palliative care Flashcards
Give 7 signs that someone is in their final days of life
- profound weakness
- more time in chair/ bed
- gaunt
- reduced appetite
- weight loss
- drowsy
- disorientated
- diminished oral intake
- cannot take oral meds
- increase in disease specific symptoms
- poor concentration
- cheyne stokes breathing pattern
- skin colour change
- incontinence
- reduced UO
- temperature change at extremities
- agitation
- raspy breathing
state the standard 4 drugs, doses and indications that are given for anticipatory prescribing in end of life care
- Morphine SC 2.5-5mg (opioid naive dose)PRN for pain and dyspnoea
- Midazolam 2.5-5mg SC PRN for dyspnoea and agitation
- glycopyrronium 200mg SC PRN or TDS for secretions
- haloperidol 1.5-2.5 mg SC PRN for agitation and nausea
What considerations need to be made for advanced care planning?
- psychosocial needs and fears
- spiritual and religious needs
- ongoing symptom management
- resus
- anticipatory prescribing
- good after death care
- food and drink, clinically assisted nutrition and hydration
- mouth care
- ceiling of care agreed
- referral when complex symptoms
- preffered place of death
What can cause pain at end of life due to cancer
- cancer invading bone, nerves, viscera, soft tissue
- anti cancer treatments causing fibrosis, neuropathy, lymphodema, incision pain, mucositis
- cancer related debility eg mucositis or neuropathy
- concercurrent disorder eg OA, spinal stenosis, unknown
What may exacerbate pain at end of life due to cancer?
- anger
- anxiety
- boredom
- discomfort
- insomnia
- social isolation
What may reduce pain at end of life (other than medications)
- acceptance
- relaxation
- mood elevation
- relief of other symptoms
- sleep
- explanation
What is the difference between nociceptive and neuropathic pain?
- Neuropathic pain is due to nerve damage, it is shooting, burning, stabbing, numbness, allodynia, hypersensitivity
- Nociceptive pain can be somatic (sharp, throbbing, localised) or visceral (diffuse, poorly localised, aching)
What NSAIDs can be given for a pt with CVS risk?
- naproxen or ibuprofen
- avoid diclofenac
When should NSAIDs be used with caution?
- CVS risk
- GI risk (do not use)
- heart failure (will exacerbate)
- renal failure (will exacerbate)
- give PPI with all
What drugs can be used for neuropathic pain?
- amitriptyline
- gabapentin
- pregabalin
- often take around 5 days to work
What drug is particularly good for boney pain
- bisphosphonates (alendronic acid PO, zoledronic acid IV)
Give 3 examples of weak opioids
- dihydrocodeine
- tramadol
- codeine phosphate
- cocodamol
Give 3 examples of strong opioids
- oxycodone
- morphine
- fentanyl
- diamorphine
Give 3 common side effects of opioids
- constipation
- dry mouth
- N+V (goes after 5 days)
- drowsiness/ sedation
What dose of morphine should be given PRN for breakthrough pain
1/6th the background daily dose
how are opioids excreted?
- fentanyl and alfentanyl excreted by liver
- others excreted renally
What is the strength of morphine relative to codeine?
morphine 10x stronger than codeine
Give an example of immediate release and slow release morphine
IR: oramorph liquid or sevredol tablets
SR: zomorph capsules
How do you calculate dose titrations for opioids?
- calculated total daily dose (TDD) (background BD dose + PRN doses)
- then do TDD/2
- give this as BD slow release dose
- then do TDD/6 and give this as PRN immediate release dose
- principle is the same on syringe drivers but half it because its twice as strong via syringe driver bcos it bypasses the first pass metabolism
What rules do you need to remember for controlled drug prescribing?
- name and ID of pt, drug, form and strength
- give total number of tablets or liquid needed in words AND figures
- on TTO give enough for 14 days
- for PRN cannot state ‘take as needed’ and should give enough for 4 doses a day for 14 days
eg:
Morphine SR (zomorph) capsules 10mg BD for 14 days, supply 28 (twenty eight) capsules
Morphine sulphate solution (oramorph) 10mg/5ml. Can take 5mg PRN up to 1 hrly for breathrough pain. supply 1 (one) 300ml bottle
How does impaired gastric emptying present? what can cause it?
