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
