Palliative Care Flashcards
What is the WHO pain ladder?
Step 1: Paracetamol
Step 2: Weak opioid e.g. codeine + paracetamol (co-codamol)
Step 3: Strong opioids e.g. morphine, diamorphine, fentanyl, oxycodone
What are the different strengths of codeine?
Weak = 8mg codeine + 500mg paracetamol Middle = 15mg codeine + 500mg paracetamol Strong = 30mg codeine + 500mg paracetamol
What is the initial dose of morphine for those on the maximum dose of weak opioids?
MST or Zomorph capsules 15-20mg BD
How much prn oromorph can you give to someone on slow release morphine?
1/6th of their total 24hr morphine dose
e.g. patient on MST 30mg bd should have oromorph 10mg prn
What can be used to manage bone pain?
IV bisphosphonates
Radio/chemotherapy to reduce size of tumour
What can be used to manage liver capsule pain?
NSAIDs or corticosteroids to reduce inflammation
What can be used to manage neuropathic pain?
Gabapentin
Pregabalin
Amitryptiline
When should you use oxycodone over morphine?
Low eGFR
If morphine causing a lot of nausea and constipation
What are some side effects of morphine?
- > 90% constipation - start them on laxative
- 30% nausea + vomiting - would begin within a week of starting morphine; don’t always start them on anti-emetic but can put them on PRN so they can have if they need
- Drowsiness - should settle within 72 hours but if it doesn’t check that they don’t have impaired renal function; don’t drive when starting it or changing the dose
- Physical dependence (psychological addiction wont happen)
- Respiratory depression - if dose is wrong
When are opioid patches appropriate to use?
If pain is stable
If poorly compliant with oral medication
If patient has problems swallowing
Severe renal impairment
What are some non-pharmacological pain-management adjuvants?
- Transcutaneous electrical nerve stimulation
- Heat therapy e.g. pads
- Palliative radiotherapy
- Nerve block
What can be given to relieve muscle spasms?
Baclofen
What are some treatments for non-reversible breathlessness?
Relaxation
Hand-held fan
Oromorph
Lorazepam
How do you know someone is dying?
- Reduced oral intake
- Sleeping more
- Not taking medication
- Cheyne-Stoke respiration
- Increased secretions
- Confusion
- Terminal agitation
- Unresponsive
What are the 4 anticipatory medications?
- Midazolam
- Hyoscine butylbromide/glycoporonim (anticholingergic) if hyoscine insufficient
- Levomepromazine/haloperidol
- Morphine/oxycodone
What are the 4 vomiting pathways?
Cerebral
Toxic
Gastric
Vestibular
How is the nausea/vomiting different in toxic and gastric pathways?
Toxic = lots of nausea, frequent small quantities, retching
Gastric stasis = large volume of vomit once or twice a day, minimal nausea
What can cause vomiting via the cerebral pathway/
Primary brain tumour or brain metastases
Raised intracranial pressure
Emotions
What can cause vomiting via the toxic pathway?
Opioids Hypercalcaemia Uraemia Jaundice Infections
What is the broad spectrum antiemetic?
Levomepromazine
What antiemetics are most appropriate for vomiting from gastric pathway?
- Metoclopramide
- Domperidone
They are pro-kinetic so increase speed at which food exits the stomach
What antiemetics are most appropriate for vomiting from toxic pathway?
- Haloperidol
- Cyclizine
- Levomepromazine
What should be given to a patient with emotion-related vomiting?
Benzodiazepines
What should be given to someone vomiting due to increase intracranial pressure?
Dexamethasone with cyclizine
What antiemetic is mostly used for nausea and vomiting related to chemotherapy?
Ondansetron
What is the main side effect of ondansetron?
Constipation
Give examples of stimulant laxatives
Senna - NICE recommended 1st line treatment for constipation
Bisacodyl
Give examples of stool softeners
Lactulose = osmotic laxative
Docusate capsules = emollient stool softener (liquid form tastes awful)
Give examples of combination stimulant + softener laxatives
Macrogol
Co-danthrusate
What opiates are safest in severe chronic kidney disease/low eGFR?
Fentanyl or Buprenorphine - both undergo hepatic metabolism and are not excreted by the kidneys
What type of drug is ondansetron?
5HT3 receptor antagonist
What drug is used for the management of intractable hiccups?
Chlorpromazine
What are most suitable drugs for agitation and confusion (not terminal phase)?
First line: haloperidol
Others: chlorpromazine, levomepromazine
How is death confirmed by a doctor?
- Individual should be observed for a minimum of five minutes
- Absence of mechanical cardiac function is confirmed using a combination of:
- Absence of central pulse on palpation
- Absence of heart sounds on auscultation - After 5 minutes of continued cardio-respiratory arrest confirm the absence of:
- Pupillary responses to light
- Corneal reflexes
- Motor response to supra-orbital pressure
Who can complete a death certificate?
Completed by a doctor who attended the patient during their illness and has seen them within the last 14 days
What goes in sections 1 and 2 on the death certificate?
Section 1 = immediate, direct cause of death on line 1a then go back through the sequence of events/conditions that led to the death
Section 2 = significant comorbidities not contributing to the cause of death in section 1
Give examples of causes of death that require referral to HM Coroner
- Poisoning or exposure/contact with toxic substance
- Use of medicinal product
- Violence, trauma, injury
- Self-harm
- Neglect and self-neglect
- Medical procedure
- Injury/disease attributable to any employment e.g. mesothelioma
What is a syringe driver?
A syringe driver is a portable, battery driven device which delivers a continuous infusion of drugs over a predetermined time.
In palliative care it is normal to use a syringe driver to infuse drugs via the subcutaneous route, as drugs are generally well absorbed and the sites can easily be changed by nursing staff.
What are the indications for a syringe driver?
- Inability to swallow drugs due to reduced conscious level, often in the last few days of life
- Persistent nausea and vomiting
- Intestinal obstruction
- Malabsorption of drugs
- Dysphagia
Inadequate pain control is not an indication for syringe driver use unless there is reason to believe oral analgesics are not being absorbed.
Which drugs are unsuitable for subcut administration and why?
Diazepam
Chlorpromazine
Prochlorperazine
They are too irritant
