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Cancer Care Block > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

Is palliative care just about dying?

A

No - its a combination of end of life care and enhanced supportive care

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2
Q

What are some of the main things palliative care aims to help with? (Physical and other)

A

Physical - pain, N/V, constipation/diarrhoea, breathlessness
Psychological, social, and spiritual needs
Planning for the future
Quality of life

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3
Q

What do we see when a patient begins to deteriorate?

A

Signs and symptoms of clinical instability

Also listen to the patient and how they’re feeling

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4
Q

What is the first step with a deteriorating patient?

A

History and examination + investigations to find an alternate explanation that is reversible

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5
Q

When investigating a deteriorating patient, what is it important to consider?

A

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

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6
Q

Talk me through SPIKES.

A 
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
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7
Q

How can we manage the setup and situation when breaking bad news?

A 
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
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8
Q

Why is the pts perception important when breaking bad news, and in other settings?

A

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.

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9
Q

Why is an invitation from the pt important when giving news?

A

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.

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10
Q

How should information be given to a patient?

A 
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

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11
Q

In case a pt cant take in all the information, what can we do?

A

Give them written information

Come back later/someone e.g. a macmillan nurse comes back after some time

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12
Q

Why is the strategy and summary part of a consultation important? (3)

A

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

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13
Q

How can we address things like DNACPRs with pts and their families?

A

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

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14
Q

WRT important decisions and family members, what can we do to help? (Excluding pts with power of attorney)

A

Explain and reassure family that the decision is not theirs and the pt is in charge, so they should not feel guilty or responsible

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15
Q

Is the pt in charge of whether they have a DNACPR?

A

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.

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16
Q

When prescribing opioids in palliative care, how should we initiate treatment?

A

Regular oral modified release morphine with PRN immediate release oral morphine for breakthrough pain.

Prescribe a laxative alongside strong opioids to prevent constipation.

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17
Q

What advice regarding nausea and drowsiness can be given to patients being started on opioids?

A

They are usually transient.
If nausea persists, antiemetics can be offered.
If drowsiness doesn’t settle, then dose adjustment should be considered.

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18
Q

What is the dose of PRN immediate release morphine based on?

A

The total daily dose of morphine - it is 1/6 of the total.

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19
Q

Who do we need to be careful with when prescribing opioids/morphine?

A

Pts with CKD

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20
Q

If a patient has CKD, what can we prescribe instead of morphine?

A

Alfentanil
Buprenorphine
Fentanyl

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21
Q

How should the regular dose of opioids be increased?

A

Based on current dose and amount of PRN morphine needed to combat breakthrough pain.

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22
Q

What medications are used to treat metastatic bone pain?

A

Strong opioids
Bisphosphonates
Radiotherapy
Denosumab

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23
Q

How does oral codeine convert to oral morphine wrt dose?

A

Division by 10 i.e. 200mg oral codeine = 20mg oral morphine

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24
Q

How does oral tramadol convert to oral morphine wrt dose?

A

Division by 10 i.e. 500mg oral tramadol = 50mg oral morphine

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25
Q

How does oxycodone compare to morphine wrt side effects?

A

Oxycodone generally causes less sedation, vomiting, and pruritis, but more constipation than morphine.

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26
Q

How does oral morphine convert to oral oxycodone wrt dose?

A

Divide by 1.5-2 i.e. 30mg oral morphine = 15-20mg oral oxycodone.

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27
Q

How does morphine convert to fentanyl patches?

A

30mg oral morphine daily is equivalent to a 12 microgram/hr transdermal fentanyl patch for 72 hours.

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28
Q

How does oral morphine convert to subcut morphine?

A

Divide by 2 i.e. 100mg oral morphine = 50mg subcut morphine

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29
Q

How does oral morphine convert to subcut diamorphine?

A

Divide by 3 i.e. 120mg oral morphine = 40mg subcut diamorphine

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30
Q

How does oral oxycodone convert to subcut diamorphine?

A

Divide by 1.5 i.e 60mg oral oxycodone = 40mg subcut diamorphine

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31
Q

What can be prescribed for intractable hiccups in palliative care?

A

Chlorpromazine generally.

Haloperidol or gabapentin can also be used, as can dexamethasone if hepatic lesions present.

