palliative care Flashcards
what are the two subcategories of palliative care?
supportive care - control symptoms and although the person will eventually die from the condition the aim is to prolong their life and maximise quality
end of life care - those who are likely to die within the next 12 months
what are examples of those in end of life?
acute condition where death is imminent
advanced progressive incurable conditions
general frailty and comorbidities
a risk of a sudden crisis in an existing condition e.g. parotid tumour eroding into carotid artery
what do end of life patients want from you?
dignity - nice environment and honesty
optimal symptom control and to be made comfortable - out of hours support, advanced prescription, regular reviews. Because comfort is the main concern stop unnecessary treatment e.g. LMWH
allowed to make choices
psychological, social and spiritual support
support for their families
why is it important end of life is delt with correctly?
otherwise it can cause complex bereavement issues and formal complaints.
what is the Liverpool care pathyway?
a pathway to aid clinicians in ensuring completeness and consistency of end of life care.. involves:
- recognising the approach of death
- assess psychological state and capacity
- spiritual support for patient and family
- prescribing
- management of symptoms
- MDT for decisions and communicate with primary/ secondary care
what is meant by a holistic approach in palliative care?
look beyond the diagnosis and consider the patients psychological, social, spiritual and physical needs. the aim is to make quality of life top priority rather than prolonging life unnecessarily
list the different people involved in the multidisciplinary approach in palliative care
Macmillan nurse Doctors Hospice staff - nurses and doctors psychologists/ counsellor physiotherapist occupational therapist social workers chaplin (church)
what is the role of a macmillan nurse?
visits patients and families, gives advice and directs them to the correct place and offers psychological support
what is the role of a social worker ?
assessment of needs
financial issues - e.g. wills
looks at family dynamics and helps advice how to break bad news to children
deals with family complications e.g. if patient is a carer for someone else
lasting power of attorney put in place
what is the role of a physiotherapist
breathing techniques to reduce anxiety and improve breathing/ coughing
mobility - e.g. walking aids? able to get out of bed?
what is the role of an occupational therapist?
to help with additional equipment needs e.g. commode.
what is the role of a counsellor in palliative care?
works with whole family after death
helps guide patient on how to tell children and offers support
what is the role of a doctor in palliative care?
prescribe and review medications
wha is the role of a hospice?
control symptoms and make patient comfortable
why do some people find a chaplin useful?
some people have faith and want to speak to chaplin before they die
what are the physical clues to recognise a dying patients
profoundly weak gaunt drowsy disorientated reduced oral intake and difficulty taking oral meds cool peripheries skin colour changes abnormal breathing pattern poor concentration
list the different symptoms that need to be managed in palliative care
pain N&V breathlessness respiratory secretions anxiety/ restlessness and agitation etc
what are anticipatory prescriptions?
in end of life patients we anticipate that symptoms could occur at some point and thus doctors prescribe things in anticipation such that nurses can give these medications when the patient starts to complain of such symptoms
e.g.
Pain - morphine 2.5-5mg s/c PRN or equivalent oral
N+V - haloperidol 1.5mg s/c PRN or levomepromazine
breathlessness - midazolam 2.5-5mg s/c PRN or morphine 2.5-5mg s/c PRN
restlessness and agitation - midazolam or haloperidol
respiratory secretions - glycopyroniunm
why are communication skills key to palliative medicine?
breaking bad news
discussing diagnosis and treatments
eliciting concerns and listening to patients concerns
discussing options for end of life and difficult conversations such as DNACPR
why is it important to manage pain in cancer patients?
pain is unpleasant for the patient
pain causes anxiety - ‘if im in pain now, what will death be like’
pain impairs other functions - shallow breaths leading to secretions and chest infections. reduces mobility
majority of advanced cancer patients are in pain
what are the causes of pain in cancer patients?
the cancer anticancer treatment concurrent disorder cancer related debility e.g. hydronephrosis from compression of ureters emotional distress and lack of support
what type of pain do cancer patients suffer from?
can be nociceptive, neuropathic, a combination.
because they may have long standing pain, there may also be an element of central sensitisation
what is meant by total pain?
physical pain and emotional pain and any other contributor of pain.
