Palliative care Flashcards
Examples of immediate release morphine
Onset of these?
How long do they last?
Oramoprh soln or sevredol tablets
onset 20 mins last 4 hours
Examples of Slow release morphine
Onset of these?
How long do they last?
MST or Zomorph capsules
4 hours
last 12 hours
How do you work out the Opioid PRN dose from the total background dose?
PRN dose is 1/6th of the total 24 background dose
What do you write on the Opioid PRN dose ‘Max’ section?
6x/day
How do you increase the background opioid dose?
Increase by 30-50%
THEN RECALCULATE PRN DOSE
What opioids are preferred in the context of renal failure?
Oxycodone, Fentanyl/Bupre patches
What drugs are usually prescribed with opioids?
A laxative like Senna
Anti-emetic like haloperidol or cyclizine
How long do Fentanyl patches last?
Up to 72 hours
How long do buprenorphine patches last?
5/10/20 MCG last 7 days
35/52.5/70 MCG last 96 hours
Indications for opioid patches?
Stable pain, renal failure, cannot take oral medication
Signs of opioid Overdosing?
Confusion Drowsiness Myoclonic jerks Hallucinations Pinpoint pupils RR<10
Conversion rate for oral morphine to:
1) SC morphine
2) SC Diamorphine
1) oral to SC morphine then DIVIDE BY 2
2) Oral morphine to SC Diamorphine then DIVIDE BY 3
Immediate release oxycodone name?
Slow release oxycodone name?
Immediate release oxycodone name- Oxynorm
Slow release oxycodone name- Oxycotin
Indications for a syringe driver?
Does this indicate EoL?
Cannot swallow LoC/Dec Consciousness Persistent N&V Intestinal obstruction Malabsorption of drugs
Important to explain that this does not indicate EoL!
Analgesic ladder
1- Non-opioids
2- Weak opioids like Co-codamol 30/500
3- Strong opioids
+/- Adjuvants like NSAIDS/Amitryptiline, Gabapentin, AD, Corticosteroids
Good treatments for bone pain
NSAIDS +/- RT/Bisphosphonates
Good treatment for bowel obstruction pain
Hyoscine butylbromide + Analgesic ladder
Treating headache due to raised ICP
Corticosteroids + NSAIDS/Paracetamol
Neuropathic pain treatment
Amitryptiline or Gabapentin
Symptoms of N&V due to gastric stasis/irritation?
Treatment?
Sudden sickness, relief upon vomiting, heart burn
Metoclopramide B/C pro-kinetic
Causes of gastric stasis/irritation?
Stomach cancer, liver mets, Ascites, Dexamethasone, NSAIDS, Aspirin
Symptoms of N&V due to toxicity?
Treatment?
Constant sickness, vomiting does not provide relief, retching
Haloperidol or cyclizine
Can then try levomepromazine
Causes of Toxicity related N&V
Renal failure Chemotherapy RT Opiates Digoxin Hypercalcaemia Electrolyte problems Infection Liver failure
Treating chemotherapy related N&V
Metoclopramide if post-med
Ondansetron +/- Dex if PRE-MED
Symptoms of N&V due to cerebral irriation?
Treatment?
Early morning headache, vomiting, severe nausea, neuro symptoms
Dex or cyclizine
Causes of N&V due to cerebral irriation?
Brain mets, Inc ICP, Sights/smells, anxiety before chemo, RT to brain
How do you treat anxiety related nausea before chemotherapy?
Lorazepam
Which anti-emetic is broad spectrum?
Levomepromazine
Anti-emetics... 5-HT3 antagonism? Antipsychotic? H1 antagonsim D2 antagonist? Various receptors?
