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 (imediate-oxynorm, slow release-oxycontin), alfentanil, methadone
What are the different strengths of codeine?
Weak = 8mg codeine + 500mg paracetamol Middle = 15mg codeine + 500mg paracetamol Strong = 30mg codeine + 500mg paracetamol (generally use this when progressing from step 1- unless elderly where lower dose may be better)
What is the initial dose of morphine for those on the maximum dose of weak opioids (co-codomol)?
-MST or Zomorph capsules 15-20mg BD is appropriate if on the full dose of weak opioids in step 2
(lower dose if elderly/frail/kidney problems)
What else must you prescribe if patients are on slow release morphine (e.g. Morphine Sulphate Tablets (MST/ Zomorph capsules)
How much should they be prescribed?
- All patients on modified release morphine should have normal release morphine (oromorph, sevredol) available p.r.n. for breakthrough pain.
- also prescribe a laxative and antiemetic for PRN (like the SABA inhaler)
the normal release morphine should be 1/6th of their total 24 hour morphine dose, e.g. a patient on MST 30 mg bd should have oramorph 10mg p.r.n. (because oromorph lasts 4 hours)
remember to prescribe PRN morphine as subcut AND oral
Explain bone pain.
What can be used to manage bone pain?
Bone pain:
- Dull ache over large area or localised
- Worse on movement/weight baring
Treatment for bone pain
- NSAIDS (e.g. diclofenac 50mg tds),
- Palliative radiotherapy
- IV Bisphosphonates (e.g. pamidronate infusion).
Describe neuropathic pain.
What can be used to manage neuropathic pain?
Neuropatic pain:
- Change in sensation-pins and needles/burning
- Assosiated factors-pallor and increase sweating
- Can be specific dermatomes
Treatment:
- Antidepressants (amitriptyline at night) -Anticonvulsants (gabapentin, pregablin)
- Compression of a nerve may be helped by corticosteroids
When should you use oxycodone over morphine?
Low eGFR
If morphine causing a lot of nausea and constipation
What are some side effects of strong opioids (e.g.morphine)?
Strong opioid side effects
- > 90% constipation - start them on laxative (co-danthramer or movicol)
- 30% nausea + vomiting - usually settles within few days (prescribe a p.r.n. antiemetic (e.g. haloperidol) so they have if needed)
- Drowsiness - should settle within 48 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)
When are opioid patches appropriate to use?
If pain is stable (take a while to kick in)
If poorly compliant with oral medication
If patient has problems swallowing
Severe renal impairment
What are some non-pharmacological pain-management adjuvants?
Bio
• Transcutaneous electrical nerve stimulation (TENS)
• Heat therapy e.g. pads
• Palliative radiotherapy (e.g. bone pain)
• Palliative chemotherapy (masses compressing on nerves)
• Nerve block
•Surgery (intramedullary nail-pain from bone mets)
Psycho •CBT •Aromatherapy • Meditation •Distraction therapy •Self help
Social
•family support?
What can be given to relieve muscle spasms?
Baclofen
What are some treatments for non-reversible breathlessness?
Relaxation Hand-held fan Morphine Benzos -Lorazepam (sub lingual) -Midazolam (sub cut if cant tolerate)
How do you know someone is dying?
Why are these important to recognise?
Signs of dying (if all reversible causes have been considered and managed)
• Reduced oral intake
• Sleeping more
• Not taking medication (too weak to swallow)
•Profound weakness
• Confusion
• Terminal agitation
• Unresponsive
• Cheyne-Stoke respiration (fast then apnoeas)
• Increased secretions (death rattle)
-help by positioning and anti secretories
•Tachycardia, hypotensive and low peripheral perfusion
Important: stop unnecessary treatment and allow patient’s family to prepare
What are the 4 anticipatory medications?