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32
Q

How can we manage agitation in palliative care?

A

Midazolam if in terminal phases.

If a cause can be found, treating the cause may help reduce agitation.

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33
Q

How can we manage confusion in palliative care?

A

Underlying cause needs to be found and treated as appropriate.

Haloperidol can be used first line for confusion if no cause found. Chlorpromazine and levomepromazine can also be used.

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34
Q

What can cause confusion in palliative care?

A 
Hypercalcaemia
Infection
Urinary retention
Medication
Brain mets
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35
Q

When can we consider using syringe drivers?

A

When a patient i unable to take oral medication due to nausea/dysphagia/intestinal obstruction/weakness/coma.

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36
Q

What might cause SoB in palliative care?

A
  • effect of cancer
  • pulmonary effusion
  • SVCO
  • ascites
  • pulmonary embolus
  • anaemia
  • pneumonia
  • pain
  • anxiety
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37
Q

How should SoB in palliative care be managed in general terms?

A

Treat the cause
Lifestyle change
Symptomatic treatment
Rehabilitation

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38
Q

What non-pharmacological interventions can we do to help with SoB?

A
  • Explain and reassure
  • Physio and reposition pt
  • Coping mechanisms and relaxation therapies
  • Fans/open a window
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39
Q

What pharmacological treatments can we give to help with SoB in palliative care?

A

Nebulisers e.g. salbutamol
Opioids (low dose, PRN)
Benzos if anxiety-related e.g. lorazepam
Glycopyrronium bromide or hyoscine hydrobromide/buscopan

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40
Q

What might cause nausea/vomiting in palliative care?

A 
Cancer - brain mets, bowel obstruction
Hypercalcaemia
Infection
Constipation
Chemotherapy
Gastroenteritis
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41
Q

How should vomiting be managed in palliative care?

A

Treat cause
Supportive
Antiemetic chosen for specific neuroreceptor depending on cause
Reassess triggers

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42
Q

How do toxins in the blood cause N/V?

A

Act on chemoreceptor trigger zone.
This has D2 and 5HT(3) receptors.
CTZ acts on the vomiting centre to cause vomiting.

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43
Q

How do cerebral tumours cause N/V?

A

They cause RICP and compress the vestibular apparatus.
This has ACh and H1 receptors.
The vestibular apparatus then signals the vomiting centre and causes emesis.

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44
Q

How does GI distension or irritation cause N/V?

A

Distension/irritation stimulates the vagus and splanchnic nerves, which then stimulate the vomiting centre -> emesis.

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45
Q

How do pain and fear cause N/V?

A

Higher cortical functions from cerebral cortex which act direcly on vomiting centre -> emesis.

46
Q

What receptors are present in the vomiting centre of the brain?

A

5HT(2)
H2
ACh

47
Q

What receptors are present in the GI tract that cause signals to be sent to the vomiting centre?

A

D2
5HT(3)
5HT(4)

48
Q

What receptors does haloperidol work on, and therefore what kind of N/V is it good for treating?

A

D2 (antagonist)

Works mainly on the chemoreceptor trigger zone so its good for metabolic disturbance or toxins in blood causing N/V.

49
Q

What receptors does metoclopramide work on, and therefore what kind of N/V is it good for treating?

A

D2 and 5HT(3)
Works on CTZ (D2) and vagus afferent from GI tract. It is therefore effective against N/V caused by gastric stasis and chemotherapy.

50
Q

What receptors does domperidone work on, and therefore what kind of N/V is it good for treating?

A

D2 antagonist in CTZ and gut so promotes smooth muscle contraction and therefore gastric emptying so used for gastric stasis or post-chemotherapy.

51
Q

What receptors does cyclizine work on, and therefore what kind of N/V is it good for treating?

A

H1 and ACh receptors as antagonist.
Therefore works directly on vomiting centres, as wel as vestibular apparatus.
This means it is effective for bowel obstruction as well as cerebral tumours/RICP.

52
Q

What receptors does levomepromazine work on, and therefore what kind of N/V is it good for treating?

A

D2 H1 ACh and 5HT2 receptors - it is generally used second line as it is good for symptomatic relief but has many side effects inc. sedation.

