Palliative care

Question 1

What is palliative care?

Answer 1

An approach that improves patients and families quality of life by…

• prevention and relief of suffering by means of
  
  • early identification
  • assessment
  • treatment of pain, physical, psychological and spiritual

Question 2

What are the prognostic indicators of frailty?

Answer 2

multiple co-morbidities with sign impairment in day to day living and…

• deteriorating functional scores
• combination of at least 3 of these symptoms;
  
  • weakness
  • slow walking speed
  • sign weight loss
  • exhaustion
  • low physical activity
  • depression

Question 3

COPD and end of life

Answer 3

At least 2 of indicators;

• Disease assessed to be severe (e.g. FEV1 <30% predicted)
• Recurrent hospital admissions (at least 3 in last 12 months due to COPD)
• Fulfils long term oxygen therapy criteria
• MRC grade 4/5 – shortness of breath after 100 metres on the level of confined to house
• Signs and symptoms of right heart failure
• Combination of other factors – i.e. anorexia, previous ITU/NIV resistant organisms
• More than 6 weeks of systemic steroids for COPD in preceding 6 months.

Question 4

Heart disease and end of life

Answer 4

At least two of the indicators below:

• CHF NYHA Stage 3 or 4 - shortness of breath at rest on minimal exertion
• Patient thought to be in the last year of life by the care team - The ‘surprise question’
• Repeated hospital admissions with heart failure symptoms
• Difficult physical or psychological symptoms despite optimal tolerated therapy.

Question 5

Cancer and end of life

Answer 5

• Any patient whose cancer is metastatic or not amenable to treatment
• some exceptions – this may include some cancer patients from diagnosis e.g. lung cancer.
• The single most important predictive factor in cancer is performance status and functional ability – if patients are spending more than 50% of their time in bed/lying down, prognosis is estimated to be about 3 months or less.

Question 6

Chronic Kidney Disease and end of life

Answer 6

Patients with stage 5 kidney disease who are not seeking or are discontinuing renal replacement therapy. This may be from choice or because they are too frail or have too many co-morbid conditions

Clinical indicators:

• CKD stage 5 (eGFR <15 ml/min)
• Symptomatic renal failure -Nausea and vomiting, anorexia, pruritus, reduced functional status, intractable fluid overload)
• Increasingly severe symptoms from comorbid conditions requiring more complex management or difficult to treat

Question 7

N+V causes during end of life

Answer 7

• Metabolic e.g. Hypercalcaemia
• Vestibular/movement
• Raised intracranial pressure
• Toxic: radiotherapy, chemotherapy, infection
• Anxiety/Fear
• Gastrointestinal :Constipation, Gastric stasis, Bowel obstruction
• Drugs

Question 8

Treatments for N+V during end of life care

Answer 8

Cyclizine – (Not to be used in heart failure)

Metoclopramide - (Not to be used in complete bowel obstruction)

Levomepromazine

Haloperidol

Question 9

Breathlessness causes during end of life

Answer 9

• Lung Tumours
• Infection
• Pleural Infusion
• Pulmonary Embolism
• Heart Failure
• Anaemia
• COPD
• Lymphangitis
• SVCO

Question 10

Treatments for breathlessness during end of life care

Answer 10

Pharmacological

• Steroids
• Dexamethasone
• Low dose opioids: reduce excessive respiratory drive + make work of breathing more efficient
• Oramorph
• Oxygen
• Short acting benzodiazepines e.g. Lorazepam to help panic + anxiety

Non-pharmacological

• Re-positioning
• Fan
• Breathing exercises
• Relaxation techniques
• Complementary therapies-acupuncture
• Hospice breathlessness group

Question 11

Delirium causes during end of life

Answer 11

• Drugs e.g. opioids
• drug withdrawal e.g. alcohol
• Dehydration, constipation, urinary retention
• Uncontrolled pain
• Liver or renal impairment, electrolyte disturbance (sodium, glucose), hypercalcaemia, infection, hypoxia, cerebral tumour or cerebrovascular disease
• Depression, dementia

Question 12

Treatments for delirium during end of life care

Answer 12

• Haloperidol
• Benzodiazepines
  - Lorazepam
  - Midazolam
  - Diazepam

Question 13

What does ABCDE stand for in end of life?

Answer 13

A- advanced care plan / refuse treatment
B - being there
C - communicate
D- dying / death is normal
E - emotional

Question 14

What can you give to help with respiratory secretions - ‘death rattle’?

Answer 14

Glycoperonium, morphine

Question 15

Summary what medications can be given during end of life?

Answer 15

• Antiemetics (N+V) e.g. cyclizine
• Pain relief e.g. morphine
• Breathlessness e.g. steroids
• Benzodiazepines (Delirium) e.g. diazepam
• Respiratory secretions e.g. glycoperonium