Palliative care Flashcards
What is the ‘end of life’?
People who are likely to die in the next 12m, including those whose death is imminent (hours-days) and those with advanced progressive incurable conditions/general frailty with a condition making them likely to die soon
What are the aims of palliative care?
Needs-based active care of pts with advanced progressive life-shortening disease (at any stage of the illness) to:
- Manage physical, psychological, social + spiritual problems
- Enable death to be in a place of their choice
- Enable acceptance of death as a normal process when life-prolonging treatments are no longer helping QoL
- Opportunity for closure + saying goodbye
- Neither hasten nor postpone death
What is end of life care?
Care at the end of life (last year), but some only receive in final weeks-days
Aim: comfort, emotional support, talking to family/friends about what happens, support with things like making a will
What is an advance decision to refuse treatment?
A statement made if 18+ with capacity, to refuse specific treatments in certain situations, e.g. not wanting Abx if only expected to live for a few days
It is legally binding (as long as they have mental capacity), most things it can be verbally expressed but better to have in writing; for life-sustaining things by law it must be written & witnessed e.g. ventilator decisions
Cannot request treatment
What should be discussed with pt + relatives for advance care planning?
- What pt wants to happen (advance statement of preference): not legally binding but take into account
- What they don’t want to happen: ADRT, DNACPR or RESPECT - legally binding for circumstances it is made for
- Who will speak for them: proxy spokesperson, Lasting Power of Attorney
What is a DNACPR and what would you explain to patients about it?
Written statement to not give CPR in a cardiac arrest
- Pt or LPA can request in the ADRT
- If not done most senior clinician in pt care will do it, if in pt best interest
Determine wishes, explain level of recovery pt may achieve. Explain involves compressions on chest, electrical shocks, injection of medicine + artificial lung inflation, in hospital 2/10 people survive on average, lower in other settings. If survive likely to have rib fractures, damage to liver/spleen, brain damage
What does the GSF say about recognising dying?
- Surprise question - would you be surprised if they died in the next few months/weeks/days? (intuitive)
- General indicators of decline - deteriorating physically, complex symptom burden, less responsive to treatments, progressive WL, repeated admissions, sentinel events like a serious fall/bereavement, functional indicators like Barthel index (for ADLs), Karnofsky performance status score (0-100), WHO/ECOG performance status (0-5, 5 is dead)
- Specific clinical indicators related to their disease - vary by disease - cancer, organ failure (erratic decline, inc COPD, HF, MND etc), frailty/dementia (gradual decline, reducing functional score, consciousness abnormalities, lack of meaningful conversation, refusing oral intake)
What are the indicators of decline in cancer patients?
- Rapid or predictable decline
- Performance status + functional ability most important factors
- Spending >50% of time in bed - ~3m prognosis
Where should you record that a pt is approaching the end of their life?
Record on the local/GP register for palliative care
What is death verification/confirmation and who does it?
Confirming that a patient is indeed dead
Needs to be a doctor who treated the patient in their final illness, and saw them within 14d of their death
How do you verify a death?
- Read notes for background + check DNACPR, confirm identify
- Inspect for obvious signs of life
- Response to verbal stimuli + pain (eg trapezius squeeze)
- Pupils - fixed + dilated
- Central pulse - carotid artery
- Heart sounds - listen for 2min
- Resp sounds - listen for 3 min
- Document
- Then need to discuss with senior Dr to clarify cause of death as need this info for cert
How do you certify a death?
Bereavement office: complete medical certificate of cause of death, and also need to externally examine body in mortuary (suspicious features, bruises/pressure sores implantable devices)
Cert includes:
- Personal deets
- Circumstances: last seen alive by me, any post-mortem deets, who saw after death
- Part I: cause of death. Main causal sequence of conditions that lead to death, 1a=direct cause then work way back until reach underlying cause (lowest completed line)
- Part II: conditions that may have contributed to death, e.g. IHD if died of pneumonia
- Your deets
- On back may need to complete if have referred to a coroner (not just if you’ve discussed and they’ve said no referral needed) or if you can provide more info in future (e.g. pending Ix results)
How do you fill out part I (cause of death) on a death cert?