53
Q

What receptors does ondansetron work on, and therefore what kind of N/V is it good for treating?

A

5HT3 antagonist - works on GI tract and CTZ so used often for post-operative N/V and post-radiotherapy N/V.

54
Q

What non-pharmacological things can we do to manage N/V?

A
  • Relaxation techniques
  • Hypnotherapy
  • Small meals/snacks
  • Cover odorous wounds
  • Avoid strong smells
  • Acupressure
55
Q

How can we manage N/V caused by constipation?

A

Give a prokinetic or laxative e.g. metoclompromide/domperidone and senna

56
Q

Why is lactulose not a good laxative to give in palliative care?

A

It requires a high fluid intake to work which may not be practical for the patient.

57
Q

What can cause constipation in palliative care?

A 
Immobility
Reduced oral intake
Fluid depletion
Medication
Obstruction
Hypercalcaemia
Hypokalaemia
Hospital environment
58
Q

What is the point of anticipatory prescribing?

A

Safety net for staying symptom free at home to prevent delays as well as distress to the patient and family.

59
Q

What are the anticipatory medications that we prescribe, and what are they for?

A

Opioid - pain and/or SoB
Anxiolytic sedative - anxiety/agitation/SoB
Antisecretory - resp secretions
Antiemetic - N/V

60
Q

What is the attitude towards death in palliative care?

A

To regard dying as a normal process while still affirming life

61
Q

Other than physical, what needs do we need to include in palliative care?

A

Psychological
Spiritual
Family’s needs

62
Q

Who provides palliative care?

A

Everyone - the pts family, carers, nurses, GP, hospital staff, hospice staff, community services… it is everybodys business.

63
Q

What things should we try to address that might be worrying a pt who needs palliative care?

A
  • Sex/sexuality
  • Work
  • Diet
  • Travelling
  • Finances and financial support
64
Q

What are some of the causes of confusion and agitation in palliative care?

A
  • Infection - uti, chest etc
  • Hypercalcaemia
  • Urinary retention
  • Medications
65
Q

How should confusion and agitation in palliative care be managed?

A

Treat the underlying cause.
If that fails, try antipsychotics:
First line - haloperidol
Second line - chlorpromazine, levopromazine

66
Q

How is agitation/restlessness managed best in the terminal stages of an illness?

A

With midazolam

67
Q

What do we use to reduced intracranial pressure, and when might this be necessary?

A

Dexamethasone (corticosteroids)

If a pt has RICP due to brain mets or primary brain tumour

68
Q

If there is cerebral oedema, what methods can we use to reduce ICP?

A

IV mannitol
IV furosemide
Corticosteroids

69
Q

What kinds of surgical interventions can we use for palliative care?

A

Debulking surgery for symptom relief

70
Q

What is licensed for management of hiccups in palliative care?

A

Chlorpromazine

71
Q

What is the most common cause of death in cancer patients?

A

Liver mets

72
Q

What % of cancer patients with liver mets can have complete surgical resection?

A

Only about 25% - this isn’t great as it is the only curtive treatment.

73
Q

If a aptient has liver mets, are they likely to have other mets as well?

A

Yes

74
Q

Which liver sign confers poor prognosis for a patient with liver mets?

A

Ascites

75
Q

How do liver mets sometimes cause jaundice?

A

Causing increased bulk of liver or by direct compression on bile ducts

76
Q

Are LFTs always abnormal if a pt has liver mets?

A

No

77
Q

What does prognosis depend on with liver mets?

A

The extent of the spread within the liver, and elsewhere, and the origin i.e. nature of the primary.

78
Q

Are spirituality and religion the same thing?

A

No - they can be linked, but they are not necessarily the same thing.

79
Q

What are the common spiritual needs that a patient will have, and how can we act to help privide this care?

A

Need for love and meaning - kindness, compassion, and deep listening.

80
Q

What % of people (ish) want to die at home?

A

Around 60%

81
Q

Is where someone wants to die always a priority for them?

A

No, and people can also change their minds if their cirucumstances change.

82
Q

Do people always discuss the needs they have in end of life care unprompted?

A

No, especially not in COPD for some reason. It is better that a healthcare provider opens this conversation up.

83
Q

What percentage of the UK populations die each year?