5-HT3 antagonism- Ondanestron
Antipsychotic- Halperidol
H1 antagonsim- Cyclizine
D2 antagonist- Metoclopramide (Pro-kinetic)
Various receptorsLevomepromazine broad spec
Examples of Softening osmotic laxatives
Lactulose
Docusate
Examples of stimulating laxatives
When do you avoid these
Senna
Bisacodyl
During colic
Softener and stimulating laxatives
When to use
Movicol
Co-danthrusate
Co-danthramer (Carcinogenic)
Infrquent, hard stools
Symptoms of intestinal obstruction
Post-prandial N&V Colicky pain Dull ache Distension Relief on vomiting
Managing intestinal obstruction symptoms
Levomepromazine
Hyoscine butylbromide
Opioid
Stop stimulants like Senn/Dantron
What sign would indicate a patient likely has constipation and not obstruction
Presence of flatus
What factors are considered for surgical intervention in intestinal obstruction ?
Performance status Disease status Co-morbidities Symptoms Level of obs
best imaging modality for Intestinal obstruction
CT
How can you relieve dyspnoea
Lorazepam PO
OR,,,
Midazolam and morphine sulphate SC
+/- Fan in face, relaxation, treat reversibility
Signs that someone is approaching end of life
Profound weakness Confined to bed Disorientation Severely limited attention span To weak to swallow Losing interest in eating/drinkin
Examples of medications that can be stopped in EoL
Vitamins Horomes Statins Abx Anticoag CS CV drugs AD
Examples of medications that should be continued in EoL
Analgesia Antiemetics Antisecretories Anxiolytics Insulin Anticonvulsants
How do you treat terminal restlessness in EoL care
Check: Pain, Bladder, Bowels, Secretions, Family (May be reversible)
Midazolam SC up to 5mg
What is a ‘death rattle’
How do you treat it?
Secretory movement in upper airways
Non-painful
Reposition
Hyoscine butylbromide
Criteria for a screening tool for cancer
Able to detect early enough by simple tests to be cured
Sensitive and specific tests
Well tolerated test (E.G Bronchoscopy is not)
Easy, inexpensive, well publicised
Current screening for…
Cervical cancer
Breast
CRC
Cervical- 25-64 smear every 3 years till 49 then every 5 years
Breast- 50-70 Women, Mammography every 3 years
CRC 60-74, Colonoscopies if at risk
Indications for DNACPR
Approaching end stage of terminal disease
Worsening frailty and multi-morbidity
Long term condition with life threatening exacerbations
Lots of unplanned hospital admissions
CPR wont work, pt doesnt want it or not in their best interests
Different co-codamol dosages
8/500
16/500
30/500
2X TAB 4X A DAY
What route can codeine not be given via
IV
What are the 4 anticipatory meds of palliative care
Analgesia
Anti-emetic
Hyoscine butylbromide
Agitation meds (Haloperidol/Benzo)
What are the 2 steps to confirming death?
1) Check mechanical cardiac function= NO PULSE AND NO HEART SOUNDS (5 mins)
2) Absence of pupillary light reflex, corneal reflexes and motor response to supra-orbital pressure
TIME OF DEATH IS WHEN BOTH ARE FULFILLED
What are sections 1a and 2a for on the death certificate
1a= Immediate direct cause of death (1b/c are events that lead to this) 2a= Significant other co-morbidities that contributed
If you put organ failure you must put what it was secondary to!
NO ABBREVIATIONS/SYMBOLS
Indications for coroner referral
Mesothelioma Violence, trauma, injury Toxic substance exposure Self-harm/Neglect Employment related Unknown cause Unknown identity No attending practitioner 14 days prior to death/not available within a reasonable time of death
Who fills out the death certificate?
A Dr who attended the patient during their last illness
within last 14 days
Must do it within 24 hours of being informed
Examine if crematorium planned
If patient is agitated but not terminal then what drug is 1st line
Haloperidol
Symptoms of terminal agitation?
What causative agents should be checked?
Restlessness, vocalisations, Emotional fluctuations
Remember to check: Pain, Bladder, Bowels, Family and compliance
When to suspect delirium in agitation?
Sepsis Multi-organ failure Cannot focus Confusion Hallucinations Disorientation
Treating agitation vs treating delirium
If agitated then consider midazolam
If delirious then make non-pharmacological changes (Routine, family involvement, same nursing staff, low lighting) and possibly consider adding haloperidol
