palliative care Flashcards
what is an unlicensed medicine
is a medicine without a European or UK marketing
authorisation for use in humans and is not licensed to be marketed in the UK.
this is legal
gain informed consent from the patient with this
off-licence medicine (off-label) medicine
is a licensed medicine used for unlicensed
applications, e.g. an unlicensed indication, an unlicensed route or at an
unlicensed dose
this is legal
gain informed
non-pharma methods
aromatherapy
reiki
preferred methods of access in palliative care patients
and why not other routes
oral - primary route and should be used if available and appropriate
subcut - preferred parenteral route which can be used for intermittent bolus injections, small volume continuous infusions and hydrations
Intravenous – hazardous and venous access can be difficult in this group of
patients.
Intramuscular – can be painful. Difficult in cachectic patients.
Rectal – patient acceptability can be an issue.
Sublingual/Buccal – sometimes useful but not if patient has a dry mouth.
Transdermal – a route being used increasingly but has some limitations; dose
titration can be difficult in some patients.
Inhalation – patient co-ordination can be an issue in the final stages of the
disease.
Spinal – specialist use only, e.g. epidural, intrathecal.
pathophys of different causes of vomiting
biochemical upset (drugs) -
- > chemoreceptor trigger zone (CTZ) - D2 + 5HT3 receptors
- > vomiting centre (Ach, H2, 5HT2)
- > perception of nausea and vomiting
anxiety/raided intracranial pressure
- > higher centres (H1)
- > vomiting centre (Ach, H2, 5HT2)
- > perception of nausea and vomiting
motion sickness
- > vestibular input (Ach, h1)
- > vomiting centre (Ach, H2, 5HT2)
- > perception of nausea and vomiting
Gastric stasis, intestinal obstruction, gastric irritation (e.g. chemotherapy, radiotherapy, hepatomegaly) -> GI tract - D2, 5HT3 -> vomiting centre (Ach, H2, 5HT2) -> perception of nausea and vomiting
causes/exacerbating factors of nausea
drug side-effects,
constipation, severe pain, anxiety, infection, cough, hypercalcaemia, raised intracranial
pressure, and bowel obstruction.
non-pharma mx of nausea/vom
Control odours from colostomy, wounds and fungating tumours
Minimise sight/smell of food
Give small snacks not large meals
Try acupressure wrist bands
drug management of nausea in palliative care - group, where they act, S/E, what nausea they are used for
haloperidol (butyrophenone antipsychotic)
- acts on D2 receptors in CTZ
- s/e = extrapyramidal, sedation, QT prolongation, depression
- chemical causes eg opioids
metoclopramide, domperidone (prokinetic agents)
- D2 receptor agonist
- met also acts on 5HT4 + 5HT3
- used for gastric stasis + ileus or chemo induced
- S/E - metoclop = extrapyramidal, drowsiness, diarrhoea, gynaecomastia, galactorrhoea and hyperprolactinaemia
- domperidone = QT-prolongation, drowsiness, dry
mouth, diarrhoea and malaise
levomepromazine, prochlorperazine (phenothiazine antipsychotics)
- acts at dopamine, H1, Ach receptors
- use for non-specific or multifactorial sickness
- s/e - extra-pyramidal symptoms, drowsiness, antimuscarinic effects, postural hypotension and QT-prolongation
cyclizine, promethazine (antihistamine)
acts on - H1 receptors centrally and peripherally
used in - obstruction, peritoneal irritation, vestibular causes
(motion sickness), raised intra-cranial pressure
granisetron, ondansetron
(5HT3 antagonists)
- used in - chemotherapy and radiotherapy induced N&V, post-operative
N&V
- s/e - constipation, headache, flushing, involuntary
movements and QT-prolongation
hyoscine butylbromide (antimuscarinic)
- act on Ach receptors
used in - smooth muscle spasm (bladder, GI tract), excessive
secretions including sialorrhoea, drooling, death rattle and inoperable
bowel obstruction)
s/e - CI in tachycardia, used in caution in cardiac disease due to causing tachycardia, hypotension and anaphylaxis
aprepitant or fosaprepitant (neurokinin receptor antagonist)
used for chemo n+v
what antiemetic would you use for a obstruction, peritoneal irritation, vestibular causes
(motion sickness), raised intra-cranial pressure sickness
cyclizine
promethazine
antihistamines
what antiemetic would you use for nonspecific, multifactoral sickness
levomepromazine
prochlorperazine
(Phenothiazine
antipsychotics)
what antiemetic would you prescribe for nausea caused by gastric stasis and ileus or for delayed
chemotherapy induced
metoclopramide
domperidone
(prokinetic agents)
what antiemetic would prescribe for chemically caused nausea
haloperidol
butyrophenone antipsychotics
what antiemetic would you prescribe for chemotherapy and radiotherapy induced N&V, post-operative
N&V
granisetron
ondansetron
5HT3 antagonists
what antiemetic would you prescribe for smooth muscle spasm (bladder, GI tract), excessive
secretions including sialorrhoea, drooling, death rattle and inoperable
bowel obstruction
Aprepitant (oral), Fosaprepitant (IV)
Neurokinin- receptor
antagonists
hyoscine
treating cough in palliative care
cough suppressants - codeine
- morphine
