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Chronic and Life Limiting Illnesses > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

What is palliative care?

A

Palliative care is an approach that improves the quality of life of the patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other peoblems: physical, psychosocial and spiritual.

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2
Q

What are the 4 domains of personhood?

A
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3
Q

Describe a holistic needs assessment.

A
  • Physical
    • Symptoms, medication review, side-effects etc.
  • Emotional
    • Psychological assessment.
  • Personal
    • Needs related to a culture, ethnicity, spirituality, sexuality.
  • Social support
    • Social care needs, welfare concerns, career assessments.
  • Information and communication
    • Ensuring the mode of communication is appropriate, establishing a key worker, ensuring all plans and assessments are documented and shared appropriately with patient, significant others and MDT.
  • Control and autonomy
    • Assessment of mental capacity, establishing preferred place of care and death.
  • Out-of-hours
    • Identifying appropriate services, ensuring all relevant out-of-hours services are aware of patient preference.
  • Living with your illness
    • Establishing rehabilitation needs, referral to other servies, planning end-of-life care, if appropriate.
  • Aftercare
    • Bereavement risk assessment, family support.
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4
Q

What questions should you be asking a palliative patient regularly?

A
  • How are you coping?
  • Are you worried about your partner?
  • What are you finding hardest at the moment?
  • Tell me about yesterday. Tell me what is was like 6 months ago.
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5
Q

How do we close the information gap?

A
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6
Q

What are the common symptoms managed in palliative care?

A
  • Pain
  • Breathlessness
  • Anxiety and agitation
  • Fatigue
  • GI problems
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7
Q

What is pain?

What are the components involved in total suffering?

A

Pain is an unpleasant sensory and emotional experience

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8
Q

Which opioids can be used in palliative care?

A
  • Morphine
  • Oxycodone
  • Diamorphine
  • Fentanyl
  • Alfentanyl
  • Methadone
  • Dihydrocodeine
  • Hydocodone
  • Tramadol
  • Loperamide
  • Tepentadol
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9
Q

What are the benefits (for the prescribing doctor) of using morphine?

A
  • Familiar
  • Available
  • Cost
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10
Q

When should you not use morphine?

A
  • Side-effect profile
  • Transdermal route is preferred
  • Occasionally cost
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11
Q

State the equipotency of morphine to:

  • SC morphine
  • SC diamorphine
  • Oral oxycodone
  • SC oxycodone
  • Fentanyl patch
  • SC alfentanil
  • Oral hydromorphone
  • SC hydromorphone
A
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12
Q

State the equipotency of oxycodone to:

  • Oral oxycodone → SC oxycodone
  • Oral morphine
  • SC diamorphine
  • Fentanyl patch
  • SC alfentanil
  • Oral hydromorphone
A
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13
Q

What are the opioid side effects?

A
  • Constipation
  • Nausea and vomiting
  • Sedation
  • Vivid dream
  • Hallucination
  • Confusion
  • Myoclonic jerks
  • Respiratory depression
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14
Q

How should you approach pain management in palliative patients?

A
  • Tell what is wrong
  • Think non-pharmacological
  • Opioids
    • Equipotency
    • Side effects
    • Toxicity
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15
Q

What adjuvant analgesia to opioids can be offered to palliative patients?

A
  • Antiepileptic
  • Antidepressant
  • Other
    • Paracetamol
    • Ibuprofen
    • Steroid
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16
Q

Describe the use of opioids in palliative patients for breathlessness.

A
  • Effect is secondary to their effects on:
    • Ventilatory response to CO2 and hypoxia (chemoreceptor).
    • Increase in respiratory flow and decreased resistive loading resulting in decreased oxygen consumption with exercise and at rest in healthy individuals.
    • Vasodilatory effect on pulmonary vascular pressures in animals has been demonstrated.
  • Used to treat anxiety and pain, which are often an integral part of the dyspnoea cycle.
17
Q

Describe the central control of nausea and vomiting.

Include all components which have an impact on N&V.

A
  • Emesis stops us from ingesting toxins.
  • Vestibulo-cochlear system.
  • CTZ is outside the BBB - detects peripheral toxins.
  • Vomiting centre - functional entity in the brainstem.
  • CNX and vestibular system (via CNVIII) input.
  • Gag reflex triggers via XI and X.
  • Autonomic reflex control.
  • Higher centres - anxiety anticipation.
18
Q

Describe peripheral input to nausea and vomiting.

A
  • Myenteric plexus - smooth muscle-parasympathetic cholinergic nerves → peristalsis.
  • Neurohormonal regulation of the gut - H2, D2, 5HT3.
  • Distension → stretch receptors → sympathetic input to the CNS.
  • G cells (via CNX and ACh) → gastrin → parietal cells → HCl + pepsin and enterochromoffin-like cells → histamine → HCl.
  • Enterochromoffin cells → serotonin in response to damage, fatty and amino acids or toxins - induces nausea via vagal afferents to CNS.
  • Serotonin → peristaltic and secretory reflexes.
19
Q

Which neurotransmitters are involved in emesis?

A
  • Histamine H1
  • Muscarinic cholinergic (ACh)
  • Dopaminergic D2 receptors
  • Serotonergic 5HT3 receptors
  • 5HT4
  • Neurokinin
  • Cannabinoids
  • Substance P
  • GABA

Neurotransmitters exist in gut and centrally. Different antiemetics work on differing receptors. Target antiemetic to the likely cause.

