Palliative care Flashcards
1
Q
What, when, who and how
A
- Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through prevention & relief of suffering by means of early identification, impeccable assessment and treatment of pain and physical, psychosocial and spiritual
2
Q
What
A
- Support for patient and family- during the patients illness and in bereavment
- Team approach- to address patients and family needs
- Enhance the quality of life- and may also positively influence the course of illness and dying
- Is applicable early and late in the course of the illness- in conjunction with other therapies that are intended to prolong life (chemotherapy or radiotherapy)
- Includes investigations- needed to better understand and manage distressing complications
3
Q
Co-ordination of palliative care and recent initiative
A
- Cancer and palliative care networks
- NICE guidance for supportive and palliative care
- End of life care stratergy 2008
- Gold standard framework 2008
- GSF is about giving the right person, the right care, in the right place, at the right time… every time
- Gold standard framework 2008
- NICE end of life care for adults 2011
- 2010-15 government policy: end of life care
- Palliative care strategy 2014
- Palliative and end of life care- priority settings 2015
4
Q
Principles of good symptoms management
A
- Anticipation
- Evaluation and assessment
- explanation and information
- Individualised treatment
- Re-evaluation and supervision
- Attention to detail
5
Q
The most commonly reported symptoms are
A
- Pain- may be multiple
- Restlessness and agitation
- Dyspnoea of breathlessness
- N&V
- Sweating
- Jerking, twitching, plucking
- Confusion
- Incontinence or retention
- Dry sore mouth
- Extreme fatigue
6
Q
Pain due to cancer
A
- 30% do not develop pain
- Pain maybe
- Cancer related
- Treatment-related
- Related to consequent disability
- Due to concurrent disorder
- Cancer pain may be controlled in 80% of patients
7
Q
Hollistic approach
A
- Physical
- Spiritual
- Social
- Psychological
8
Q
Types of pain in advanced cancer
A
- Visceral/soft tissue- often opioid sensitive
- Bone- may be opioid sensitive, often sensitive to NSAIDs
- Neuropathic- Often opioid sensitive, consider adjuvant
- Incident pain- opioid sensitive
9
Q
Step 3 opioid analgesic: First line
A
- Morphine- oral strong opioid of choice
- Immediate release- liquid, tablet, suppos, injection
- MR- tabs and caps
- Diamorphine- used for S/C infusion at higher doses
10
Q
Initiating morphine as a strong opioid
A
- If previously on weak opioid give 10mg 4 hourly or MR 20-30mg BD
- If frail or elderly 5mg 4 hourly
- In reduced renal function reduce the dose or lengthen dose interval or both
- If 2 or more PRN doses are taken in 24 hours increase by 30-50% every 2-3 days as long as the pain is opioid responsive
- If using MR morphine also provide immediate-release morphine: liquid or tabs
11
Q
What else needs to be prescribed
A
- Look at anticipated adverse effects and treat before they occur
12
Q
Side effects
A
- Constipation
- Nausea
- Hallucinations
- Drowsiness
13
Q
Alternative step 3 opioid analgesics
A
- Fentanyl- TD- reservior or matrix; Nasal, S/C, Mucosal
- Hydromorphone- IR caps, MR caps, injection
- Oxycodone- IR/MR caps, liquid, injection
- Alfentanil- Injection for renal failure
- Methadone- Liquid, tabs/caps- specialist use only
- Buprenorphine- TD
14
Q
Why use a 2nd line opioid
A
- Unable to swallow
- Adverse effects
- Renal failure
- Genetic differences
15
Q
Receptor affinity of opioid analgesic
A
16
Q
Episodic pain
A
- Breakthrough pain- (Exacerbations against a background on controlled pain or occurring before the next opioid dose is due)
- Spontaneous pain- idiopathic pain unpredictable
- Incident pain- (Predictable) related to specific actions e.g. movement, dressing change, coughing
- End-of-dose failure
- Any acute transient pain that is severe and has an intensity that flares over the baseline EPAC working group 2002
17
Q
Anticipate- rescue dose
A
- Choose opioid prescribed for the regular medication (exception may be fentanyl and methadone)
- Dose= up to 1/6 of the 24-hour dose of baseline analgesia
- Oral doses- max every 60-90 minutes
- Parenteral doses- max every 15-30 minutes
18
Q
Which opioid for breakthrough
A
19
Q
Conversion doses
A
- Refer to tablets- as guidance only
- NB- opioid metabolism varies between individuals
- Titrate to individual requirements
- NB- compromised renal or hepatic function and concomitant drugs
20
Q
Mild/Moderate opioids
A
- Tramadol
- Developed 1977 launched UK 1997
- Synthetic analoge of codeine
- Racemic mixture
- Pharmacology complex
- Activates u-receptor and inhibits NA and 5-HT reuptake
- Phase I metabolism via CYP receptors
21
Q
Weak opioids
Tapentadol
A
- Classed as MOR-NRI
- Full u-receptor agonist
- Activates alfa 2 adrenoreceptors