- methadone
demulcents
- soothing agents: glycerol, syrup, simple linctus
- short-lived
expectorants
- encourage morer productive cough
- NaCl 0.9% nebs 5ml PRN
treating dyspnoea in palliative care
- goal
- non pharma
- pharma
goal is to improve subjective sensation rather than function
non-pharma - cool draught (open window, fan),
breathing exercises, relaxation therapy, positioning and modifying lifestyle (e.g. bed
downstairs, walking aids). Refer to physiotherapy and occupational therapy where
appropriate
pharma
- airways ob -> bronchodilators eg salbutamol, corticosteroids eg dexamethasone, steroid inhalers
- COPD, malignancy -> resp sedative eg morphine
- heart failure -> diuretics, ACEi, digoxin, resp sed (morphine)
- SVCO - corticosteroids (dexamethasone), chemo, radio, stenting
treating bleeding in palliative care
- how often
- causes
- mild/moderate
- major
20% of cases
Consider thrombocytopenia, vitamin K deficiency, heparin-induced thrombocytopenia
(HIT), hepatic impairment and renal impairment
mild/moderate
- surface bleeding = tranexamic acid
- radiotherapy for lung bleeding
- Topical treatment for fungating wounds and anterior epistaxis: gauze
soaked in adrenaline 1:1000 or tranexamic acid 500mg/5ml injection
solution. Apply with pressure for 10 minutes
- Topical treatment for oral bleeding: tranexamic acid 500mg/5ml
mouthwash/gargle
major
- when major artery eroded by tumour
- usually leads to death in matter of minutes
- dark coloured towels to make it less scary
- consider giving midazolam 5-10mg IV/IM to reduce awareness and fear
what are the four components of pain
- physical
- psychological
- social
- spiritual
different types of pain
- soft tissue
- visceral
- bone
- neuropathic
name and describe adjuvant analgesics
amitriptyline
- neuropathic pain offlicense
- s/e - anticholinergic effects (dry mouth, blurred vision, urinary
retention, constipation), sedation, postural hypotension, QTc interval prolongation.
- Benefit in neuropathic pain takes < 1 week
carbamazepine
- neuropathic pain off license
- s/e - headache, ataxia, drowsiness, nausea, dizziness
- blood monitoring needed for prolonged treatment
gabapentin
- licensed for peripheral neuropathic pain
- s/e - drowsiness, constipation, dry mouth, hypertension
pregablin
licensed for peripheral + central neuropathic pain
- s/e - drowsiness, dry mouth, GI disturbances
clonazepam -
off-license for neuropathic pain
s/e - co-ordination disturbances, dizziness, drowsiness, fatigue
duloxetine
- off-license for neuropathic pain
- s/e - dizziness, drowsiness, dry mouth, headache, nausea
oxcarbazepine
- indicated for neurpathic off license
- s/e - dizziness, drowsiness, headache, hyponatraemia (monitor
sodium level)
what is an adjuvant analgesic
Adjuvant analgesics are defined as drugs with a primary indication other than pain that
have analgesic properties in some painful conditions
before starting someone on a strong opioid what do you need to know?
previous opioid exposure - people who have never had an opioid will need weaker dose
how can strong opioids be initiated and titrated
- Prescribe the dose on a four hourly as required (‘PRN’) basis (Note for patients that
are not self-administering this relies on the patient asking for pain relief and receiving
it in a timely fashion) - Prescribe the dose on a regular basis every four hours (Note for patients that are not
self-administering this ensures the patient receives pain relief).
in both methods assess patients pain after 24 hours
If the patient is pain free the total dose that has been administered over the past 24
hours should be added up and converted into a twice-daily sustained/modified release
(SR/MR) dose by dividing the total 24 hour dose by two.
If the patient is still reporting pain first confirm adherence and then consider increasing
the dose prescribed and re-assessing after another 24 hours
explain breakthrough pain and the types
end-of dose interval pain - pain occurring just
before the next dose of regular analgesic is due
Predictable (incident) pain: an exacerbation of pain caused by weight bearing and/or
an activity/trigger which may or may not be associated with a background of constant
(though controlled) pain at the same location
- Unpredictable (unexpected) pain: spontaneous pain unrelated to weight bearing or
an activity/trigger e.g. colic or stabbing pain associated with nerve injury
how to control breakthrough pain
immediate release
Commonly 1/10th to 1/6th of
the equivalent total daily dose of the drug is recommended
Please note that the 1/10th to 1/6th dosing schedule does not apply to methadone,
transmucosal/sublingual/buccal fentanyl, sublingual buprenorphine or ketamine which are individually titrated.
adverse effects of opioids
Nausea and/or vomiting. Ensure a suitable antiemetic is prescribed. If this adverse
effect is refractory to treatment, consider an opioid switch.
Constipation. Ensure a softening and stimulant laxative is prescribed. Where
response to standard laxative therapy has failed methylnaltrexone or naloxegol may
be considered.
