Palliative care Flashcards
What is palliative care?
An approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early indentification and impeccable assessment and treatment of pain and other problems; physical, psychosocial and spiritual.
Who are the members of the hospice MDT
Nursing, AHP, chaplain, Psychologist, OT, TOC, physiotherapist, wellbeing/complimentary medicine, social worker and medical.
Structure for assessing N/V?
3 B’s
Bowel - mucositis, constipation, infection, gastric stasis, obstruction
Brain - Raised ICP, mets
Biochemical - medications, hypercalcaemia, hypomagnesia, uraemia, infection
Name some anti-emetic drugs and structure it by where they predominantly act
Bowels - Domperidone
Hyoscine butylbromide
Brain - cyclizine, prochloperazine
Bowels and brain - ondansetron, metoclopramide (not for Parkinson’s)
Biochemical and brain - levomepromazine, haloperidol
Palliative management for a patient with nausea and vomiting following chemotherapy
Anti-emetics (may need to be SC if still vomiting) - ondansetron Analgesia - oromorph Antacids - reflux Lanzoprazole - reflux Lidnocaine mouthwash - for ulcers IV fluids Nutritional support
What is the usual daily dose of paracetamol?
Exceptions to this?
4g (1g QDS)
Cachexia (Weight <50KG)
Liver impairment
Both can only have 2g (500mg QDS)
What do you need to check before prescribing NSAIDs?
Renal function
Platelets
Contraindications - GI bleeding or ulcer history, asthma
Concurrent medications - warfarin, digoxin, steroids
Describe the analgesic ladder
Simple analgesia - paracetamol, NSAIDs
Weak opioids - codeine, dihydrocodeine, tramadol
Strong opioids - morphine, fentanyl, buprenorphine, diamorphine, oxycodone
What are the factors to consider before starting a strong opioid?
Previous experience with them - prior side effects Renal and liver function Age Frailty - small dose and titrate Are they driving?
What is the conversion between codeine/ tramadol and morphine?
10:1. So 10mg codeine/tramadol = 1mg of morphine
Opioid conversion charts are available to make it easier
What is background pain?
Breakthrough pain?
Why are these useful to distinguish?
Pain at rest/ persistent
Transient exacerbation
Need analgesia for the immediate pain (oromorph)
What is the conversion between oxycodone and morphine?
2:1
If a patient has 30mg modified release morphine BD, what should be there PRN dose be? Explain calculation
60mg BD?
10mg oromorph
PRN should be 1/6 the daily dose so 30x2=60. 60/6=10mg.
20mg
What drugs should be co-prescribed with opioids?
Anti-emetics
Stimulant laxatives - dulcolax
What route of analgesia can be used if oral is not tolerated?
How long does it take to reach full effectiveness?
In what situations should you be aware for OD?
How often are they changed?
Topical patches
1-3 days
High temperatures (septic, heat pack) increases absorption
Every 7 days
A palliative patient starts to develop renal impairment, what medications typically cause this?
What are the alternatives?
Morphine, oxycodone
Fentanyl, buprenorphine, methadone, alfentanil
What are the risk factors for febrile neutropenic sepsis?
Diagnostic criteria?
Tx?
Following chemotherapy (2-3 weeks)
Bone marrow infiltration
Haematology patient
Temp >38
Neutrophils <0.5
W/ Clinical infection (chest, urine, skin, GI, line)
IV access Broad spectrum abx Close observation Fluid resus IX - FBC, U/E, LFT, CRP, Cultures, Lactate
Causes of superior vena caval obstruction?
S/S?
Ix?
Tx?
Lung cancer/ tumour involving the right upper lung or mediastinum
Facial swelling, redness Periorbital oedema, engorged conjunctivae Arm swelling Breathlessness Distended vein of chest
CT chest
Dexamethasone
Anticoagulation
Stenting
Radiotherapy
Causes of stridor in palliative care?
S/S?
