Palliative Care Flashcards
3 parts to palliative care
- Physical
- Psychosocial
- Spiritual
3 reasons symptomatic relief is important
Reduces QoL
Causes distress
Results in admissions
Nausea + vomiting causes?
3B’s + examples
3 B’s:
1. Bowels - constipation, infection, obstruction, mucositis
- Brain - Raised ICP
- Biochemical - Meds (e.g. opioids), hypercalcaemia, infection, uraemia
Central + 4 surrounding systems that play a role in vomiting + their receptors
ALL FEED INTO VOMITING CENTRE - 5HT3, H2, ACh
- Chemoreceptor trigger zone (CMT) - 5HT3 + D2
- Gut wall - 5HT3
- Limbic system/Higher centres - Neurokinin 1 + GABA + 5HT3
- Vestibular system - H1 + muscAch
How do causes (3b’s) + systems of vomiting = cause it?
Gut wall –> distension stimulates vagus - constipation, chemo, obstruction = stimulates enterochromaffin cells
Chemoreceptor trigger zone - uraemia, drugs, chemo, hypercalcaemia
Vestibular system –> vertigo+motion sickness
Limbic system –> emotion + hyponatraemia
Name some antiemetics + which nausea cause (3B’s) they work on.
What is most often used first-line in palliative care + why?
Bowels only:
Domperidone (D2)
Bowels+Brain
Ondansetron (5HT3)
Metoclopramide (D2)
Biochemistry+Brain
Haloperidol (D2) - EPSE!!
Levopromazine (D2, H1, 5HT3, Anti-musc)
Brain only:
Cyclizine (H1, Antimusc)
RECEPTORS ALL A BIT BOLLOCKS - SO DON’T WORRY ABOUT ‘EM
Haloperidol used 1st line - as acts on CTZ = outside blood-brain barrier. Opioids are commonly used in palliative care patients and don’t cross blood-brain barrier, so haloperiodol is good at prevent nausea from these.
Why shouldn’t you prescribe cyclizine + metoclopramide?
C = constipating
M = Diarrhoea (as is a prokinetic)
the 2 counteract each other in the bowels
Define pain
An unpleasant sensory or emotional experience associated with actual or potential tissue damage
WHO pain ladder:
- What’s it used for
- Brief outline
used for CANCER PAIN
Outline:
- weak analgesia
- Paracetamol + NSAIDs
- Adjuvants - Weak Opioids
- Codeine/Tramadol
- Adjuvants
- Non-opioid - Strong Opioids
- Morphine, Oxycodone, Diamorphine, Fentanyl, Bupenephrine…etc.
- Adjuvants
- Non-opioid
Cautions with paracetamol?
Liver impariment
cachexia
Cautions with NSAIDs?
inlcuding CIs + drug interactions
Renal impairment
Low platelets
CIs:
-GI bleed, asthma
Drugs:
Warfarin,
Digoxin
steroids
Cautions with strong opioids?
Opioid naive Renal impairment Driving Prescribe for side effect - i.e. GIVE stimulant+softening LAXATIVE Patient stigma
What 2 types of pain = trying to be controlled in palliative care?
Background
Breakthrough
Potency of Codeine/Tramadol to Morphine?
C/T 1:10 Morphine
Morphine is 10x as potent
Which is stronger Morphine or oxycodone? By how much?
Oxycodone (also better SE profile)
2x
How much PRN dose should you give (if giving modified release)
1/6th of daily dose
What to prescribe alongside opioids? Why?
Stimulant+softening Laxative
PRN antiemetics
SIDE EFFECTS = common
OPIOIDS
Common SE?
Less common/Serious SE?
Common:
Constipation, sedation, nausea, dry mouth
Less Common:
Myoclonus (jerky movement) - look for sippy cup instead of mug for tea
Confusion
Rare
Resp depression
Pruritus
Morphine - dose adjustments for oral –> IV/SC
Morphine SC/IV = 2x oral
Examples of morphine / oxycodone for background + breakthrough pain?
