Palliative Care Flashcards
What is palliative care?
Palliative care – care that is not aimed at curing someone of an illness but of making them comfortable and live as long as possible with as high a quality of life as possible. It involves physical, mental, social and spiritual care and may involve the family as well.
In palliative care active treatment is still undertaken if the underlying cause is reversible e.g. PE, constipation etc.
How should pain be assessed?
It’s always important to assess pain properly using SQITARS and the 1-10 rating.
Does regular PRN use of analgesia mean daily doses need to be increased?
When evaluating PRN use check it’s not just being given for when care is given – this is fine to do but doesn’t mean the overall dose needs increasing.
What is nociceptive pain?
Nociceptive pain = normal nervous system identifying lesion or insult causing tissue damage. Can be somatic or visceral. Described as sharp, throbbing and ache.
What is neuropathic pain?
Neuropathic pain = malfunctioning nervous system or damage to nerve structure. Described as stabbing, shooting, burning, numbness and stinging.
Describe the WHO analgesic ladder?
1) Non-Opioids
Paracetamol
Ibuprofen, diclofenac or naproxen (PPI needed)
1) Opioids for mild-moderate pain
Codeine phosphate/Dihydrocodeine
Tramadol
Co-codamol
1) Opioid for moderate-severe pain Morphine Diamorphine Oxycodone or Buprenorphine (moderate renal impairment) Alfentanil (severe renal impairment) Fentanyl (severe renal impairment)
Should you stop step 1 WHO ladder analgesia when starting stages 2 and 3?
Paracetamol and NSAIDs can be opioid sparring and should be alongside steps 2 and 3
What drugs need prescribing alongside opiates?
Prescribe PRN laxatives and anti-emetics with strong opioids
What adjuvants can be prescribed alongside analgesia?
Other Adjuvants include amitriptyline, pregabalin, gabapentin, corticosteroids, benzodiazepines, bisphosphonates and nerve blocks.
Which drugs are good for nerve pain and what are their side effects?
Amitriptyline (confusion, hypotension), pregabalin and gabapentin (sedation, tremor, confusion, dizziness) are good for neuropathic pain
What are the 4 most important rules for pain relief prescribing?
Pain relief should be given my mouth
Regularly (by the clock)
Follow the ladder (by the ladder)
Be individually titrated
What dose of morphine should you start on in an opioid naive patient?
In an opioid naïve patient, you should start with a very low dose of morphine usually 5mg every 4 hours (IR) plus 5mg PRN for breakthrough pain maximum hourly. Increase dose by 30-50% until pain is controlled.
If someone is taking too much PRN often how should you alter their daily dose?
Once controlled add up all daily doses and PRNs used and give modified/slow release (SR) over 2 doses during the day. PRN dose should be a 6th of this given hourly maximum and up to 6 times a day.
Always prescribe a PRN IR dose of morphine, preferably oral but can be SC
Give some examples of IR and SR morphine
IR morphine = Oromorph – liquid, Sevredol – tablets
SR morphine = Zomorph – capsules
If oral analgesics are contraindicated what should be given?
Fentanyl patches are first line for those who oral analgesics are contraindicated
What is the opioid ratio of codeine/tramadol to morphine and morphine to SC morphine?
Codeine/Tramadol: Morphine is 10:1
Oral morphine: SC morphine 2:1
As opioids are controlled drugs what must you do when prescribing TTOs?
Opioids are controlled drugs so when prescribing for TTOs you have to write them out fully.
Write prescription as normal then exactly what the pharmacist should supply
NAME FORM and STRENGTH
Supply NUMBER (written both ways) then dose of tablets/bottles/patches
e.g. Oral Morphine (SR) Zomorph 20mg BD Supply 28 (twenty eight) 20mg tablets
If prescribing liquid/patch/syringe driver analgesia how do you write the total dose?
Make sure to supply whole bottles
Patches usually last 3 days (but take 12 hours to start working properly) and are dosed in mcg/hour
If giving by syringe driver then write SCSD
What are the side effects of opioids?
Constipation, nausea and vomiting (usually just transient), drowsiness (in first 5 days) and dry mouth. If difficulty tolerating or toxicity, then switch to oxycodone.
What are the features of opioid toxicity
Sedation, respiratory depression, visual hallucinations, myoclonic jerks, pinpoint pupils and delirium. Causes are usually recreational use, stepping up dose too quickly or renal impairment.
Important to diagnose early so Naloxone can be avoided. Check O2 sats and give oxygen as needed, reduce opioid dose and hydrate well. Naloxone should only be used in severe respiratory depression as it can lead to pain crisis and fatal acute withdrawal.
What causes nausea due to reduced gastric motility and how should it be treated?
Reduced gastric motility – can be opioid related.
Due to serotonin and dopamine receptors
Metoclopramide
Domperidone
What causes chemically mediated nausea and how should it be treated?
