Palliative Care

Question 1

What pts do the palliative care team see?

Answer 1

Cancer
Organ failure e.g. end stage-renal/liver failure
Progressive neurodegenerative disorders e.g. MND

Question 2

What needs do the palliative care address?

Answer 2

Hollistic support for patients and their families

Medical
Psychological
Spiritual
Social

Specialist palliative care team: provides needs that general ward cannot provide

Question 3

What happens in a hospice

Answer 3

Inpatient unit
- Symptom control, end of life care
50% people die in hospice die, some will go home/care home

Most symptomatic, patients with prognosis of weeks

Daycare unit
Life-limiting illness but well enough to travel there. Access to group support, family/children support, complementary therapy, outpatient clinics, OT/physio

Community palliative care nurses
People not well enough to travel to hospice, but too well to be admitted to hospice

Question 4

What is a MacMillan nurse

Answer 4

Cancer specialist nurse

Question 5

Syringe driver

Answer 5

SC continuous infusion
Runs fixed rate every 24hrs

Indications:
Oral route not valid e.g. oesophageal Ca, no safe swallow, nausea

Chart:
Max 3 drugs
Choose right dilutent

Complications:
Syringe driver site reaction

Sites:
Top of arms, top of legs, abdo

Question 6

Anticipatory medications

Answer 6

Sx:
Pain - opiods e.g. morphine (unless end-stg renal disease (CD5, then use alfentanil (30x more potent than oromorph) - Subcut
Opioids can also help with SOB

Respiratory tract secretions - Hyoscine butylbromide (Buscopan)

Anxiety -
Midazolam - SC
Lorazopam - sublinguial, PO

Nausea/vomiting -
Levoprochlorperazine

Question 7

WHO analgesic ladder

Answer 7

1. Non-opioids e.g. paracetamol, NSAIDs
   Paracetamol continued for steps 2/3
2. Opioids for mod pain e.g. codeine
3. Opioids for severe pain e.g. morphine, diamorphine
   SE: nausea, constipation, resp depression (do no use in hepatic failure)
   Adjuvants: amitriptyline, pregabalin, corticosteroids, nerve block, radiotherapy

Question 8

Opioids

Answer 8

Start low, go slow (5mg 4hrs)
1st line: Oropmorph
If can’t use oral: diamorphine, morphine
Use PRN for breakthrough: 1/10th - 1/6th total daily dose

SE: N+V, constipation, dry mouth

Toxicity: resp depression, hallucinations, delirium
Pts with renal impairment at risk of toxicity eGFR<30
Alfentanil, Fentanyl hepatic metabolism

Morphine resistance pain:
Ketamine, methadone

Question 9

Non-pain sx

Answer 9

N+V -
Causes: chemo, constipation, pain, drugs
Tx: reversible causes

Clyclizine (H1 receptor antagonist, anti-cholinergic. Central action. Good for intracranial disorders)
SE: urinary retention

Metoclopramide (D2 antagonist. Prokinetic) - gastric stasis/gastroparesis
SE: extrapyramidal side effects

Haloperidol (D2 receptor antagonist. Blocks central chemoreceptor trigger zone) - metabolic/drug induced nausea
SE: extrapyramidal side effects

Ondansetron (5HT3 antagonist) - chemo/radiotherapy induced nausea
SE: constipation

Levomepromazine - broad spectrum.
SE: sedation

Constipation
Stimulant: Senna
Osmotic laxatives

Breathlessness:
Opioids

Oral:
Maintain frequent fluid intake, mouth wash
Treat oral candidiasis - fluconazole

Insomnia: