Palliative care Flashcards
palliative care definition
an approach that increases the Qol of patients and their families
for those that are facing problems associated with life-threatening illness
is symptomatic rather than curative
through the identification of pain and other problems; physical, psychological and spiritual
how often does the GP have to visit at end of life
every 2 weeks or else will go to coroner
how long have I got?
doctors tend towards over optimism
this denies the opportunity to advace care plan, make other informed choices, risks futile infvestigations
gold standards framework - prognostic indicator guidance
three triggers for palliative care are used
- the surprise question - would you be suprised if the patient died in the next 6-12 months
- general indicators of decline - are there no further active treatment options
- specific clinical indicators - e.g. needing ventilator support
types of pain fibres
c fibres - unmyelinated
transmit dull, poorly localised, ill-defined sensation
a delta fibres - myelinated
transmit fast, sharp, well localised sensation - synapse with 2nd order neurons in the dorsal horn - gate control theory of pain
total pain
a concept that recognises pain as being physical, psychological, social and spiritual (PPSS)
describes how pain is not just a physical sensation but might be a consequence of lonliness, spiritual distress, inappropriate diet, influenced by financial problems…
WHO pain ladder
- NSAIDs and paracetamol
- weak opiods - DTC (do think codeine; dihydrocodeine, tramadol, codeine)
- strong opioids - FMOD (four more opioids down) - fentanyl, morphine, oxycodone, diamorphine)
- nerve block, epidurals, PCA pump, neurolytic block therapy, spinal stimulators)
counselling on morphine side effect
common initially - N+V
common ongoing - contipation
occasional - dry mouth, sweating, pruritus, hallucination
rare - with toxicity can cause respiratory depression
how can SE of morphine be minimised
by switching to an alternative:
- oxycodone - reduced hallucinations + nausea but INCREASED constipation
- fentanyl - (patch = continuous levels - don’t apply heat to patch (will work faster), don’t cut then and put on different parts, store them flat so is all even across patch)
is less constipating than morphine
dose conversion of morphine - what is 10mg of morphine equivalent to
100mg codeine
100mg dihydrocodeine
100mg tramadol
types of morphine
Immediate release: - Oramorph liquid - Sevredol tablets Rapid onset 20 - 30 minutes (time to peak plasma concentration 15-60 minutes) Starts to wear off at 4 hours
Slow release:
MST (= morphine slow release tablet)
Zomorph
Given every 12 hours
Patient is on 20mg morphine BD + takes 5mg four times in 24 hours as PRN
how to titrate dose so that pain is controlled if it isn’t
is on 60mg total
so make new BACKGROUND dose 60mg
so give 30mg BD
for the breakthrough calculate 1/6th-1/10th of NEW daily dose so 60/10 = 6, 60/6 = 10
6-10mg PRN
SO 30mg BD + 6-10 PRN (4 times)
adjuvants to the WHO pain ladder
- Anti-depressants – e.g. in neuropathic/nerve pain
- Anti-convulsants – gabapentin, pregabalin, carbamazepine for nerve pain
- Benzodiazepines – e.g. for nerve pain
- Smooth muscle relaxants
- Steroids
- Bisphosphonates
- Corticosteroids
- Nerve block
- TENS – gate control theory of pain
- (Radiotherapy)
- (Surgery, Chemotherapy)
analgesia in cancer pain
- By mouth - don’t want to be sticking needles in them – mouth is the preferred method
- By the clock – regular and PRN use
- By the ladder - WHO pain ladder
somatic pain definition and management
aching, often constant. may be dull or sharp.
well localised pain
e.g. bone mets, arthritis, fracture
often treated with NSAIDs
degree of pain relief with opiods
visceral pain definition and management
constant or crampy
poorly localised
referred
often responds well to opioids
also consider steroids e.g. dexamethasone for tumour oedema
neuropathic pain
• caused by a lesion or disease of the somatosensory system, including peripheral fibres (Aβ, Aδ and C fibres) and central neurones
e.g. diabetic neuropthay (causing dyseathetic pain - abnormal), trigeminal neuralgia, nerve root compression
partially responsive to NSAIDs and opioids
other options include anti-depressants, anti-convulsatns, steroids, nerve block
incident pain
- E.g. pain precipitated by movement
- is a major problem for most patients with cancer pain – the problem is that doses of opioids high enough to control episodic incident pain are too high when that pain is absent, leading to adverse effects
- and usual analgesics don’t work quickly enough to help
- Traditional treatment has been oral liquid morphine (10mg/5ml )
- Transmucosal opioids may be faster acting e.g. Fentanyl lozenge
- Newer alternatives include sublingual and buccal Fentanyl tablets / nasal sprays
how is breakthrough pain dose calculated
as a 1/6th of total (24hr) morphinne requirements
e.g. for patients on 15mg BD MST - give 5mg oromorph for breatkrhough
maximum PRN dose of morphine
max 6 x a day
e.g. 2-4 hours PRN
side effects of opioids
most common = Constipation, nausea and sedation/drowsiness
others
- Respiratory depression
- Myoclonic jerks
- Miosis
- Dry mouth
- Confusion
- Visual hallucinations (Stop/reduce// switch - Haloperidol?)
- Itching
- Euphoria
how to manage the constipation, nausea and sedation SEs with opioids
Coprescribe laxative permanently e.g. polyethylene glycol and anti-emetic PRN first 5-7days
for sedation - assess – may pass / reduce but advise re e.g. driving
physical and pyschological dependence
physical = withdrawal syndorme occurs when an opioid is aburptly discontinued - this can happen in cancer patients
psychological = continued craving for an opioid which manifests as compulsive drug seeking behaviour - generally not seen in cancer care
rough percentage that you would increase background dose by for opioids
30-50%