- AXIOLYTICS- Midazolam
- ANTISECRETORY
- Hyoscine butylbromide (buscapan)-antisecretory and anti spasmodic or glycoporonim (anticholingergic) if hyoscine insufficient
(anti musc>block parasympathetic>stop secretions)
- ANTIEMETIC- Levomepromazine/haloperidol
- ANALGESIC- Morphine/oxycodone
- can also do ANTIPSYCHOTIC (haloperidol)
What are the 4 vomiting pathways?
(brain, balance, belly, botulinum)
- Cerebral (morning after-smells like alcohol)
- Toxic (too much alcohol in system)
- Gastric (downing a pint-vommiting)
- Vestibular (room spinning at home)
Explain features of vomiting via the gastric pathway.
Causes of gastric pathway vomiting?
Treatment for gastric pathway vomiting?
GASTRIC STASIS/IRRITATION VOMITING
Features
- Large vomits once or twice a day
- Minimal nausea between vomits
- Stasis: early satiety, epigastric fullness
- Irritation: hiccups, heartburn,
Causes
- gastritis (causes: radiotherapy, drugs-give PPI)
- gastric stasis (liver mets-hepatomegaly, drugs may cause dysmobility, obstruction by tumour)
Treatment- pro-kinetics so increase speed at which food exits the stomach
1. Metoclopramide 30 mins before meals (EPSE e.g. acute dystonic
reaction such as oculogyric crisis
2. Domperidone (fewer side effects and interactions)
Explain features of vomiting via the cerebral pathway.
Causes of cerebral pathway vomiting?
Treatment for cerebral pathway vomiting?
CEREBRAL VOMITING
Features
-signs of raised ICP (early morning headache, vomiting, may be little nausea)
-associated neurological symptoms/signs.
Causes
- primary brain tumour/brain mets
- raised ICP
- emotions (anticipatory/nervousness)
- radiotherapy
Treatment
- Raised ICP=Cyclizine and dexamethasone
- Anticipatory/nervousness=Benzodiazepines, CBT and complimentary therapies. could also give levomepromazine
Explain features of vomiting via the toxic pathway.
Causes of toxic pathway vomiting?
Treatment for toxic pathway vomiting?
TOXIC VOMITING Features -persistant intermittent nausea -small vommits (possets) -retching and lots of nausea
Causes
- drugs (opioids, digoxin, anti epileptics, chemo, RT, HT)
- electrolyte abnormalities (hypercalceamia/uremia)
- reduced clearance- bowel, kidney, liver problems
- infection (UTI/pneumonia)
Treatment
- HALOPERIDOL at night
- Cyclizine
- Levomepromazine
if its caused by chemo-give ONDANSETRON
What is the broad spectrum antiemetic?
Levomepromazine
What antiemetic is mostly used for nausea and vomiting related to chemotherapy toxicity?
Ondansetron is best for nausea and vomiting caused by chemo toxicity
What is the main side effect of ondansetron?
ondansetron causes constipation
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
-can also get both of these as patches
(can use oxycodone but with caution)
What type of drug is ondansetron?
5HT3 receptor antagonist (antiemetic)
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 any doctor (can be F1) 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
What is a syringe driver?
What: A syringe driver is a portable, battery driven device which delivers continuous medication with a very fine needle under the skin SUBCUT
Why: your body might not be able to absorbs oral drugs or because of your swallow/vomiting
How long? Drugs delivered ober 24 hours, might take ¾ hours for effect. It is calculated so enough medicine will reach you
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
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
Domperidone is the only N+V drug that is oral only
They are too irritant
Explain visceral pain.
What is the treatment for visceral pain? (specifically liver capsule and bowel colic)
Visceral pain:
- dull, deep seated, poorly localised pain (may be over a particular organ e.g. liver)
- some visceral pain is spasmodic (bladder spasm and bowel colic)
Treatment visceral pain:
-analgesic ladder
-liver capsule pain (caused by visceral stretch):
NSAIDs or corticosteroids will reduce inflammation
-colic pain: anticholinergic drugs such as subcutaneous hyoscine butylbromide for bowel colic and oral oxybutynin for bladder spasm.
Explain a raised ICP headache pain?
Raised ICP headache: worse on waking, coughing, sneezing and may be associated with nausea and vomiting.
Treatment: Corticosteroids to reduce the oedema (e.g.16mg po dexamethasone daily, reduced to lowest effective dose), NSAIDs and paracetamol.
Signs of strong opiod toxicity?
Opoid toxicity- Check dose and renal function
- persistent nausea or vomiting
- persistent drowsiness/confusion
- pinpoint pupils
- visual hallucinations
- myoclonic jerks
- respiratory depression
What are the 2 forms of morphine?
Morphine forms
•Normal / immediate release tablets and liquid
-expected to be effective after 20-30 minutes and to last up to 4 hours
-e.g. oramorph liquid or sevredol tablets
•Modified /slow release tablets, granules, or capsules
- expected to last up to 12 hours
- e.g. Morphine Sulphate Tablets (MST), Zomorph capsules
How should you increase the morphine dose in step three of the ladder?
Titrate morphine dose upwards by 30-50% amounts until:
- pain is relieved
- unacceptable adverse effects occur
How do you convert oral morphine/diamorphine to subcut morphine/diamorphine injection?
Both diamorphine and morphine sulphate can be given as when required (with a duration of action of up to 4 hours) or as a continuous SC infusion via a syringe driver.
- Total 24 subcut continuous DIAMORPHINE dose should be one third if the 24 hour oral morphine dose (parental diamorphine is 3 times as strong as oral morphine)
- Total 24 subcut continuous MORPHINE dose should be half of the 24 hour oral morphine dose (parental morphine is 2 times as strong as oral morphine)
A patient receives 30mg BD of oral morphine and wants to switch to subcut infusion of morphine. How much subcut morphine should the patient receive?
Subcut morphine
e.g. a patient on 30mg BD should have 30mg morphine sulphate SC over 24 hours (60 mg in 24-hours divided by 2)
A patient receives 30mg BD of oral morphine and wants to switch to subcut infusion of diamorphine. How much subcut diamorphine should the patient receive?
Subcut diamorphine
e.g. a patient on 30mg BD should have 20mg diamorphine SC over 24 hours (60 mg in 24-hours divided by 3)
When would you use Fentanyl patches?
How long do they last for?
Fentanyl patches are mainly suitable for patients with severe chronic pain already stabilised on other opioids.
Fentanyl transdermal patches have a duration of action of 72 hours.
Other routes of fentanyl:sublingual, buccal and nasal).
Dry mouth
- what causes it?
- complications?
- how do we treat complications?
Dry mouth xerostomia Causes -reduced fluid intake -radiotherapy to head/neck -chemotherapy drugs -antiemetics -antidepressants
Complications
- hallitosis
- reduced taste
- anorexia
- dysphagia
- oral thrush (candidosis) (asymptomatic, pain, altered taste)
Treatment of thrush
-Treat with systemic antifungals (fluconazole 50mg o.d. 7 days) or topical agents (nystatin 1ml q.d.s 7 days).
Treating anorexia in palliative setting?
Anorexia (pallative)
- determine if there is a cause
- present food nicely, small portions
- no pressure
drugs
- Dexamethasone may help for a couple of weeks
- Megestrol acetate is effective for longer but may cause fluid retention
Features of vestibular nausea/vomiting?
Causes of vestibular nausea/vomiting?
Treatment of vestibular nausea/vomiting?
VESTIBULAR NAUSEA AND VOMITING Features -may be associated with movement -hearing loss -vertigo (room spinning) -tinnitus
Causes
-cerebellar lesion
Treatment
-Cyclizine, hyoscine or cinnarizine
What condition is it really important that you don’t stop medication for in end of life care?
