Palliative Care Flashcards
Define palliative care.
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness
through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual.
Define end of life, according to the GMC.
‘Approaching the end of life’
– likely to die within the next 12 months
Those facing imminent death and those with:
– Advanced, progressive, incurable conditions
– General frailty (likely to die in 12 months)
– At risk of dying from sudden crisis of condition
– Life threatening conditions caused by sudden catastrophic events
Identify principles of delivering good end of life care.
Open lines of communication
Anticipating care needs and encouraging discussion
Effective multidisciplinary team input
Symptom control – physical and psycho-spiritual
Preparing for death - patient & family
Providing support for relatives both before and after death
Identify possible causes of pain in end of life.
Background/ Breakthrough/Incident pain
Physical causes
– Cancer related (85%)
– Treatment related
– Associated factors-cancer and debility – Unrelated to cancer
Overlap of physical/ psycho-spiritual causes
Can be multifactorial
True or false: most end of life patients have more than one pain.
TRUE
Identify the main pain syndromes felt in end of life.
• Bone pain – Worse on pressure or stressing bone / weight bearing • Nerve pain (neuropathic) –Burning/shooting/tingling/ jagging/altered sensation • Liver Pain – Hepatomegaly/right upper quadrant tenderness • Raised Intracranial Pressure – Headache (and/or nausea) worse with lying down, often present in the morning • Colic – Intermittent cramping pain
Identify a tool used in palliative care medicine in pain history taking.
Brief Pain Inventory (Short Form), alternative to SOCRATES (too basic for palliative care medicine):
- Any pains other than everyday kinds
- Shade area on diagram where feel pain, put X on area hurts most
- Rate pain at its worst
- Rate pain at its least
- Rate pain on average
- Rate pain right now
- Treatments for pain ?
- In last 24 hrs, how much relief has any treatment provided ?
- How much has pain interfered with general activity, mood, walking ability, normal work, relationships, sleep, enjoyment of life
Describe the WHO analgesic ladder for cancer pain.
STEP 1 (MILD PAIN) -Non-opioid simple analgesic (aspirin, paracetamol, NSAID) ± Adjuvant
STEP 2 (MODERATE PAIN) (if pain persists or increases) -Weak opioid (codeine, tramadol) for mild to moderate pain ± non-opioid ± adjuvant
STEP 3 (SEVERE PAIN) (if pain persists or increases) -Strong opioid (morphine) for moderate to severe pain ± non-opioid ± adjuvant
STEP 4 Nerve block Epidurals PCA pump Neurolytic block therapy Spinal stimulators
Add other medications for neuropathic pain (e.g. amitriptyline, gabapentin) at any step if required
FOR CANCER PAIN, START AT STEP 1 AND INCREASE IE NEEDED
FOR ACUTE NOCICEPTIVE PAIN, START AT STEP 3 (including any post-op drugs) AND STEP DOWN
What is the first line strong opioid ?
Morphine
MORPHINE
- Indications
- Actions
- Cautions
- Administrations
MORPHINE
-Indications: moderate-severe pain/dyspnoae (e.g. end stage COPD)
-Actions:
Opioid receptor agonist (μ-receptors)
Centrally acting
-Cautions
– Longlist in BNF; including renal impairment and elderly; Avoid in acute respiratory depression
– ‘…in the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to use of opioid analgesics’
-Administrations
– Enterally- oral (if possible)/ rectal
– Parenterally- im / sc injections
– Delivery via syringe driver over 24 hours
Identify the main kinds of release for morphine.
1) MODIFIED RELEASE
2) IMMEDIATE RELEASE
What is the main indication for modified release morphine ? How many time a day ?
– ‘Background’ pain relief
– Either twice daily preparation at 12 hourly intervals
– Or once daily preparation at 24hourly intervals
What is the main indication for immediate release morphine ? How many time a day ?
– ‘Breakthrough’ pain
– As required (PRN)
Identify an example of preparation for immediate release morphine.
E.g. Oramorph liquid/ Sevredol tabs
Identify examples of strong opioids other than morphine.
Diamorphine
Oxycodone
Fentanyl
State some differences of Diamorphine cf Morphine, and its route of adminsitration
Semi-synthetic morphine derivative
More soluble than Morphine→ smaller volumes needed
Can be used for parenteral administration (injection / syringe driver)
In which situations should we consider switching opioids ?
– Opioid sensitive pain with intolerable side-effects
OXYCODONE
- Indications
- Side effects
OXYCODONE
- Indications: Second line opioid
- Side effects: Less hallucinations, itch, drowsiness, confusion
FENTANYL PATCH
- Indications
- Duration
FENTANYL PATCH
- Indications: second line opioid, only use in stable pain, useful if oral and subcutaneous routes not available, and useful if persistent side-effects with morphine/diamorphine
- Duration: 72 hours
Identify other names of Oxycodone.
Oxynorm/Oxycontin
Identify most common side effects of opioids.
NandV Constipation Dry mouth Biliary spasm Watch for signs of opioid toxicity
Describe management of opioid side effects.