20
Q

What might you elicit in a nausea history

A
  1. Intermittent postprandial, early satiety, bloating, full, small undigested food, relieved by vomiting?
  2. Persistent, worse with food and smells and unrelieved by vomiting?
  3. Intermittent, bile, altered bowel habit, cramps, faecal vomit?
  4. Early morning and associated headaches?
  5. Vertigo or worse on movement / turning head?
  6. Agitation and anxiety or anticipation?
  7. Bile, bleeding, undigested food, faecal?
  8. Drugs ?recent changes - SSRI, opioids, NSAIDs?
  9. Other associated symptoms - pain, fever.
  10. Toxins - infection / metabolic disturbance.
  11. D&V ?infectious
  12. Constipated? Gastric stasis or squashed stomach?
  13. Features of increased intracranial pressure?
  14. Where is the disease? Peritoneal or brain mets?
21
Q

What should you look out for on examination of a palliative patient with nausea?

A
  • Obstruction - distension ?bowel sounds.
  • Jaundice
  • Ascites
  • Organomegaly
  • Epigastric tenderness
  • Dehydration
  • Sputum production
  • AF/ sepsis
  • Signs of opioid toxicity?
  • ?Hypotension
22
Q

What should you do over and above hx and examination in a nauseated patient?

A
  • Check drug chart
  • Relevant bloods:
    • Calcium
    • U&E
    • LFT
    • FBC
  • AXR if acute obstruction
  • Urinalysis / MSU
  • Look at any scan reports to see if they explain the symptoms.
  • Assess if surgical candidate in obstruction.
23
Q

What are the non-pharmacological options for management of nausea?

A
  • Avoid food smells and strong smells.
  • Small bland meals frequently.
  • Peppermint tea / caps.
  • Positioning during meals.
  • Ask family not to pressurise the patient to eat.
  • Encourage fluids
  • Ginger tea?
  • Accupuncture / sea bands for accupressure.
24
Q

Which drugs should be used as anti-emetics?

A
  • Domperidone - prokinetic. Does not cross the BBB so is good in elderly or px with Parkinsons. PR or PO only. QTC↑ - no longer OTC.
  • Metoclopramide - central acting + prokinetic, EPSE common.
  • Cyclizine - useful for motion / ↑ICP. Potential for abuse, IV reactions, onfusion, dry mouth can limit use.
  • Haloperidol - no effect on gut; use in metabolic or toxin-related nausea as has central effect on CTZ.
  • Levomepromazine - effective but sedating.
  • Ondansetron - good for short-term use: post-op / chemo / XRT but profoundly constipating if >3 days.
  • Aprepitent
25
Q

What are the principles of prescribing antiemetics?

A
  • Give regular antiemetics instead of prn.
  • Check - is an alternative route required?
  • Is it possible to direct antiemetic to cause?
  • Stop emetogenics.
  • Reverse the reversible (infection, constipation, metabolic disturbances, decrease ICP, treat pain, anxiety and acid reflux).
  • Are they subacutely or fully obstructed?
  • Surgical candidate? (Drip, suck and refer).
  • Rest the gut, consider IV fluids +/- NG drainage.
26
Q

What percentage of bowel obstruction is caused by malignancy?

A
  • 15% of bowel obstruction is caused by malignancy.
  • 30% of people with ovarian cancer.
  • 20% of people with bowel cancer.
  • Peritoneal disease.
27
Q

Describe the treatment ladder for bowel obstruction.

A
28
Q

Describe how to treat subacute bowel obstruction.

A
  • Malignant bowel dysfunction often present.
  • Consider metoclopramide or domperidone with close review - if increasing colic, stop - risk of perforation.
  • Consider parenteral route - can swap back to PO.
  • See if bowel can be moved - PR+/- enema and consider codanthramer (used for constipation in palliative care).
  • Docusate (stool softner) alone to keep bowels soft if colic.
  • Reccommend easily digestible food or fluids.
29
Q

What drugs should be used to paralyse the gut in bowel obstruction?

A
  • Hyoscine (butyl bromide also helps colic - hydrobromide works as antisecretory).
  • Cyclizine (can add haloperidol if persistent nausea) or levomepromazine.
  • Rest drip and suck (where appropriate).
  • Consider NG with aspiration.
  • Octreotide.
  • Dexamethasone where lymph nodes, mass, squashed stomach / hepatomegaly.
30
Q

What are the surgical options for bowel obstruction?

A
  • Venting gastrostomy / ?RIG / stent.
  • Palliative surgery should be considered for patients with advanced cancer and intestinal obstruction.
  • Mortality high (12-30%), survival time short, high incidence of enterocutaneous fistulae.
  • Surgery is usually contraindicated in multilevel obstruction.
  • TPN decisions can be complex.
  • Look at performance status.
31
Q

Describe the examination of a patient who is constipated.

A
  • Needs a PR
    • ​Is there stool moving through?
    • Is this obstruction versus dysfunctional gut?
  • Full abdo exam
    • ​Often palpable stool in left iliac fossa
    • Feel for peritoneal disease
    • Feel for ascites
32
Q

Describe the treatment for palliative constipation.

A
  • PR / examine abdomen ?obstruction / dysfunction.
  • Suppositories / enemas where vomiting.
  • Soften - docusate.
  • Stimulate - senna, bisacodyl.
  • Gentle and does a little of both but need to drink a lot - laxido.
  • Do it all (soften and stimulate) and easy to take but carcinogenic.
  • Also picolax, methlnaltrexone, fybogel - bulks.
  • Reduce contributing factors, push fluids, privacy.
  • Avoid lactulose (except liver failure) as bloat, cramps.

Chronic and Life Limiting Illnesses (36 decks)

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