PARKINSONS SHOULD BE MANAGED AS NORMAL THROUGH END OF LIFE
When prescribing modified slow release morphine, what should you remember?
Prescribing morphine
- PO and S/C are different so specify
- prescribe 12 hours apart
- always prescribe breakthrough pain as well (1/6 of total morphine dose including fentanyl patch) as PRN both SUBCUT AND ORAL (separate prescriptions)
- prescribe laxative PRN e.g.
- always prescribe antiemetic PRN just in case they need e.g. haloperidol
What palliative care drugs are contradicted in Parkinsons?
Drugs contra-indicated in Parkinsons
- Haloperidol
- Metroclopramide (ESPEs)
- Levomepromazine (D2 antag)
What should you consider when talking to family about taking patients from fluids?
- at the end of life the body needs less food and water
- they wont die from lack of fluids/food-they will die from disease
- fluids don’t always help with relieving symptoms such as dry mouth (this is better done with mouth care)
- fluids may actually cause some problems (overload may lead to breathing problems
- benefits of stopping fluids (prevention of needless in arm, reduction in barriers between family and patient, less vomiting and incontenence -fluid has to come out (less catheter need)
- we both want the best for… and so if you would like we can try for 24 hours and if no affect we can stop them
How do you manage terminal agitation?
Look for reversible causes (infection, pain, drugs, dehydration, retention, hypercalceamia)
- Midazolam is a useful short acting sedative/anxiolytic/muscle relaxant/anticonvulsant (subcut or infusion)
- Sometimes levomepromazine may be needed.
Generally when will the death certificate be provided and when may it be delayed?
Generally we inform the GP and aim to give death certificate after 24 hours, however in certain cases a coroners report will be neccecary, e.g:
- unusual occupational related deaths (mesothelioma)
- if unknown cause
- if suicide
- sudden death (<24 hours of admission)
- if patient was not seen by GP for 2 weeks for illness that caused death (NO LONGER A THING-not everyone can be seen that often)
- prosecution of death by dangerous driving
- all deaths under 18
- deaths caused by medical treatment, surgery or anaesthetic
- unusual diseases (hepatitis and TB)
What medications should be stopped at end of life stage?
Only continue medication needed for symptom management at end of life. The following can usually be stopped when the patient is no longer able to swallow: • Vitamins/iron • Hormones • Anticoagulants • Corticosteroids • Antibiotics • Antidepressants • Cardiovascular drugs • Anticonvulsants used for pain
three causes of pain in cancer patients?
Causes of pain in cancer patients
- the disease itself e.g. bone invasion
- the treatment e.g. radiotherapy induced oesophagitis
- a concurrent disease e.g. osteoarthitis
Name 2 causes of bowel obstruction.
How are these different causes treated
Bowel obstruction
Mechanical
-don’t give pro-kinetics as risk of perf
-treat reversible causes (surgery, chemotherapy)
Functional (sleepy bowel-mets or surgery)
-give metaclopramide to ‘wake up bowel’
Causes of vomiting in cancer patient
- cerebral (brain mets)
- toxic (gastro-enteritis/UTI, hypercalceamia)
- gastric (tumour or ascites causing obstruction)
poor prognostic markers in cancer patients?
poor prognostic markers in cancer patients
- low albumin
- high calcium
- low sodium
- low Hb (bone marrow infiltration)
- CHANGE IN PERFORMANCE SCORE
What are some examples of analgesic patches and what are the difference?
Analgesic patches (remember to rotate sites)
BUPRENORPHINE
- lasts 7 days
- looks like a plaster (patient I saw)
FENTANYL
- 72 hours (12 hours to kick in, then steady)
- clear patches
- better tolerated
If a patient is on a patch and they need to change to morphine because they are getting worse what do you do?
