Palliative care Flashcards
Palliative care: Definition
The active, holistic care of patients with advanced progressive illness. It combines management of pain and other symptoms, with the provision of psychological, social and spiritual support.
Palliative care: Important FACTORS to consider (4)
Palliative care should run in parallel with other medical treatments. Important factors to consider include:
- Physical
- Psychological
- Spiritual
- Social
Palliative care: Management of pain
Aim to modify the underlying pathology where possible e.g. radiotherapy, chemotherapy, surgery. Use analgesia to relieve background pain and provide additional PRN does for ‘breakthrough pain’. Effective analgesia is possible in most patients by combining the following 5 principles:
- By the mouth - given orally whenever possible
- By the clock - given @ fixed intervals to offer continuous relief
- By the ladder - following WHO stepwise approach
- For the individual - there are no standard doses for opiods, needs vary
- Attention to detail - communicate, set times, warn of side effects
WHO analgesic ladder: Overview
Increase and decrease the analgesia required according to the ‘steps’ on the ladder.
- Non-opiod e.g. paracetamol
- Opioid for mild-moderate pain e.g. codeine
- Opioid for moderate to severe pain e.g. morphine, diamorphine, oxycodone
Adjuvants which can be added at any time include: NSAIDs, amitriptyline, pregabalin, corticosteroids, nerve block, transcutaenous electrical nerve stimulation (TENS), radiotherapy
Palliative care: Non-pain symptoms
- Nausea + vomiting
- Constipation
- Oral problems (e.g. thrush, herpes)
- Insomnia
- Pruritis
- Venepuncture (extravasation, phlebitis)
- Agitation
- Respiratory tract secretions
Palliative care: Spiritual pain
Spirituality is a means of experiencing life.
Spiritual pain or suffering is common when people are facing death. It can include feelings of hopelessness, guilt, isolation, meaninglessness and confusion.
Consider:
- The past: painful memories, guilt
- The present: isolation, anger
- The future: fear, hopelessness
- Remember the whole person
- Companionship is essential in spiritual support
- Spiritual pain is exacerbated by physical symptoms.
Palliative care: Care in the last few days of life
The focus of care should be the relief of distressing symptoms.
An individualised care plan should be made and discussed with your patient, their family and relevant medical staff.
Continue to treat reversible problems as appropriate (e.g. urinary retention).
Prescribe as required subcutaneous end of life drugs.
Start a syringe driver.
Palliative care: Syringe driver
Syringe drivers allow a continuous SC infusion of drugs avoiding repeated cannulation and injection when the oral route is no longer feasible. Some medications should not be put in the same syringe - check interactions.
Symptoms that can be managed include:
- Pain
- Anxiety, agitation, delirium
- N&V
- Respiratory secretions
- Seizures
Palliative care: AIMS in the last few days of life
- Manage agitation
- Manage excessive secretions
- Hydration
- Plan for death (DNACPR)
- Respond to changes in the clinical situation
- Communicate
Palliative care: Syringe driver
- Symptom
- Drug
- Pain: morphine
- Anxiety, agitation, delirium: Midazolam, levomepromazine, haloperidol
- N&V: Cyclizine, haloperidol, levomepromazine
- Respiratory secretions: Hyoscine butylbromide, glycopyrronium
- Seizures: seizure prophylaxis
Clinically assisted nutrition includes:
- Intravenous feeding
- Feeding by nasogastric tube
- Feeding percutaneous endoscopic gastrostomy (PEG)
- Radiologically inserted gastrostomy (RIG) feeding tubes through the abdominal wall.
ETHICS of clinically assisted nutrition and hydration
Nutrition and hydration provided by tube or drip are regarded in law as medical treatment, and should be treated in the same way as other medical interventions.
Good practice in decision making
Includes dealing with:
- making decisions with patients who have capacity
- what to do if your patient doesn’t have capacity
- assessing the overall benefit of treatment
- advanced care planning
- meeting a patients’ nutrition and hydration needs
- cardiopulmonary resuscitation
- the role of relatives, partners and others close to the patient
- organ donation and care after death.
Supportive care
- Macmillan nurse referral
- Symptom control
- Benefits - people with life expectancy <12 months are eligible for top rate of Disability Living Allowance, this is not means tested and isn’t backdated.
- Discussion regarding life expectancy
- Discussion regarding place of death
- Hospice
- DNAR (Do not allow resuscitation/AnND (allow a natural death)
- Family social concerns