Chemically mediated
Secondary to hypercalcaemia, opioids or chemoterhapy
Ondansetron, haloperidol and levomepromazine
What causes visceral/serosal mediated nausea and how should it be treated? (this includes raised ICP)
Visceral/serosal
Constipation or oral candidiasis
Cyclizine and levomepromazine
Anticholinergics can be useful
Raised ICP
Cyclizine
Dexamethasone
(radiotherapy for cranial tumours)
What causes vestibular mediated nausea and how should it be treated?
Vestibular
Activation of acetylcholine and histamine receptors, can be opioids related, motion related or base of skull fracture
Cyclizine
If refractory – metoclopramide, prochloperazine or atypical antipsychotics
What causes cortical mediated nausea and how should it be treated?
Cortical
Anxiety, pain, anticipatory due to GABA and histamine receptors
Anticipatory – lorazepam
Cyclizine if benzos aren’t ideal
Ondansetron and metoclopramide can be trialed
What are the benefits and problems with levomepromazine as an antiemetic?
Levomepromazine – broad spectrum affecting all receptors but may cause sedation.
What route should be used for anti emetics?
Consider route as oral absorption may be poor – SC for first 24 hours
If first anti-emetic doesn’t work combine with another with different mechanism
What causes constipation in palliative patients?
Causes: Opioids, Hypercalcaemia, Dehydration and Intrabdominal obstruction.
Name the anti-constipation meds classes and examples of each?
Stimulants – Senna
Faecal softener – Sodium docusate
Osmotic laxatives – Macrogol/Movicol, Lactulose and Laxido
Bulking agents – Fybogel
Rectal Treatment – glycerol suppositories and phosphate enemas
How should breathlessness be assessed and managed in palliative patients?
First must look for reversible causes: PE, infection, effusion, CCF, COPD, anaemia, arrythmia or SVC obstruction. Reversible causes can be treated as normal.
If non-reversible or intractable then management is different. Use gravity to aid breathing Remain calm and confident Airflow across face from fan or window Oxygen if hypoxic
How can breathlessness be managed pharmacologically?
Pharmacological management
Trial low dose opioid, if opioid naïve then start at around 2.5mg IR every 4 hours. Benzodiazepines may help if anxiety related to breathlessness – trial Lorazepam or midazolam.
How can oral problems be managed - especially dry mouth?
Generally important to give good mouthcare and stay well hydrated.
Consider side effects of drugs which may be influencing any symptoms.
Sugar free chewing gum, normal saline mouth washes and soft toothbrush. Avoid products containing alcohol as they will sting. Salivary stimulants (better than substitutes) can be helpful such as pilocarpine eye drops on the floor of the mouth QDS.
How should oral candidiasis be managed in pallaitive patients?
Candidiasis – topical miconazole oral fluconazole but check interactions e.g. warfarin.
Herpes simplex – oral ganciclovir or aciclovir.
What advice can you give patients suffering from insomnia?
Most important points are sleep hygiene Don’t drink too much before going to bed Dark quiet room Avoid screens Don’t look at the clock if you wake up
What pharmacological management can be given for insomnia?
Zopiclone or benzodiazepines can be used to re-establish normal sleep wake cycles but should not be used indefinitely.
What causes pruritis in palliative patients?
Causes: systemic disease (renal failure, hepatitis and polycthaemia), cancer related (cholestasis, lymphoma, leukaemia, hepatoma, myeloma and paraneoplastic), primary skin disease and drug reactions.
How can pruritis be managed in palliative patients?
Management
Treat underlying causes where possible.
If opioid, then consider antihistamine or opioid switch.
Topical emollients and as a soap substitute
How should agitation and confusion be managed in palliative patients?
Check for underlying reversible causes first: infection, delirium, hypercalcaemia, or medication.
If required how can agitation and confusion be managed pharamacolgically?
First choice treatment is Haloperidol, Chlorpromazine or Levomepromazine
In the terminal phases of illness then SC midazolam is indicated.
What drug class do cyclizine, metoclopramide, domperidone, haloperidol, prochloperazine, ondansetron and hyoscine butylbromide
Antihistamines Cyclizine
Dopamine antagonists Metoclopramide
Domperidone
Haloperidol
Prochloperazine
Serotonin antagonists Ondansetron
Anticholinergics Hyoscine butylmromide
Describe the WHO performance status
- 0: Fully active, no restrictions on activities. A performance status of 0 means no restrictions in the sense that someone is able to do everything they were able to do prior to their diagnosis.
- 1: Unable to do strenuous activities, but able to carry out light housework and sedentary activities. This status basically means you can’t do heavy work but can do anything else.
- 2: Able to walk and manage self-care, but unable to work. Out of bed more than 50% of waking hours. In this category, people are usually unable to carry on any work activities, including light office work.
- 3: Confined to bed or a chair more than 50 percent of waking hours. Capable of limited self-care.
- 4: Completely disabled. Totally confined to a bed or chair. Unable to do any self-care.
- 5: Death