- 1a = main condition that lead directly to death, there may only be one cause e.g. SAH
- Be specific e.g. adenocarcinoma of the right main bronchus rather than just lung cancer
- If 2 separate conditions led directly to death put both on same line and in brackets say joint cause
- Cannot write failures as a sole 1a cause - so can’t just put HF/RF; (CCF is ok); can’t put only cause as cacehxia/cardiac arrest/coma/exhaustion/frailty [and can only mention frailty as a cause if >80]
How do you fill out part II (contributors of death) on a death cert?
Not the entire medical history, but things that played a role in hastening the death without being part of the main causal sequence
e.g. IHD if died of pneumonia
Why would you refer a death to coroner?
Written on the form but things like unknown cause of death, sudden/unexpected (inc any death <24h after hospital admission), if not seen by a doctor within 14d, suspicious/violent/accident/self-neglect/neglect by others, if death could be due to an abortion, if could be due to employment, if occurred during/shortly after a period of police custody, if occurred during an operation/before recovery from GA
What is anticipatory prescribing and what might it entail?
Prescribing medicines that a pt may need to manage sx likely to occur in the last days of their life e.g. agitation, breathlessness, N+V, resp secretions, pain, catastrophic haemorrhage, seizures
- Analgesia
- Opioid for breathlessness
- N+V increase dose
- Anxiolytics may increase dose to max, or if not currently on any prescribe midazlolam or similar BZD
- Delirium: can have haloperidol or levomepromazine for SC
- Secretions: up dose or use hyoscine hydrobromide or glycopyrronium bromide
Principles of N+V prescribing
- Check N+V and not regurgitation/expectoration
- Search for reversible causes
- Give drugs regularly (stat when initially starts obv) not PRN; and by appropriate route
- Non-drug measures may also help
Pathophysiology of N+V
Neurotransmitters in the gut + brain (and also receptors in gut+brain)
Vomiting centre in brainstem stimulated by:
- Chemoreceptor trigger zone in brainstem receives input from drugs/toxins + neuroendocrine pathways
- Vestibular system
- Higher cerebral cortex
Which anti emetics can cause EPSEs?
Haloperidol, metoclopramide, levomepromazine, olanzapine
- don’t routinely combine, may be worsened with SSRI/TCA
- for Parkinson’s use domperidone
Which anti emetics have anticholinergic side effects?
Cyclizine + levomepromazine
What anti-emetics are used for opioid-induced N+V and why?
Haloperidol 1st line - as affect the CTZ which is main issue with opioids
Metoclopramide - as opioids can also cause gastric stasis
Which anti-emetics are best for delayed gastric emptying?
- Prokinetics - metoclopramide or domperidone
- PPI/H2RA to reduce secretions
- Dexamethasone for hepatomegaly
Which anti-emetics are best for metabolic causes like hypercalcaemia and renal failure?
Haloperidol
Levomepromazine
Which anti-emetics are best for chemotherapy N+V?
Granisetron or metoclopramide
Dexamethasone
Aprepitant
Which anti-emetics are best for brain disease?
Cyclizine
Dexamethasone for RICP
Carbamazepine in leptomeningeal disease
Which anti-emetics are best for vestibular causes of nausea?
Vestibular histamine/ACh receptors so cyclizine or levomepromazine
Which anti-emetics are best for N+V caused by anxiety + pain?
- Non-pharm like CBT
* Anxiolytics
Which anti-emetics are best for liver disease?
Avoid hepatotoxins
Metoclopramide
Ondansetron
What causes dyspnoea?