- No clinical effect on serotonin pathway
- Single molecule
- Better CNS penetration
22
Q
Adjuvant analgesics
A
- NSAIDs- anti-inflammatory action
- Corticosteroids- nerve compression, liver capsule pain
- Anti-depressants- neuropathic pain (Gabapentin, pregabalin, carbamazepine
- MNDA receptor blockers- Ketamine, methadone
- Antispasmodics- GI pain, hyoscine
- Muscle relaxants- BZs , baclofen, tizanidine
- Bisphosphonates- Bone pain
- Entenox
- Hypnosis, aromatherapy, message
23
Q
When should a syringe driver be started
A
- Persistent N&V
- Difficulty swallowing
- Poor alimentary absorption
- Intestinal obstruction
- Unconscious or profoundly weak
24
Q
Data on drug compatibility and stability is limited
A
- Generally dilute with water- unless 0.9% saline is specific
- Avoid mixing more than 2 drugs in a syringe, unless stability data is available
- Consider volume available: 10-30mL
25
Side effect- constipation
* Due to physical immobility, poor oral intake, opioids and other drugs
* Prescription of opioids should always have laxatives co-prescribed and titrated to a dose of opioids
* Usually combination of stimulant and softener
* Symptoms related to constipation
* Ab pain and cramps
* Bloating and abdominal distension
* Flatulence
* Nausea
* General malaise and headache
* Overflow diarrhoea in faecal impaction
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1st line laxatives
* Stimulant
* Dantron
* Bisacodyl
* Docusate
* Senna
* Sodium Picosulfate
* Osmotic
* Latulose
* Macrogols
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Non-laxative agents
* Pro-kinetic (metoclopramide, domperidone)
* Pro-motility (erythromycin)
* Prostones (lubiprostone)
* 5-HT-agonists (Procalopride)
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3rd line PAMORAs
* Peripherally acting u-opioid receptor antagonist
* Oral naloxone
* Methylnaltrexone
* Targinact
* Naloxegol
* Alvimopan
* Naldemedine
29
Side effect- N&V
* Nausea- unpleasant feeling of need to vomit accompanied by cold sweats, salivation, tachycardia, diarrhoea
* Retching- rhythmic laboured spasmodic movement of diaphragm and ab muscles
* Vomiting- forceful propulsion of gastric content
* Regurgitation- effortless expulsion of foodstuff e.g. oesophageal obstruction
30
Antiemetics
* First-line agent- based on the underlying cause- haloperidol, metoclopramide, cyclizine
* A second line, add another first-line or change to the broad spectrum e.g. levomepromazine
* Thrid line, if other agents not controlling try 3 days 5-HT3 receptor antagonist
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Anti-emetic
Site of action
32
Antiemetics- in syringe drivers
* Cyclizine and levomepromazine- irritation at infusion site
* Cyclizine/diamorphine mixture may precipitate if cyclizine conc \>10mg/mL or either drug \>25mg/mL use larger volume
* Do NOT mix cyclizine and oxycodone
33
Terminal respiratory secretions
* Positioning
* Reassurance
* Hyoscine hydrobromide- crosses BBB, absorbed transdermally, paradoxical agitation, sedation
* Glycopyrronium- For excessive respiratory secretions and bowel colic. Does not cross BBB. Unstable above pH6, avoid mixing with dexamethasone
34
Breathlessness
* Morphine sulfate
* Start at 0.5mg and titrate up
* Oxygen
* Hand held fan
35
Midazolam 10mg/2mL
* Agitation and anxiety
* Consider causes e.g. drugs (opioids), biochemistry (e.g. calcium) infections, constipation
* In response to infection, SCC, brain tumour, stroke, kidney or liver failure or exacerbated by drugs, rapid escalation of opioid dose and anticholinergics
* Myoclonic jerks
* Epileptic fits
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Levomepromazine
* N&V
* Agitation and delirium
* Anxiety
* Breathlessness
* Exertion
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Use of drugs beyond license
* A legitimate aspect of clinical practice
* Currently both necessary and common
* Professionals should inform, change and monitor.. in light of evidence from audit and published research
38
Case: Male 51 years old
* Diagnosis melanoma
* Pain- right hip- fracture
* Reduced mobility- constipation
* Admitted taking
* Codeine 60mg QDS
* Paracetamol 1g PRN max QDS
* Occasional ibuprofen
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What needs to be considered
* Polypharmacy
* Tablet burden
* Choice of drugs and effectiveness
* Consider side effects
40
Case: 41 year old lady
* Recovered from breast cancer
* Has had paclitaxel as part of chemo
* Presented with painful peripheral neuropathy
* Has already tried:
* Tramadol (developed rash)
* Amitriptyline (adverse effects)
* Gabapentin (‘spaced out’)
* Pregabalin (‘spaced out’
* Refuses ‘strong opioids’
41
CASE : 86 year old male
* Chronic Kidney Disease (eGfr 15)
* Angina/LVF/IHD
* Ca prostate
* Pain? Where ?
* NIDDM (non insulin dependent DM)
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