Palliative Care Flashcards
What symptoms are often controlled in palliative care?
- fatigue
- nausea and vomiting
- breathlessness
Why is communication so important in palliative care?
- patients have a lot of questions
- helps patients come to terms with the concept of palliative
- families need to know what is going on with their relative (don’t assume that they KNOW)
How do all the different professionals involved in a patients care know the general aims and plans for the patient?
Electronic Advance Care Plans or ‘ACPs’
- created by GPs and shared with other professionals
- called a “Key Information Summary” or KIS
What conditions are most likely to require palliative care?
Cancer
Organ failure (e.g. RESP-COPD, Liver failure)
Progressive neurological disease (e.g. MND)
Frail patients with dementia
Describe the illness trajectories of Deterioration in Terminal Illness compared to Organ Failure and Frailty.
Deterioration in terminal illness
- predictable decline
- can happen relatively quickly (steep curve drop)
Organ Failure
- exacerbations of disease create a “wave” like curve
- this trajectory is often present until death
Frailty
- low level of baseline function
- deterioration often subtle
- often over a long period of time
What other members are part of the palliative care team apart from Doctors/Nurses/AHPs?
Chaplains
Bereavement workers
Social Work
Community Palliative Nurses (e.g. MacMillan)
Describe the basic steps of the WHO pain ladder
MILD
- paracetamol
- NSAIDs
+/- aduvant
MODERATE
- codeine/ co-codamol
+/- adjuvant
SEVERE
- morphine
+/- paracetamol/NSAID/adjuvant
What are the two different types of pain that patients experience and how do we manage these differently?
Background
- managed with modified release preparations that last around 12 hrs in the body
Breakthrough
- managed with immediate release preparations that last around 4 hours in the body
What brands of Morphine are Modified Release (MR)?
MST Continus
ZoMorph
What brands of Morphine are immediate release?
Sevredol
Oramorph
How do we normally work out the dose to initiate patients on morphine?
Usually patients are on MAX. codeine in one day
i.e. 60mg QDS => 240mg
THIS IS EQUIVALENT TO AROUND 30mg MORPHINE
Split the dose of morphine into 2 for modified release preparation.
=> morphine 15mg M/R BD
How strong should the pain relief given for breakthrough pain be?
1/6 of the total daily dose of morphine
What are the common symptoms of opiate toxicity?
- Hallucinations
- Sudden jerking (myoclomus)
- Drowsiness
- can also cause respiratory depression
If a patient becomes opioid toxic, what should you check for?
Decreased renal function
- as morphine accumulates if renal function declines
What drug is used to reverse the effects of opioid toxicity, and how should it be used?
Naloxone can reverse morphine very quickly
=> must be used as a diluted preparation to treat opiate side effects like resp. depression
What other opioids can be used aside from morphine?
oxycodone
Why does the dose need to change when swapping patients from morphine to oxycodone?
Oxycodone is 2x as strong as morphine
=> A patient on Morphine 10mg M/R BD
changes to Oxycodone 5mg M/R BD
What signs are important to recognise that may indicate a patient is nearing death?
- General weakness
- Loss of swallow mechanism
- Lose interest in food/fluids
- Sleeping more often
What conditions may mimic patients deteriorating which are actually reversible?
- Opiate toxicity
- Delirium
- Sepsis
- AKI
How can we ensure patients are most comfortable at the end of life?
- Stop inessential medications (statins)
- Oral meds converted to alternative route if no swallow
- Don’t miss urinary retention as a cause of agitation
- Stop routine obs/monitoring/take out unused cannulas
- Appropriate environment (e.g. side room) and equipment in place (e.g. if patient wishes to die at home)
What route of delivery is often used for drugs if oral drugs are no longer tolerated?
continuous subcutaneous infusion (CSCI)
using a syringe driver
What are the advantages of using a syringe driver to deliver medications?
- can be used in home or community
- can mix 3 different drugs in syringe for delivery together
Morphine delivered through a syringe driver infusion is weaker than if it is given orally. TRUE/FALSE?
FALSE
morphine given as a CSCI is 2x as strong as oroal morphine
If patients are having to use immediate release morphine for breakthrough pain often during the day, how do we manage this?
Increase the background M/R dose
What other drugs are given in palliative care for symptom control?
Midazolam - for distress
Levomepromazine - for nausea
Hyoscine Butylbromide (Buscopan) - for secretions
What are “Just in Case” boxes?
Boxes kept in patients homes which are useful for symptom control in the community
What can be given in patients are showing signs of dehydration in the final stages of life?
Trial of artificial hydration if patient is distressed due to dehydration
**SCUT/IV fluids not routinely used **
Patients whose death was expected can have their death verified by a nurse working on the ward. TRUE/FALSE?
TRUE
What checklist must a doctor complete before verifying a death?
Check for:
- spontaneous movement (inc. respiratory effort)
- reaction to voice and pain (sternal rub)
- Palpate 2 major pulses for 1 min
Inspect the eyes looking for
- dryness
- fixed dilated pupils
- absence of corneal reflexes
- clouding of the cornea
Auscultate the heart and lungs for 1 min
NOTE pacemaker or other implantable device!! (cremation)
When would a death need to be reported to the procurator fiscal?
e.g. mesothelioma => work related death
