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PH4703-Practical therapeutics > Palliative care > Flashcards

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
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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
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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
  • 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
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4
Q

Principles of good symptoms management

A
  • Anticipation
  • Evaluation and assessment
  • explanation and information
  • Individualised treatment
  • Re-evaluation and supervision
  • Attention to detail
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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
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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
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7
Q

Hollistic approach

A
  • Physical
  • Spiritual
  • Social
  • Psychological
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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
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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
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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
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11
Q

What else needs to be prescribed

A
  • Look at anticipated adverse effects and treat before they occur
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12
Q

Side effects

A
  • Constipation
  • Nausea
  • Hallucinations
  • Drowsiness
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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
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14
Q

Why use a 2nd line opioid

A
  • Unable to swallow
  • Adverse effects
  • Renal failure
  • Genetic differences
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15
Q

Receptor affinity of opioid analgesic

A
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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
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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
Q

Side effect- constipation

A
  • 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
26
Q

1st line laxatives

A
  • Stimulant
    • Dantron
    • Bisacodyl
    • Docusate
    • Senna
    • Sodium Picosulfate
  • Osmotic
    • Latulose
    • Macrogols
27
Q

Non-laxative agents

A
  • Pro-kinetic (metoclopramide, domperidone)
  • Pro-motility (erythromycin)
  • Prostones (lubiprostone)
  • 5-HT-agonists (Procalopride)
28
Q

3rd line PAMORAs

A
  • Peripherally acting u-opioid receptor antagonist
    • Oral naloxone
    • Methylnaltrexone
    • Targinact
    • Naloxegol
    • Alvimopan
    • Naldemedine
29
Q

Side effect- N&V

A
  • 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
Q

Antiemetics

A
  • 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
31
Q

Anti-emetic

Site of action

A
32
Q

Antiemetics- in syringe drivers

A
  • 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
Q

Terminal respiratory secretions

A
  • 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
Q

Breathlessness

A
  • Morphine sulfate
    • Start at 0.5mg and titrate up
    • Oxygen
    • Hand held fan
35
Q

Midazolam 10mg/2mL

A
  • 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
36
Q

Levomepromazine

A
  • N&V
  • Agitation and delirium
  • Anxiety
  • Breathlessness
  • Exertion
37
Q

Use of drugs beyond license

A
  • 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
Q

Case: Male 51 years old

A
  • Diagnosis melanoma
  • Pain- right hip- fracture
  • Reduced mobility- constipation
  • Admitted taking
    • Codeine 60mg QDS
    • Paracetamol 1g PRN max QDS
    • Occasional ibuprofen
39
Q

What needs to be considered

A
  • Polypharmacy
  • Tablet burden
  • Choice of drugs and effectiveness
  • Consider side effects
40
Q

Case: 41 year old lady

A
  • 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
Q

CASE : 86 year old male

A
  • Chronic Kidney Disease (eGfr 15)
  • Angina/LVF/IHD
  • Ca prostate
  • Pain? Where ?
  • NIDDM (non insulin dependent DM)
42
Q
A

PH4703-Practical therapeutics (36 decks)

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