How is pain managed?
WHO analgesic ladder + adjuvants.
most advanced cancer patients are on strong opioids
what are the different forms of morphine?
immediate release (IR) - given PRN
- oromorph - liquid 10mg/5ml, 100mg/5ml
- sevredol - tablets 10,20,50mg
slow release - SR - continuous to prevent pain
- zoromorph capsules BD
- morphine sulphate tablets BD
- 24 hour continuous syringe driver
how do we titrate opioid doses up?
find total daily dose (TDD) usually total of last 24 hour PRNs and continuous dose.
then divide by 2 for new Slow release
then divide by 6 for new PRN dose
how is oral morphine converted to subcutaneous?
divide by 2
what dose of oral morphine is usually used to begin with?
2.5-5mg
how is oral codeine converted to oral morphine?
divide by 10
how is oral morphine converted to subcutaneous diamorphine?
divide by 3
what are the causes of nausea and vomiting in cancer patients?
cancer itself treatment of cancer - opioids, chemotherapy, radiotherapy (chemo induced NandV can be anticipatory) specific examples - impaired gastric emptying - chemical / metabolic changes - raised ICP - constipation - oral thrush - uraemia - infection - malignant bowel obstruction
what can impair gastric emptying in cancer patients? what symptoms will this cause?
locally advanced cancer, liver metastasis, ascites, morphine and anticholinergics.
reduced appetite, epigastric discomfort, bloating and intermittent vomiting
what can cause metabolic/ chemical changes in cancer patients? how will these patients present?
drugs (opioids, SSRIs, Abx)
hepatic, renal failure
sepsis
tumour toxins
nausea, aggravated by sight and smell of food.
what are the causes of raised ICP in cancer patients?
brain metastasis, haemorrhage, meningeal disease
what causes constipation in cancer patients?
drugs (opioids), hypercalcaemia, immobility, reduced nutrition/ hydration, malignant obstruction
what are the risk factors for chemotherapy induced nausea and vomiting?
female, <50 yrs , previous history e.g. pregnancy or motion sickness, specific chemoagents.
what are the consequences of nausea and vomiting in cancer patients?
dehydration anxiety debilitating malnutrition electrolyte disturbance
how is nausea and vomiting in cancer patients managed?
regularly assess and treat any reversible causes e.g. PPIs for gastritis, bisphos for hyperCa
non pharm - small meals, reduce anxiety, low fat
depends on cause:
- impaired GI emptying - levomepromazine/ domperidone
- radiotherapy - haloperidol or odansetron
- chemical/ metabolic - haloperidol
- intracranial - cyclizine and dexamethasone
what durgs are most commonly used for nausea and vomiting in cancer patients?
haloperidol or levomepromazine
can prescribe these in anticipation
what are the causes of breathlessness in cancer patients?
tumour obstructing airways - lung cancer pleural effusion - lung cancer SVC obstruction ascites anxiety phrenic nerve palsy weakness and fatigue treatment related - lobectomy, radiotherapy, chemo infection P.E rib metastasis anaemia
how is breathlessness treated?
treat specific cause - drain pleural effusion/ ascetic fluid drainage, heart failure/ P.E/ infection
non pharm - fan on face (stimulates trigeminal nerve and sensation is interpreted as air entering lungs) , positioning (sit up), physio/ breathing techniques, CBT/ anxiety reduction
pharm:
- salbutamol
- small dose opioids (2.5mg -5mg) - reduces respiratory drive and sensation of breathlessness.