- epigastric pain, reduced appetite, fullness/ bloating
- vomiting large volumes, usually relieves the nausea
- caused by locally advanced disease, morphine/ anti cholinergic or autonomic neuropathy
How should impaired gastric emptying be managed?
- treat cause if possible
- give metoclopramide or domperidone for symptomatic relief
How does chemical/ metabolic disturbances causing N+V present? what can cause it?
- persistent nausea aggravated by the sight and smell of food
- V doesn’t relieve N
- causes inc drugs (morphine, abx, SSRI, digoxin), renal or hepatic failure, low Na, high Ca, sepsis, tumour toxins
How are chemical/ metabolic disturbances causing N+V managed?
- haloperidol or metoclopramide
- correct cause
How does raised ICP causing N+V present and how is it managed?
- V is projective
- N worse in morning
- worse on head movement, headache
- causes by cerebral mets, haemorrhage, meningeal disease
How is raised ICP causing N+V managed?
- treat cause
- give cyclizine or/ and dexamethasone
What causes N+V after radiotherapy and what is it treated with?
- due to serotonin release
- treat with ondansetron
What drugs are good for managing N+V due to malignant bowel obstruction?
- cyclizine or dexamethasone
What drugs are good to manage N+V associated with chemotherapy?
- aprepitant
- hypnosis, acupuncture also have good evidence
how should N+V due to constipation be managed?
- laxatives
What antiemetic is a good all rounder and can be used 2nd line for all causes?
- levomepromazine
- can try combining different antiemetics, giving them SC and regularly
How do metoclopramide and haloperidol work?
Dopamine receptor (D2) antagonists - acts at chemoreceptive trigger zone (CTZ) which responds to toxins in blood. Metoclopamide has some action at serotonin receptor also
How does levomepromazine work?
- D2 and serotonin receptor antagonost- acts at CTZ
- also inhibits mACH receptor at the vomiting centre which is why its so versatile
How doe hyoscine work?
inhibits mACH receptor at VIII nucleus (acts on CTZ and vomiting centre)
How does ondansetron work?
serotonin receptor antagonists - acts at vomiting centre which responds to CTZ, higher centres and autonomic afferents
How does cyclizine work?
inhibits histamine receptor at VIII nucleus and vomiting centre
What causes constipation in end of life?
- Disease related: immobility, reduced food intake/ low reside diet, intrabdominal and pelvic disease
- Fluid depletion: poor intake, lots of losses, vomiting, sweating, fistulae
- Weakness- cant poo
- Obstruction
- Medications (opioids, diuretics, anticholinergics, SSRIs)
- Biochemical disturbances (hypercalcaemia, hypokalaemia)
Give an example of a stimulant and a stimulant/ softener?
stimulant: senna or bisacodyl
Both: sodium picosulphate
Give an example of a softener?
docusate
Give an example of an osmotic agent?
lactulose
movicol
laxido (macrogol)
What drugs are good at palliating bowel obstruction?
octeride and buscopan- reduce GI secretions and hence volume of vomiting as well as reducing peristalsis
Give 5 treatable causes of breathlessness that are common in palliative care
- anaemia
- PE
- CCF
- COPD
- pneumonia
- pleural effusion
- pericardial efusion
- SVCO
- anxiety
How is end of life breathlessness (of no specific cause) managed?
- sit them up
- open window/ give fan
- oxygen if hypoxic
- morphine (1-2mg PRN SC/ PO or 5-10mg/ day SC driver)
- Benzos (lorazepam 0.5- 1mg SL PRN, midazolam 2.5mg SC PRN)
How can insomnia in end of life be relieved?
- appropriate room temp
- blackout blinds
- give steroids in the morning
- avoid waking them at night
- discuss psychosocial issues
- zopiclone or benzos can be used to help re- establish normal sleep wake cycles but may cause delirium