A

1%

84
Q

What does dying at home rely on?

A

Someone to be around 24/7 to look after the patient at home, usually partner or other close family member.

85
Q

What is the most common emotional need a dying patient will have?

A

Fear - usually ased around uncertainty of disease progression, symptom, and how the people around them will cope.

86
Q

How can we help deal with fear of the unknown and the future in a dying patient?

A

By formulating an Advanced Care Plan with them while they have the capacity to do this.

87
Q

If a patient is bed bound, has difficulty moving, and experiences incontinence, what do we need to be on the look out for and protect against?

A

Pressure ulcers

88
Q

In palliative care, who else besides the patient needs caring for?

A

The carer - caring for a sick or dying loved-one is very emotionally, physically, and often financially demanding.

89
Q

What is an advanced care plan?

A

Document formulated from the conversation between a patient, their family, carers, and those looking after them about their fture wishes and priorities for care.

90
Q

What are the 3 possible decisions that can be made as part of advanced care planning?

A
  • Advance statements
  • Advance decision to refuse treatment
  • Lasting power of attorney
91
Q

What is an advance statement?

A

Documented statements about a person’s wishes wrt medical and social care in the future, for when capacity is lost.

92
Q

Is an advance statement specific or general?

A

It can be both - it can lay out general preferences, as well as individual scenarios and the patient’s wishes should those specific things happen.

93
Q

What is an advance decision to refuse treatment?

A

Legally binding statement regarding refusal of specific medical treatments in the event a patient loses capacity.

94
Q

What is a lasting power of attorney?

A

The nomination of another person to make decisions on the patient’s behalf in the eent of loss of capacity.

95
Q

What are the 2 types of lasting power of attorney?

A
  1. Property and affairs i.e. financial

2. Health and welfare

96
Q

How does someone nominate a power of attorney?

A

While they still have capacity, they must fill in a form and register it with the Office of the Public Guardian.

97
Q

Who is required to fill out different sections of a power of attorney form?

A

The applicant
A witness
The nominated attorney
Signatory who confirms capacity e.g. GP or someone who has known the patient for 2+ years and doesn’t benefit from the LPA.

98
Q

What are the advantages of advance care planning?

A

Reassurance and sense of control are generally the biggets benefits to the patient and family.

99
Q

Can an advance decision to refuse treatment include refusing basic care?

A

No

100
Q

What NHS document can people read at home to start them thinking about advance planning?

A

NHS Guide “Planning for your future care”

101
Q

Where can you advise people to find a LPA application form where required?

A

gov.uk website

102
Q

How can advance care plans be made more accesible when required e.g. on admission to hospital?

A
  1. Have a record of it on the GP system

2. Have a copy at home alongside medication list etc that can be brought to any appointment or admission

103
Q

What are some of the major palliative care needs experienced by patients with chronic heart failure?

A
  • Fatigue
  • Breathlessness
  • Depression
  • Pain
  • Nausea and decreased appetite
104
Q

What measures can be used for patients with chronic heart failure to combat breathlessness and fatigue?

A
  • How they are positioned i.e. prone/supine, upright or lying flat.
  • O2 requirements
  • Morphine for dyspnoea
105
Q

Which antidepressants are best avoided in chronic heart failure patients?

A

TCAs

106
Q

What is a common cause of pain in chronic heart failure patients?

A

Stretching of the liver capsule due to oedema

107
Q

In what way is managing pain in chronic heart failrue different to managing pain in other patients?

A

NSAIDs should be avoided.

108
Q

Who can be very useful in managing chronic heart failure patients palliative care needs?

A

Specialist heart failure nurses!

109
Q

Why is it important to discuss prognosis early with patients with heart failure?

A

They have preserved cerebral flow at the time of diagnosis, where as further down the line they may have impaired cognition due to poor cerebral blood flow

110
Q

Which is worse - life expectancy with cancer or with chronic heart disease?

A

Chronic heart disease.

111
Q

Which are the most common primary sites for bone mets?

A 
Breast
Prostate
Lung
Kidney
Thyroid
112
Q

An elderly person presents with a pathological fracture. What do we need to do in this case?

A

Rule out bone mets, or find a primary source for any existing met.

Cancer Care Block (10 decks)

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