- benzo - reduces anxiety (midazolam/ lorazepam)
- steroids - reduces tumour oedema and may improve breathlessness
- oxygen
are respiratory secretions during dying uncomfortable for the patient?
no not usually but can be distressing for the family
how can respiratory secretions be managed?
change patient position
prescribe glycopyrronium (in anticipation)
give glycopyrronium SC and PRN when symptoms start
sometimes may use suction
stop IV fluids
what is an alternative to glycopyrronium ?
hyoscine hydrobromide - however this is sedative and can cause confusion
how is restlessness and agitation managed in end of life patients?
human presence can help
explore their spirituality - often seeing a chaplin can calm them
support their family and friends
prescribe anticipatory midazolam
consider underlying cause - pain, urinary retention, constipation, breathlessness etc
what medications would you use for anxiety in comparison to delirium?
midazolam for anxiety
haloperidol / levomepromazine for delirium
how is constipation managed in palliative patients?
encourage mobilisation if possible
increase oral intake
laxative - usually stimulants
what are the causes of cough in cancer patients ?
lung cancer
chemo/ radiotherapy
how is a cough in cancer patients managed?
positioning and physio
simple linctus - reduces coughing by coating pharynx
opioids supress cough stimulus
what are the causes of diarrhoea in end of life patients and how can it be treated?
infection chemo radio antibiotics laxatives overflow from constipation
treat cause , can give loperamide
why is dry mouth common in end of life patients?
anticholinergics, chemo and radio and dehydraton
chemo/radio can cause mucositis making the mouth vulnerable to infection (usually given prophylactic fluconazole)
how is dry mouth in end of life patients managed?
treat any thrush - fluconazole/ nystatin spray
good oral hygiene, mouth wash, saliva substitutes
what is cachexia?
loss of muscle mass and fat due to increased metabolic demands in advanced cancer
poor prognostic factor
often accompanied by low appetite
how can we treat/ help with cachexia?
nutritional support
steroids can improve appeptite but can add to muscle wasting
IV / SC fluids
NGT for fluids/ foods
PEG or IV feeding
when are fluids/ nutritional support withdrawn?
when it is clear the patient is dying and in their final hours.
this is important because fluid withdrawal can reduce respiratory secretions and pulmonary/ cerebral oedema and make dying more comfortable.
how can we help with lymphoedema?
tissue massage
compression bandages
skin care can help
if a patient refuses treatment, how should this be dealt with?
capacity should be assessed
if a patient has capacity:
- doctor and patient assess the situation
- doctor recommends a particular option but no pressure put on patient
- patient weighs up benefits and risks
- agreement is made based on patients best interest.
what things should be put into place before a patient deteriorates such that important decisions are known.
DNA-CPR
advanced discussion to refuse treatment before patient looses capacity e.g. often discussed with the patient if they want to go to hospital if something was to happen or if they just want to be made comfortable.
what happens if the patient does not have capacity and a decision is needed?
doctor makes decision in patients best interest
there may be a lasting power of attorney
there may be advanced decisions to refuse treatment been put in place previously
what structure do we follow to break bad news?
SPIKES
- setting
- perception
- invitation
- knowledge
- emotions
- strategies and summary
how do we ensure there is a good setting for BBN?
private room
avoid interruption
appropriate introduction
before going in ensure you have all the background information and there are tissues.
how can we assess a patients perception before BBN?
what do you make of the illness/ situation so far?
How can we invite the patient to the BBN?
would you like me to tell you the details of the prognosis or are you someone who prefers not to know?
How should knowledge of bad news be delivered?
use warning shots ‘ unfortunately things have got worse’
pauses
information given
treatment plan given
prognosis can be given in a vague way - ‘ I cant be certain but I can tell you that it will be months rather than years’
SLOW
how are the patients emotions addressed after BBN ?
address with empathy
lots of pauses
‘ what are your main concerns? what are you thinking/ feeling?’
‘I cant begin to imagine what you must feel like, can you run me through some of your thoughts at this point’
how do we summaries after BBN?
reassure them that you will do anything to support/ make them comfortable
explain what happens next for them and family
list examples of controlled drugs?
opioids
midazolam
ketamine
what additional tests should be done for those individuals on steroids?
BM testing once a day for 3 days and then once a week
because steroids can make sugars rise
How is death verified
No pulse , heart sounds or resp effort and check for 2 mins
Pupils fixed and dilated
Unresponsive
