Palliative Care Flashcards
Is palliative care just about dying?
No - its a combination of end of life care and enhanced supportive care
What are some of the main things palliative care aims to help with? (Physical and other)
Physical - pain, N/V, constipation/diarrhoea, breathlessness
Psychological, social, and spiritual needs
Planning for the future
Quality of life
What do we see when a patient begins to deteriorate?
Signs and symptoms of clinical instability
Also listen to the patient and how they’re feeling
What is the first step with a deteriorating patient?
History and examination + investigations to find an alternate explanation that is reversible
When investigating a deteriorating patient, what is it important to consider?
The ceiling of treatment - how far can we take it with any particular patient where benefit still outweighs cost to the pt. Its all about what the patient wants and needs
Talk me through SPIKES.
S is for setting P for pts perception I is for invitation K is for knowledge E is for empathy and emotions S is for summary and strategy
How can we manage the setup and situation when breaking bad news?
Be on the same level eg sitting down Privacy Check who is present and if the pt is comfortable with it Is the pt physically comfortable? Minimise interuptions
Why is the pts perception important when breaking bad news, and in other settings?
Helps set the pace of the interaction, and gives opportunity for pts to clarify anything they don’t understand so far. Gives clinician a starting point for conversation.
Why is an invitation from the pt important when giving news?
They might not want to know as much as you do, or only want to know certain things.
Also waiting for invitation means the pt has some time to process and be ready for information.
How should information be given to a patient?
At an appropriate pace With opportunity for questions Small bits of info at a time At an appropriate level for the pt No jargon
Keep checking they are understanding
In case a pt cant take in all the information, what can we do?
Give them written information
Come back later/someone e.g. a macmillan nurse comes back after some time
Why is the strategy and summary part of a consultation important? (3)
Makes the plan clear and simple to pt
Ensures the whole plan is clear to the team
Summary in the notes is important for continuity of care
How can we address things like DNACPRs with pts and their families?
Talk about it in positive terms. Getting benefit rather than avoiding risk.
E.g. it will protect pt dignity VS it will avoid broken ribs and long term complications
WRT important decisions and family members, what can we do to help? (Excluding pts with power of attorney)
Explain and reassure family that the decision is not theirs and the pt is in charge, so they should not feel guilty or responsible
Is the pt in charge of whether they have a DNACPR?
No, its a medical decision that should be explained and communicated to the pt and relatives.
They can agree to it, but if it is medically necessary they can’t refuse it.
When prescribing opioids in palliative care, how should we initiate treatment?
Regular oral modified release morphine with PRN immediate release oral morphine for breakthrough pain.
Prescribe a laxative alongside strong opioids to prevent constipation.
What advice regarding nausea and drowsiness can be given to patients being started on opioids?
They are usually transient.
If nausea persists, antiemetics can be offered.
If drowsiness doesn’t settle, then dose adjustment should be considered.
What is the dose of PRN immediate release morphine based on?
The total daily dose of morphine - it is 1/6 of the total.
Who do we need to be careful with when prescribing opioids/morphine?
Pts with CKD
If a patient has CKD, what can we prescribe instead of morphine?
Alfentanil
Buprenorphine
Fentanyl
How should the regular dose of opioids be increased?
Based on current dose and amount of PRN morphine needed to combat breakthrough pain.
What medications are used to treat metastatic bone pain?
Strong opioids
Bisphosphonates
Radiotherapy
Denosumab
How does oral codeine convert to oral morphine wrt dose?
Division by 10 i.e. 200mg oral codeine = 20mg oral morphine
How does oral tramadol convert to oral morphine wrt dose?
Division by 10 i.e. 500mg oral tramadol = 50mg oral morphine