.
3
metoclopramide 10 mg tds or corticosteroids (e.g. dexamethasone 2–8 mg tds) high-energy drink supplements
If opioids need to be maintained, the laxatives need
to be ________, not bulk-forming agents
peristaltic stimulants
Laxatives:
Aim for firm faeces with bowels open about every __________
third day.
How to use laxatives
_______ 20 mL bd
or
_______ one to two sachets, in 125 mL water,
1, 2 or 3 times daily
Rectal suppositories, microenemas or enemas
may be required (e.g. Microlax).
lactulose
Movicol,
_______ cocktail is useful for severe
constipation. With a small quantity of water melt one
tablespoon of Senokot granules in a microwave oven
Shaw’s (or PCU)
Noisy breathing and secretions:
Conservative:____________
repositioning to one side, reduced
parenteral fluids and nasogastric suction
Noisy breathing and secretions:
• __________20 mg SC, 4
hourly or 60-80 mg daily by SC infusion
or
• ________ 0.2 mg SC as a single dose followed
by 0.6-1.2 mg/24 hrs by continuous SC infusion
hyoscine butylbromide (Buscopan)
glycopyrrolate
Noisy breathing and secretions:
For unconscious patient, as above, also consider:
________ 0.4 mg SC, 4 hourly or
0.8-2.4 mg/24 hrs by continuous SC infusion
or
________0.4-0.6 mg SC 4-6 hourly (be cautious of
delirium
- hyoscine hydrobromide
* atropine
Dyspnoea
Identify the cause, such as a _______, and
treat as appropriate
pleural effusion
Morphine can be used for _______ e.g. 2.5–5 mg (o) 4 hourly, together with haloperidol or a phenothiazine for nausea.
intractable dyspnoea
Dyspnea
Use a short acting benzodiazepine e.g.
______ 0.25–5 mg sublingually if anxiety is a
component.
lorazepam
Terminal distress/restlessness:
1st choice:
_______
0.5 mg SC bolus or 0.25–0.5 mg (o) 12 hourly
(drops SL) (3 drops = 0.3 mg) or tabs 7
1–4 mg over 24 hours in SC syringe driver
_________ 2.5–5 mg SC 1–3 hourly prn or
2.5–10 mg sublingual or intranasal
(or 15 mg/day by SC) infusion
clonazepam
midazolam
Terminal distress/restlessness:
If very severe: add _____ as SC infusion or
(with care because of fitting) haloperidol
phenobarbitone
Options for nausea and vomiting:
If due to Morphine:
\_\_\_\_\_\_\_\_\_\_\_ 1.5–5 mg daily 1 (can be reduced after 10 days) o r \_\_\_\_\_\_\_\_\_\_\_10–20 mg (o) or SC 6 hrly or \_\_\_\_\_\_\_\_\_\_ (Stemetil) 5–10 mg (o) qid or 25 mg rectally bd
haloperidol
metoclopramide
prochlorperazine
Alternatives for nausea and vomiting due to Morphine:
Alternatives: promethazine, cyclizine
Nausea and vomiting:
If due to poor gastric emptying, use a prokinetic
agent: _____
metoclopramide or cisapride or domperidone
Consider _____ and _____ for nausea
and vomiting induced by cytotoxic chemotherapy and
radiotherapy
ondansetron or tropisetron
Wound dressings
To reduce pain, apply a mixture of 10 mg/mL _______
topical
morphine with 8 g/mL Intrasite hydrogel
Cerebral metastases
Common symptoms are headache and nausea.
Consider __________ (e.g. dexamethasone
4–16 mg daily). Analgesics and antiemetics such as
haloperidol are effective
corticosteroid therapy
Hiccoughs 7, 8
Try a starting dose of
_____ 0.25–1 mg (o) bd
or
______ 2.5 mg bd
clonazepam
haloperidol
Depression
\_\_\_\_\_\_ 30 mg (o) daily, helpful for nighttime sedation and appetite. • consider \_\_\_\_\_\_\_\_\_\_\_ 5 mg (o) bd since evidence indicates an improvement in symptoms
• mirtazapine
methylphenidate (psychostimulant)
Weakness and weight loss
This problem may be assisted by a high-calorie and
high-protein diet. Otherwise consider _________
total parenteral nutrition.
Delirium
Determine the cause, including adverse opioid
effect. Investigations include FBE, MCU, CXR, pulse
oximetry. Consider treatment with _____ and ____
olanzapine and
haloperidol
Consider _______ in the presence of
drowsiness, confusion, twitching and abdominal
pain.
hypercalcaemia
Hypercalcemia:
It may be a ______ effect of myeloma
and cancers (particularly lung and breast). It carries a
poor prognosis—monitor serum calcium_____
paraneoplastic
> 3 mmol/L.
The commonest malignancy is________. Other important malignancies include: lymphomas, cerebral tumours, bone
tumours and solid tumours
acute lymphatic
leukaemia
Palliative care in children:
_______is the most commonly used opioid for
pain although fentanyl and hydromorphone are
now widely used
Morphine
Special problems for palliative care in children
Adverse reactions to tranquillisers,
corticosteroids, anti-emetics and aspirin are a
special problem
It should be an uncommon experience to be confronted
with a request for the use of ________, especially as
the media clichés of ‘ extreme suffering’ and ‘agonising
death’ are uncommonly encountered in the context
of attentive whole-person continuing care
euthanasia
Origin of pain:
- Skin mucosa Bones and joints Pleura and peritoneum
symptoms?
1 Somatic
Localised stinging or burning
Dull ache
± Pain on movement
Origin of pain:
Solid or hollow organs
Visceral
Deep, diffuse pain
Poorly localised
± Colic
± Nausea and vomiting
Origin of pain:
Skeletal muscle
Smooth muscle
Symptoms
Muscle spasm
Pain worse on movement
Severe colic
Tenesmus
Types of nocicieptive pain
symptoms
Somatic, visceral and muscle spasm
Types of neuropathic pain
Neuropathic and central pain
