Palliative Care

Question 1

what are the 3 main domains of palliative care?

Answer 1

1) physical
2) psychosocial
3) spiritual

Question 2

what is palliative care?

Answer 2

discipline dealing with supportive care, end of life care, terminal care and bereavement support.

with ageing population and most people wanting to die at home this is becoming more relevant.
symptomatic relief important as it reduces QoL, causes distress and results in admissions.

Question 3

what are the 3 Bs that cause nausea and vomiting?

Answer 3

1) Bowels - mucositis, constipation, infection, obstruction
2) Brain - raised ICP
3) Biochemical - medications, hypercalcaemia, uraemia, infection, hypomagnaesaemia

Question 4

what 4 systems act on the vomiting centre leading to nausea? and what neurotransmitters work in each?

Answer 4

1) Vestibular system - motion sickness/vertigo - H1, muscAc
2) Limbic system - emotion and hyponatraemia - neurokinin 1 + GABA + 5HT3
3) Chemoreceptor trigger zone - base of V4, uraemia, drugs, chemotherapy, hypercalcaemia - 5HT3 + D2
4) gut wall - distension stimulates vagus - constipation, obstruction, chemo - 5HT3

Question 5

learn anti-emetic use and side effects

Answer 5

?

Question 6

why shouldn’t you prescribe cyclizine and metoclopramide?

Answer 6

metoclopramide (D2) is a prokinetic and can cause diarrhoea.
cyclizine (H1, antiMusc) is constipating.
they counteract each other in the bowels.

Question 7

what are the different treatment goals in managing pain?

Answer 7

1) good night’s sleep
2) pain free at rest
3) pain free on movement

trying to control background and breakthrough pain (PRN vs regular modified release)

Question 8

what are the simple analgesics and key things to be aware of for each

Answer 8

paracetamol - liver impairment, cachexia

NSAIDs - renal impairment, low platelets. CI in GI bleed, asthma. meds: warfarin, digoxin, steroids.

Question 9

what are the weak opioids and what should you be aware of for them?

Answer 9

codeine, dihydrocodeine, tramadol.

all have a ceiling effect - so REPLACE them with strong opioids rather than adding them together.

Question 10

what are the strong opioids and what should you be aware of for them?

Answer 10

morphine, diamorphine, oxycodone, buprenorphine, fentanyl.
specialist palliative care ones - alfentanil, methadone, ketamine.

beware - opioid naive, renal impairment, driving, prescribe for SEs, patient stigma

Question 11

give some general tips for prescribing opioids

Answer 11

start low and go slow, titrate according to pain and need for PRN meds.
PRN dose = 1/6th of 24hr dose.
deal with SEs - stimulant laxatives + PRN antiemetics.

common SEs - constipation, nausea, sedation, dry mouth.
less common - myoclonus and confusion.
rare - resp. depression and pruritus.

Question 12

what things are required to produce a legal CD prescription?

Answer 12

Indelible ink
Patient demographics: name + address + age <12
Drug name and formulation
Route
Frequency
Formulation
Strength
Total quantity in words and figures
Signed with name written
Dated (only valid 28 days)

Question 13

give some basic info on fentanyl

Answer 13

used for stable opioid responsive pain.
indicated if poor oral route or renal impairment.
takes 12hrs to reach analgesic concentration so not for acute pain (lasts 72hrs).
25mcg fentanyl patch = 90mg morphine/24hrs.

Question 14

what are some adjuvant analgesics?

Answer 14

• antidepressants - neuropathic pain e.g. amitryptiline
• antiepileptics - neuropathic pain e.g. pregabalin, gabapentin
• antispasmodics - muscle spasms e.g. baclofen
• steroids - compression symptoms e.g. dex
• benzodiazepines - spasms e.g. clonazepam, diazepam
• bisphosphonates - bone pain e.g. zolendronic acid

Question 15

what is terminal care?

Answer 15

likely to die in next 12 months or death imminent.

preparation helps with symptom management, QoL, practical and personal preparation, carer support.

key concepts - formal advanced care planning (advanced statement, power of attorney, advanced decision to refuse treatment), DNACPR (medical decision but should be informed by patient/carers).

how to recognise dying - change in symptoms, sudden deterioration. last days (2-14 days of daily deterioration) + last hours (body is shutting down)

Question 16

things to consider for advanced care planning?

Answer 16

1) Preferred place
2) Medical interventions they would or wouldn’t want e.g. ADRT IV ABX, PEG, escalation
3) DNACPR
4) A bucket list for the patient

Question 17

what 5 key symptoms are you aiming to control in the dying patient? and what meds for each?

Answer 17

1) pain - PRN morphine on syringe driver, continue patch medication
2) breathlessness - PRN opioid SC and SC benzodiazepines
3) resp. secretion - PRN hyoscine hydro/butylbromide (buscopan) also good for colicky pain 20mg sc PRN hourly
4) N&V - Haloperidol D2 (also?domperidone/metoclopramide) 0.5 - 1.5mg sc PRN 4 hourly (also for agitation/delirium
5) distress/agitation - Midazolam 1.25 -2.5mg SC PRN hourly

want to pre-empt these, prescribed in packs for patients at home so district nurse etc can administer PRN

Question 18

what are the 5 priorities of care for the patient that might die in next few hours/days?

Answer 18

1) Possibility is recognised and clearly communicated to patient
2) Sensitive communication occurs between staff and patient/family
3) Dying person/family involved in treatment and care planning
4) Needs of family are identified and actively explored
5) An individual plan of care including food and drink, symptoms and psychosocial/spiritual support is delivered