PATCH>MORPHINE
- keep patch on
- calculate extra dose of morphine required and give via syringe driver (using wheel)
- adjust PRN including fentanyl and syringe driver (1/6th of 24 hour dose)
for PRN breakthrough pain what should the special instructions be?
-1 hourly. If used more than 3 doses in 3 hours then bleep. Max 6 doses
Explain the WHO performance status.
What does this mean for cancer treatment
What are other examples of performance status scales?
WHO PERFORMANCE STATUS 0- normal functioning and able to work 1- restricted but can do light work 2-cant do work, up and about 50%+ 3-limited self care, 50%+ spent in bed 4- completely disabled, totally in bed 5-dead
- generally chemo would not be given for 2+
- Barthels and karnofskys (goes up in 10). Both /100 and other way around
causes of constipation in pallative care?
Constipation in palliative care
- immobility
- reduced food and fluid intake
- drugs (e.g. opioids)
- bowel pathology
- hypercalcaemia.
what drugs interact with metaclopramide?
- Metaclopramide and haloperidol should not be prescribed together (too much D2 antag-may cause ESPE)
- Metaclopramide and buscapan (speed up vs slow down bowel)
- Metaclopramide and cyclazine (cyclazine absorbed by gut and its being sped up)
Give examples of stimulant laxatives (when would you give)
When should you avoid?
STIMULANTS (give if reduced frequency)
- Senna - NICE recommended 1st line treatment for constipation
- Dantron
- Bisacodyl
Avoid stimulants if patient has colic
Give examples of stool softeners (when would you give)
STOOL SOFTENERS (SDL) (give if hard stool)
- Lactulose (can cause flatulance/bloating as sugary)
- Docusate capsules
Give examples of combination stimulant + softener laxatives
When would you give?
COMBINED (include co in name)
- Macrogol (movicol) -needs a lot of liquid
- Co-danthrusate (dan-stim and doc-soft)
**Give if delayed frequency and hard stool (combined)
Signs/symptoms of intestinal obstruction?
Which cancer patients are more likely to get bowel obstruction?
- colicky pain (can be dull)
- nausea/vomiting
- abdo distention
- constipation/diarrhoea
- tinkling sounds
-Ovarian and bowel cancer have high incidence of obstruction
Short term treatment of obstruction?
- surgery if they are suitable
- DRIP AND SUCK (reverse NG ryles tube and fluids if not (can still eat if they want)
- stop stimulant laxatives (senna) and pro kinetics (metoclopramide)
- prescribe antispasmodics (hyoscine butylbromide).
- dexamethasone and octreotide (somatostatin analogue) may also be used.
How do you treat a cough in palliative care?
COUGH
- treat underlying cause (infection, ACE inhib, secretions, reflux)
- saline nebulisers if patient can’t expectorate (cough up)
- cough supressors (e.g. codeine linctus, normal/immediate release oral morphine)
How do you treat bronchial obstruction by tumour?
Dexamethasone, stents or laser
How do you treat pleural effusion?
- Pleural effusion treated with pleural aspiration
- Recurrent pleural effusions treated by pleurodesis
What does Levomepromazine do?
Levomepromazine
- Antiemetic
- Antipsychotic
- Sedative
What does midazolam do?
Midazolam
- Sedative
- Anxiolytic
- Anticonvulsant
Important thing to note when completing death certificate?
Do they have a pacemaker?
How do you mix cyclizine for syringe driver?
CYCLIZINE SHOULD NOT BE MIXED WITH SODIUM CHLORIDE
use either water for injection or 5% dextrose
Treatment for vestibular vomiting?
Cyclizine (used for cerebral and vestibular-anything in head)
Hyoscine hydrobromide -motion sickness
Anxiety/psychosis in LBD/parkinsons disease?
Dont give them haloperidol!!!!
-Dont give metroclopramide or prochlorperazine either
**give Lorazepam instead
How do you manage opiod overdose?
Naloxone 400mg (competes for mu receptors) -short half life (bolus and infusion)
