Palliative Care Flashcards
What is Palliative Care?
The active total care of patients whose disease is not responsive to curative treatment
The goal is the achievement of the best quality of life for the patient and their family
What are the disease trajectories for the following diseases?
Cancer
Heart/Lung Faliure
Frailty/Dementia
Left = Cancer
Middle = Heart/Lung Faliure
Right = Frailty/Dementia
In terms of symptom control, what does the acronym IMPACT stand for?
Identify concerns
Make an accurate assessment
Plan your action
Act
Consistnetly re-evaluate
Talk to other HCPs
What are some of the ways that we can assess patients pain?
Pain Scale
Visually looking –> Do they look in pain?
Questionnaires
Types of pain
History of pain –> If theres a history then they’re more likely to score it lower as they’re used to it! And visa versa
When prescribing strong opioids, what else do we need to manage?
Constipation –> 90% of patients get it, so prescribe laxatives
Nausea –> Most people will be nauseous, but will often stop after 4-5 days…so anticipatory prescribing isnt always required
Drowsiness –> Common when starting strong opioids, but normally transient
What is opioid rotation?
A switch from one type of opioid to another to get a batter balance between the analgesia and the side effects
- Evidence for and against this being clincially useful
How are opioid conversions done?
Calculate the 24hr requirments
Convert back to oral morphine
Convert to new opioid to work out the new dose
Work out BCP dose
Why does Fentanyl cause less constipation than Morphine?
As Fentanyl can pass into the CNS easier, and so less is present in the periphery….so less can bind to peripheral receptors and cause constipation
What can be used for BCP when using Fentanyl as the SR opioid?
Fentanyl Lozenges or Sublingual
Alifentanil Sublingual or Spray
When would Hydromorphone be used?
If side effects of normal morphine are intolerable
In renal faliure, due to only having one active metabolite….so it is more readily excreted and glucoronidated
What is the main difference between Oxycodone and Morphine?
Oxycodone has slight Kappa agonist activity
What are the positives and negatives of methadone use for pain?
Positives –> Long-half and NMDA activity means it can be used for neuropathic pain
Negatives –> Long-half life makes titration very difficult, Sc infusion can be irritating
What type of Bone Targeting Agents (BTAs) can be used for bone pain?
Bisphosphonates
Strontium Ranelate
Denosumab
What is Allodynia?
Having hypersensitive nerve endings….so you feel pain for no real reason
How could we help treat neuropathic pain?
NOT with opioids!!
Dexamethasone –> Shrink tumours if they are pushing on nerves
Antidepressents –> Promote inhibitory pain pathways
AEDs –> Activate pain suppression pathways
Gabapentin –> Increases GABA (inhibitory) synthesis in the CNS
Ketamine –> NMDA antagonist in the spine that can be given in high doses
- Must be prescribed with diazepam or midazolam
Explain the functions of the following anti-emetics
Metoclopromide
Cyclizine
Haloperidol
Metoclopromide –> D2 antagonist, so best for gastritis by increasing peristalsis
Cyclizine –> Targets the vomiting centre, so best for motion sickness
Haloperidol –> Targets the CTZ, so best for chemcial related N+V
Explain the functions of the following anti-emetics
Levomepromazine
Hyoscine Butylbromide
Octreotide
Levomepromazine –> Broad acting anti-emetic, that can also be used for agitation
Hyoscine Butylbromide –> Works only on the muscarinic receptors, and so best for reducing GI motility
Octerotide –> Somatastain analogue that can be mixed with morphine
Explain the functions of the following anti-emetics
Ondansetron
Dexamethasone
Aprepitant
Ondansetron –> Specific to 5HT3, so not often used in palliative care
Dexamethasone –> An adjuvant anti-emetic in bowel obstruction
Aprepitant –> An NK1 antagonist
What was the Liverpool Care Pathway?
A pathway that was designed to ensure that all patients got the same end of life care regardless of where they were living
Was not followed correctly, and so replaced with NICE Guideline 31
What is Antcipatory Prescribing?
Prescribing in advance to allow easy access to drugs quickly in the community , especially when the patient deteriorates out of hours
Most effective when the GP has been caring for the patient for a prolonged period of time, as they will understand what is likely to be an issue (eg, N+V or constipation over other things prehaps
What is the first line drug for patients with excess secretions/colic?
Hyoscine Butylbromide
What are the symptoms and treatments of Hypercalcemia of Malignancy?
Dehydration, N+V, constipation, fatigue, confusion, cardiac complications and myopathy
Treatment –> Rehydratrion and bisphosphonates
What do you give STAT is there are symptoms of spinal cord compression?
16mg Dexamethasone
What is the conversion of prednisolone to dexamethasone?
6mg Prednisolone = 1mg Dexamethasone
Why may a patient need a syringe driver?
NBM
Unconscious/Weak
Lots of N+V
In what pHs is diamorphine less stable?
Higher pHs (more alkaline)
Why is using clonazepam in a syringe driver problematic?
As it no longer licenced as a solution for injection
So either cant be given, or needs to be ordered as a special
What should you be thinking about when prescribing anticipatory medicines?
Likelyhood of the specific symptoms occur
Benefits and harms of giving the drugs/not giving them
The risk of sudden deterioration
The place that care is occuring, and so the time it’ll take to get the drugs