Background - modified release:
- MST (tablet) - morphine
- Zomorph (Capsule) - morphine
- Oxycontin - (oral) oxycodone
Breakthrough - immediate
- Oramorph (liquid) - morphine
- Oxynorm (liquid/tablet)
What can reverse opioids? When to give?
NALOXONE
RR<8
SpO2<92%
Renal impairment + Morphine/Oxycodone
Renal impairment due to accumulation of morphine
Can use oxycodone with renal impairment = as excreted by kidney differently - doesn’t accumulate
Patient taking morphine = renal impairment - options?
- Reduce dose/frequency
- use renal-friendly option:
- Fentanyl (e.g. patch)
- buprenorphine
- Methadone
- Oxycodone
When to use fentanly?
- Renal impairment
- For background pain
- If patient cannot take oral medication - it’s a PATCH
Not good though - as conversion charts from morphine–>fentanyl = not precise
Adjuvants? Classes + what they’re used for + example
Neuropathic Pain:
- Antidepressants - amitryptilline
- Antiepileptics - pregabalin, gabapentin
Muscle spasms:
- Antispasmodics - baclofen
- Benzodiazepines - diazepam, clonazepam
Bone Pain
Bisphosphonates - zoledronic acid
Compression symptoms (e.g. spinal cord compression/^ICP) Steroids - dexamethasone
Key concepts in terminal care?
Advance care planning
DNACPR (medical decision, but should be informed)
What does advance care planning involve?
Advance statement/decision Power of attorney Advanced decision refuse treatment - MUST SAY that refusal may shorten life Preferred place Bucket list for patient
Symptoms/Change that may signify dying?
Sudden deterioration Weight loss/poor appetite Fatigue Poor mobility Social withdrawal Struggling with medications CV changes (pulse, mottled skin, cool peripheries) Resp changes (noisy secretions, laboured breathing)
5 key symptoms of dying patient + what meds to give to control each?
Pain - morphine PRN (syringe driver w/ patch)
Breathlessness - PRN SC opioid / SC benzo
Resp secretions - PRN hyoscine hydro/butylbromide
Nausea/Vomiting - Haloperidol PRN
Distress/Agitation - Midazolam
What to give in constipation in dying patient?
What laxatives are poorly tolerated?
Softener (docusate) + stimulant (Senna)
Macrogols + lactulose = poorly tolerated
5 priorities of care - if pt going to die in next few days?
- Idea of dying communicated to pt
- Sensitive communication - between staff+pt/family
- Pt/fam involved in treatment/care planning
- Needs of fam = identified+explored
- Individual plan of care - inclu. food+drink, symptoms, psychosocial/spiritual support = delivered
Good communication = improves bereavement process.
What formal support is offered?
Counselling
referral to GP
specialist psychological therapy
5 Palliative care emergencies?
Malignant spinal cord compression
Superior Vena cava obstruction
Malignant hypercalcaemia
- Commonly breast/lung/MM
- Mechanism - PTHrp(80%) + bone mets (20%)
Opioid overdose/toxicity
Acute bleeding
-Mainly H+N cancers / gastro
Tx for malignant spinal cord compression
8mg IV dexamethasone BD
Analgesia
Tx Superior vena cava obstruction
Dexamethasone
Malignant hypercalcaemia Mx?
IV zoledronic acid (bisphosphonate)
IV fluids
Mx of acute bleeding?
Pain relief
Sedation -morphine 10mg IV/IM + midazolam IV/IM
Light pressure with dark, ideally green blanket
DDx confusion in dying + decreased AMT
Hypercalcaemia!!
Infection
brain mets
Lacks capacity and want to prevent pt leaving, what do you use? Acid test for this?
DOLS = part of MCA
Acid test:
1) person under continuous supervison
2) not free to leave
3) cannot consent to these arrangements