Distortion + stimulation of mechanoreceptors in the airways
- Cancer related: airway obstruction, lung mets, lymphangitis carcinomatosis, effusions, SVCO, phrenic nerve palsy, ascites, pain, fatigue
- Treatment-related: surgery, RT/CT causing pneumonitis/fibrosis, meds causing oedema/bronchospasm
- Other condition like infection, PE, COPD, HF, pneumothorax, anaemia
- Psychological: fear, distress, claustrophobia
Outline management strategies for dyspnoea
- Specific treatments for a cause e.g. aspirating an effusion, transfusion for anaemia, stenting for SVCO
- Non-pharmacological: fan/window, tripod sitting position, breathing techniques/PT (encourage relaxation, help secretion expectoration), energy conservation, distraction
- Explanation
- Pharmacological
What drugs can be used for dyspnoea?
- Bronchodilators e.g. ipratropium (salbutamol more s/e)
- Opioids: may also improve sleep, titrate, initially IR morphine, they don’t cause CO2 retention
- Steroids: reducing oedema e.g. lung mets. Trial with oral dexamethasone for a week
- BZD: for the anxiety that accompanies it e.g. lorazepam, midazolam in SCSC
- Oxygen: no consistent evidence, but if fan not working can use it (but logistical + safety issues)
How is terminal breathlessness dealt with?
- Harder to relieve than pain
- Morphine/diamorphine via the CSCI
- Can add midazolam and/or levomepromazole
- Discuss rationale for these with pt + family to avoid misconceptions about hastening death
What is the aetiology of pain in advanced cancer?
- Cancer effects: organ infiltration, remote effects like myopathies
- Pain syndromes from treatment: radiation (fibrosis, neuropathy, lymphoedema), surgery (incision or phantom pain), chemo (neuropathies, necrosis, polyarthritis)
- Unrelated pain like OA, spinal stenosis
How should you assess a pts pain?
- Severity
- Impact on all areas - physical effects (activities, sleep), psychological (isolation, worries it will never end), social (relative having to everything around the house)
- Their understanding of the pain
- Concerns they have about treatment
What are the general principles of analgesic prescribing?
By the mouth (PO 1st), by the clock (regular to maintain blood levels), by the ladder, dose titration, adjuvants, r/v
Don’t give them an overdose, give PPI with NSAIDs
Transdermal patches - for stable pain, and only if issues with oral
Significant ongoing pain - regular opioids
If on opioids they also need breakthrough analgesia
What are adjuvant analgesics?
A drug with a different primary indication but that can be used as an analgesic, good if only partial response to opioids
E.g. corticosteroids, amitriptyline, duloxetine, pregabalin, gabapentin, hyoscine butyl bromide (Busopan), BZDs, bisphosphonates, ketamine
Which NSAIDs are safer to give?
- Caution if bleeding, CV risk or poor renal function
- Ibuprofen, diclofenac + naproxen generally safe if no GI or CV risk
- Celecoxib good if have GI risk (but not CV risk)
- HF worsened by all NSAIDs
Outline the WHO ladder for pain relief
- Mild pain: a non-opioid +/- an adjuvant so paracetamol +/- NSAID
- Usually move directly from 1 to 3 in palliative, but step 2 is for mild-moderate pain with a weak opioid + non-opioid +/- adjuvant. So add in codeine, tramadol or dihydrocodeine (but don’t rotate between these, if max dose not working need step 3)
- Moderate-severe pain: strong opioid + non-opioid +/- adjuvant. Morphine gold standard and 1st line, others include oxycodone (2nd line), fentanyl and diamorphine
How do NSAIDs work and what routes
Inhibit prostaglandin synthesis via COX pathways to reduce inflammatory sensitisation of nerves
No clear evidence of one being better
Can e PO, topical or SC (parecoxib)
NSAID s/es
- Gastric: dyspepsia, ulcers, celecoxib lower risk
- Bleeding
- Renal impairment
- CVS: coxibs + high dose diclofenac increase MI/stroke risk by 1/3, and all increase HF risk (naproxen lowest CV risk)
Which opioid side effects are more common in advanced cancer?
Constipation - 95%
Dry mouth
N+V - usually settles after a week
Drowsiness/sedation - usually on dose increases then settles
Long-term can cause resp depression but actually used for helping breathing, resp depression only an issue in renal impairment (as morphine excreted renally)
What should you co-prescribe with opiates?