Ix?
Tx?
Head and neck tumour
Lung or upper GI tumour
Noisy breathing on inspiration
Harsh breath sounds
Breathlessness - can be a late sign of compensation
Clinical diagnosis
Upper airway visualisation - ENT/Max-fax
Upper airway imaging - CT
Oxygen Dexamethasone Urgent ENT review Tracheostomy Stenting Radiotherapy
Causes of malignant hypercalcaemia?
S/S?
Ix?
Tx?
Cancers - particularly those that go to bone (breast, lung, kidney, thyroid
1. Thirst Confusion Constipation Global detrioration 2. Chronic: Stones - abdo pain Bones - pain Groans - constipation Thrones - Psych undertone
Bloods - corrected calcium (>2.6, >2.8 is symptomatic)
IV fluids - dilutes calcium
IV bisphosphonate
?Denosumab
Causes of massive haemorrhage?
S/S?
Ix?
Tx?
Head and neck tumours
Lung tumour w/ history of bleeding
GI tumour w/ history of bleeding
‘Herald’ bleed
Sudden blood loss and loss of consciousness
Clinical
Stop anticoagulation Palliative specific: - dark towels - stay with patient - midazolam - calm them down
Risks for opioid overdose? S/S? Side effects of opioids? Ix? Tx?
On strong opioids, change in condition, sudden resolution of pain, renal/hepatic impairment, patches and a fever, swigging (having too much PRN), methadone
Reduced consciousness level
Reduced RR/SpO2
Myoclonic jerks
Pinpoint pupils
Confusion
Hallucinations
N/V and constipation
Clinical assessment
Response to treatment
Naloxone 400mcg (palliative care will be less because you don’t want to remove effects)
Dose reduction
Close observation
Causes of metastatic spinal cord compression?
S/S?
Ix?
Tx?
Cancer to bone - breast, lung, kidney, thyroid, prostate
Weakness and paraesthesia below level
Cauda equina - faecal incontinence, urinary retention
Back pain, off legs
MRI spine
Dexamethasone
Radiotherapy
What is the time frame for ‘end of life’?
Likely to die within the next 12 months
What are the formal features of advanced care planning?
What the patient wants to happen - advanced statement of wishes
What the patient doesn’t want to happen - advance decision to refuse treatment
Who will speak for them - Lasting power of attorney for health and welfare
Signs of a dying patient?
Weight loss and poor appetite
Fatigue and sleeping more
Deteriorating mobility/ worsening performance status
Social withdrawal
Changes in consciousness
Change in CV system (mottled, change in colour)
Change in resp system (noisy secretions, laboured breathing, Cheyne-Stokes breathing)
Struggling with medications/ becoming ineffective
Progressive organ failure
Does the patient think they are dying?
How to structure breaking bad news?
What falls into each category?
SBAR
S: Identify yourself to patient and loved ones
Describe how the patient is today
B: What brought the pt into hospital, what has happened since, what treatment/interventions have been undertaken, the response to these
A: Based on the above assessment inform that you believe the patient is dying in the next x (hours/day) best estimate
R: Develop an individual plan of care for the last days of life
Ceiling of care, what will and won’t be done, rationalise medications/ fluids, the care package in place, what to expect, psychological support
What are the 5 key symptoms of dying?
What could be pre-emptively prescribed for each?
Pain - Morphine 1.25mg-2.5mg Breathlessness - morphine 1.25mg-2.5mg0 Respiratory secretions - buscopan 20mg N/V - Haloperidol 0.5-1.5mg Distress/ agitation (delirium) - Midazolam 1.25-2.5mg
What is necessary to do regarding nutrition and hydration in end of life care?
Support oral food and fluids as long as patient enjoys it
Mouth care
Prevent the feeling of thirst
What should be done regarding bereavement in end of life care for the loved ones?
Discuss if wanted
Counselling
Referral to GP
Specialist bereavement psychology support