CONSTIPATION – Stimulant and softening laxative: -Senna / Bisacodyl + Docusate -Magrogol (e.g. laxido / movicol) -OR Co-Danthramer alone (if trying to reduce polypharmacy and only used one)
NAUSEA
– Antiemetic, especially:
-Metoclopramide
-Haloperidol (consider QT interval) (anti-psychotic that can helps with anti-emesis)
Identify the main signs of opioid toxicity.
– Shadows edge of visual field – Increasing drowsiness – Vivid dreams / hallucinations – Muscle twitching / myoclonus – Confusion – Pin point pupils – Rarely, respiratory depression
Identify examples of adjunct medication which may be taken alongside pain treatment in end of life care.
• Liver capsule pain/raised intracranial pressure
– Steroids (e.g. Dexamethasone)
– Remember to consider gastroprotection
• Neuropathic pain
– Amitriptyline/ Gabapentin/ Carbamazepine
• Bowel/ bladder spasm
– Buscopan (Hyoscine Butylbromide)
• Bony pain/ soft-tissue infiltration
– NSAIDs/ Radiotherapy for bony metastases
In which cases may syringe drivers be used ? How do they work ?
Useful when oral route inappropriate. Often useful for rapid symptom control.
Delivery over 24 hours, generally subcutaneous. Multiple medications can be added.
What is one problem associated with syringe drivers ?
Stigma of being on a ‘pump’
Identify the main components of “total pain”.
PHYSICAL
- Treatment
- Primary disease
- Co-morbid causes
- Side effects
SOCIAL
- Financial concerns
- Worries about family
- Loss of role/status
- Dependency
PSYCHOLOGICAL
- Depression
- Anxiety
- Fear of suffering of pain
- Experience of past illness
SPIRITUAL
- Loss of faith
- Anger at God
- Fear of death/unknown
- Existential pain
Define psycho-spiritual distress. When may this occur?
Psycho-spiritual distress can be defined as the impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, nature, or a power greater than oneself.
How may psycho-spiritual distress present ?
Psycho-spiritual distress may be expressed as - or magnify the intensity of - physical symptoms.
When may psycho-spiritual distress occur ?
Spiritual distress may occur when the individual is faced with challenges that threaten an individuals’ beliefs, meaning, or purpose.
Psycho-spiritual distress may occur at various points during the patients’ journey but in particular
• at diagnosis
• at home after initial treatment
• at disease progression or recurrence
• at the terminal phase
Describe management of psycho-spiritual distress.
- Affirm patient by attentive listening. If appropriate, explore current thoughts and feelings with focus on particular fears and anxieties.
- Key issues in managing Psycho-spiritual distress include:
- Encouraging hope, purpose and meaning
- Respecting religious/cultural needs,
- Affirming the patient’s humanity,
- Protecting the patient’s dignity, self worth and identity,
- Encouraging relationships,
- Encouraging forgiveness/reconciliation,
- Refer to colleagues in wider MDT / specialist services
Distinguish between the old and newer concepts of bereavement and grief.
OLD CONCEPT
Curative care takes the majority of the care. Once it has been established that nothing can be done (at the very end), palliative care takes over.
NEW CONCEPT
At the beginning of end of life care it’s mainly disease modifying/potentially curative but also a little palliative. As the illness progresses, the use of palliative care increases whilst the use of curative care deceases. Towards the end (before death), bereavement care also begins to prepare the patient for death. Bereavement care continues even after death to help relatives cope.
Refer to slide 25 in lecture on “Palliative Care”
Define anticipatory grief.
What happens before patient dies. NOT grief (i.e. if family enters anticipatory grief prior to patient dying, will NOT make it easier post-death)
What proportion of all grief does non-complex (normal) grief, and complex (unresolved) grief make up ? What do these terms mean ?
- Non-complex (normal) Grief (90-94%) AKA will not need support from medical or psychological support
- Complex / Unresolved Grief (6-10%)
To what extent is grief an indicator of the relationship between bereaved and deceased ?
Grief is not a measure of the relationship between the bereaved and the deceased
Identify “cures” patients may look for in a phase of grief.
• Medication
- Antidepressants
- Benzodiazepine
- “Sick line” (but better for patients psychologically to get back to normal life as soon as possible)
- Counselling
However, the vast majority of those experiencing grief only require support and space to be heard.
To what extent is it good to give grieving patients antidepressants ?
Anti-depressants have no effect on grief/bereavement. Latter can lead to depression, but does not in itself constitute depression.
What is the most important therapeutic intervention you can offer for grieving patients ?
Your presence and listening ear is the most important therapeutic intervention you can offer.
Identify important principles of talking with someone who is grieving.
- Acknowledge the persons loss
- Take time to listen to the persons stories, allow them to talk about their loss, their feelings and how they are coping
- Mirror the words and phrases used by the person
- Learn how to recognise anticipatory and unresolved Grief and any complications (especially depression).
Should acute grief be medicalised ?
Acute grief can be highly distressing and disabling, but grief should not be medicalised.
Define grief.
Grief is the body’s natural response that evolves as a bereaved person adapts to their loss.