Anti-Emetics for 5-7d at least
Regular laxatives
Which analgesics are best suited to which specific locations of pain?
- Bone (well localised aching tenderness): bisphosphonates, radiotherapy, NSAIDs/opiates (partial)
- Liver: steroids, NSAIDs
- Soft tissue: opioids
- Visceral: opioids (may be partial)
- Neuropathic: adjuvants (often poor opioid response)
- Incident pain like dressing change - IR opioid
Why are patients often anxious about taking morphine and how might you alleviate this?
- Dependence/addiction fears - reassure this won’t happen as they’re not recreationally using so won’t get the euphoria, and to stop you just titrate down over a few days
- Driving - can drive if they feel ok
- EOLC - explain actually improving their state so they can do moe activity
- Using too soon - better to control early as hard to control severe pain once has started, can increase dose
Opioid toxicity
- Causes: increasing dose too quickly, renal impairment, poorly opioid-responsive pain e.g. neuropathic but dose raised anyway
- Signs: miosis, hallucinations, drowsiness, vomiting, confusion, myoclonic jerks, resp depression
- M: IV naloxone
Principles of morphine prescribing in advanced cancer
- Regular oral MR (or IR) morphine plus oral IR for breakthrough pain (usually 1/6 of TDD, can repeat every 2-4h or hourly in last days, but should raise total dose
- Acutely start with IR then once controlled switch to MR with the same TDD, plus the PRN
- To increase dose: by 30-50%, only need to stop when pain relieved or ADRs unacceptable
- Consider adjuvants
How do you convert doses of morphine from co-codamol, codeine, dihydrocodeine, tramadol?
Oral codeine to morphine = divide by 10
Oral tramadol or dihydrocodeine to morphine = divide by 10
Which opiates are best in CKD?
Alfentanil
Buprenorphine
Fentanyl
How to calculate the breakthrough dose of morphine?
Traditionally is 1/6 of the total daily dose, 1/10 may be enough (recommended in BNF)
Transdermal opiate preparations
Give big doses, take ~12h to get full effect and last ~72h - good for stable pain, unsuitable for acute/changing pain
Titrate with morphine to dose needed, then swap once you know the dose needed to alleviate the pain and alter this to the equivalent for the drug:
Fentanyl 12 microgram patch = 30mg oral morphine per day
Buprenorphine 10 microgram patch = 24mg oral morphine daily
What drugs can be used in a syringe driver?
- Cyclizine, levomepromazine, haloperidol, metoclopramide (N+V)
- Hyoscine hydrobromide (resp secretions)
- Hyoscine butylbromide (bowel colic)
- Midazolam, haloperidol, levomepromazine (agitation)
- Diamorphine (pain)
Some cant be used together, cyclizine can only be used alone
How do you convert oral opiates into SC?
Oral morphine - SC morphine = TDD/2
Oral morphine - SC diamorphine = TDD/3
Oral oxycodone - SC diamorphine = TDD/1.5
How would you convert the dose of morphine into oxycodone and what are the differences?
Divide by 1.5-2
Oxycodone generally has less sedation + vomiting + pruritus, but more constipation
What are the types of morphine?
- Immediate release: oramorph (liquid morphine sulfate solution, comes as 10mg/5ml or 100mg/5ml), sevredol (tablets)
- Slow-release: also prescribe IR for breakthrough. Zomorph capsules, MST tablets
How do you prescribe oramorph?
Write full name morphine sulfate oral liquid (oramorph)
Dose e.g. 10mg/5ml
Supply 1 (one) 300ml bottle
Take 10mg (5ml) PRN up to 1hrly
How do you write a prescription for controlled drugs (any opioid and BZD)?
- Drug name, form (e.g. capsules) and strength
- Need to write the word supply, and give pharmacist exact instructions
- Amount of drug in words + figures (inc if patches/bottles). E.g. supply 56 (fifty six) 10mg tablets
- For oramorph remember concentration and size of bottle e.g. 1 (one) 300ml bottle
- For patches e.g. supply fentanyl patches 25 microgram/hour, total 5 (five) patches
- For syringe driver: e.g. supply morphine for injection 10mg/ml ampoules. Total of 14 (fourteen) ampoules
How to assess constipation in EOLC?
- Exclude bowel obstruction e.g. known abdomen tumour, absence of flatus, colicky pain, N+V, distension
- Contributing drugs/other factors
- Severity + impact: N+V, appetite loss, pain, incontinence
- Effectiveness of management trialled
What is the management of constipation at the EOL?
- Prevention: prescribe a stimulant laxative when prescribing opiate e.g. senna
- In renal failure prescribe lactulose plus senna, or co-danthramer
- Encourage fluids + fruit juice + fruit
Gastric distension
Pressure on stomach by tumour - give a prokinetic e.g. domperidone
Anorexia/malaise
Due to cancer cachexia + chronic stimulation of acute phase response + substances secreted by the tumour (lipid mobilising and proteolysis inducing)
SO calorie-protein support has limited benefit (even parenteral feeding)
Corticosteroids help weight gain by fluid retention, but they also cause muscle catabolism …
Bowel obstruction
Partial obstruction - metoclopramide
Complete - not meto as worsens it, can give hyoscine butylbromide,
Octreotide (somatostatin analogue to reduce secretions + vomit volume)
Ranitidine for gastric secretions
Physical e.g. venting gastrostomy
Depression + anxiety
Often respond well to usual antidepressants, CBT, increased social support
Care of people with non-malignant disease
Similar symptom burden but may life longer than with cancer with more erratic decline, often need bespoke management. Sudden death fairly common for CV/diabetes
- HF: many drugs CI but may be used when dying, reprogram ICD to pacemaker mode as defibrilation whilst they are dying is distressing, peripheral oedema often quite resistant to diuretics
- Chronic resp disease: breathlessness services, opioids, may need NIV
- Renal disease: complicated prescribing, withdraw dialysis if effort of attendance too great
- Neuro: swallowing difficulties + loss of mental capacity main issues, MS pain often prominent cos of muscle spasm
- Dementia
Why is their caution for using cyclizine?
- Causes skin reactions in the SC route
* In a syringe driver it can’t be mixed with other drugs
Mechanism + routes of domperidone
Dopamine receptor antagonist in the gut (prokinetic) [doesn’t cross BBB]
Oral only
Mechanism + routes of metoclopramide
Dopamine receptor antagonist and serotonin 5HT4 agonism - central + gut (pro kinetic)
PO, IM, IV, SC
Mechanism + routes of haloperidol for N+V
Typical antipsychotic, dopamine antagonist in the CTZ - central, not prokinetic
PO, IM, SC
Mechanism + routes of cyclizine
Histamine and ACh antagonism - works in the vestibular system + vomiting centre
PO, IM, IV, SC, PR
Mechanism + routes of ganisetron and ondansetron
Serotonin 5HT3 antagonism - central + gut effects
PO, PR, IM, IV
Mechanism + routes of levopromazine
Serotonin 5HT2, dopamine, ACh and histamine antagonism - central effects
SC, IM, IV, PO
Which anti-emetics can be used in a syringe driver?
Hyoscine hydrobromide Levomepromazine Cyclizine (but not mixed with other drugs) Haloperidol Metoclopramide
Hyoscine hydrobromide for N+V?
ACh antagonism in vestibular system + VC
PO, SC
Aprepitant for N+V?
Neurokinin-1 receptor, central action, only used if specifically highly-emetogenic chemo causing N+V
PO
Olanzapine for N+V?
Dopamine, serotonin 5HT2, ACh, and histamine actions, centrla
Broad spectrum, good if levo not tolerated but risk of sudden stroke/sudden death esp in elderly
Which anti-emetics are a/w QTc prolongation?
Antipsychotics, domperidone and ondansetron
How do you work out oral morphine dosage?
IR given 4-hourly as a PRN so is the TDD/6
MR given 12-hourly, so dose is the TDD/2