Cognitive impairment, drowsiness, myoclonic jerks, dysphoria and respiratory
depression are dose-related side-effects. Consider a reduction of the opioid dose,
review of adjuvants and/or opioid switch.
Urinary retention. This may be resolved by dose reduction or opioid switch.
Acute respiratory depression/bradypnoea. This is rarely a problem if titrated correctly.
Note both respiratory rate and oxygen saturations will be decreased if it is opioid
induced. Naloxone may be required. Refer to the BNF and local hospital Trust
guideline for dosing and administration details.
Hallucinations
Dry Mouth
Sweating
Pruritus
Psychological dependence (addiction) is rare in patients requiring pain-relief for a
terminal illness.
oxycodone
- potency comparison
- when used
oxycodone
- 2 x potency
- 2nd line to morphine
- dose reductions in renal + hepatic impairment
- less s/e than morphine
fentanyl
- form
- used for
- when effective
- what to avoid
- transdermal patch
- chronic pain not acute
- effective 12-15 hours
- steady plasma concs in 24-72 hours
- half life 13-27 hours after removal
- AVOID heat pads/electric blankets as increases absorption
- useful for those that are renal impaired
buprenorphrine
- how it works
- form
- what use for
- avoids
- partial agonist + antagonist
- transdermal patch + sublingual
- chronic not acute
- avoid heat
- use for patients with renal impairment
alfentanil
- who for
- potency comparison to morphine
- format prescribed
only for patients with severe renal impairment
10x potency of subcut diamorphine
30x more potent than oral morphine
usually prescribed via syringe driver with breakthrough doses PRN
methadone
- how it works
- supervision
- pharmacokinetics
- adverse effects
- s/e in comp to morphine
- mixed properties (opioid receptor agonist, NMDA [Nmethyl-D-aspartate] receptor channel blocker and pre-synaptic blocker of serotonin
and noradrenaline re-uptake) - specialist supervision needed
- has to be inpatient
- rapidly distributed - 2-3 hours
- takes 4-5 days to rreach steady stat- accumulates in tissue and takes 15-60 ours to eliminate
adverse effects - QTc interval prolongation. ECG monitoring is required. Advisable to avoid concurrent use with other drugs that prolong the QT interval
-orally - neuropathic pain
- Less constipation, hallucinations, sedation and nausea than with morphine
- Interacts with numerous other drugs
ketamine licensed for? how given s/e how long lasts
licensed as a general anaesthetic - NMDA receptor channel blocker - specialist supervision -last resort if unresponsive to methadone all other opioids - oral, IV, subcut, or subcut infusion - shirt half life - s/e - hypertension, vivid dreams, hallucinations, hepatobiliary toxicity and urinary tract toxicity
conselling points for opioid prescribing + prescription requirements
milligrams not millilitres!! as differing strength liquids
Remember to counsel patients on the common side-effects and proactively prescribe
regular laxatives and a ‘PRN’ antiemetic
when removing buprenorphrine patch how long do you wait until you prescribe opioid
24 hours
converting from oral opioid to fentanyl patches
the regular
opioid needs to be continued for the first 12 hours after the patch is applied to allow
plasma fentanyl to increase to a therapeutic level
terminal patient with rapidly escalating pain on fentanyl patches, what do you do?
it is best to continue transdermal fentanyl and give rescue doses of their usual
subcutaneous opioid or add a continuous subcutaneous infusion of their usual opioid.
what symptoms do you pre-emptive prescribe for?
pain dyspnoea n +v agitation resp tract secretions
indications for using a syringe driver
- Patient unable to take medication orally
- Poor absorption of oral medication (N&V, oedema)
- Intestinal obstruction
advantages of using a syringe driver
Increased comfort for patients because there is less need for repeated
injections
Control of multiple symptoms with a combination of drugs
Round-the-clock comfort because plasma drug concentrations are maintained
without peaks and troughs
Independence and mobility maintained because the device is lightweight and
can be worn in a carrier under or over clothes
Generally only needs changing once a day
disadvantages to a syringe driver
Patients fear that it is a last resort and a sign they are approaching the
terminal phase of their illness
Training for staff is necessary
Lack of flexibility with a once daily prescription
Injection site problems can occur e.g. inflammation, irritation and pain
how can site irritation at the syringe driver be minimised?
Increasing the volume of the infusion e.g. 12 hourly infusion however note this
option is no-longer available in Sheffield due to the pre-set 24 hour infusion
devices used
Consider needle allergy/trauma. Teflon and plastic cannula are less allergenic
than metal. Note metal cannulas are no longer used in Sheffield
Changing the injection site
Changing the diluent to sodium chloride 0.9% where compatibility allows.
what is the maximum amount of drugs that can be used in one syringe driver?
three
if more than three drugs needed then review therapy or 2 syringe drivers could be used
what is chemical stability within the syringe driver dependent on
dose or concentration
- therefore the higher
dose/concentration contained within the syringe, the more probability that
problems will occur
why do you have to be careful at mixing acid + bases in the syringe driver?
acid + base = salt + water
which drugs are known to be particularly problematic and need extra caution in syringe drivers?
- cyclizine
- ketorolac
- ketamine
syringe driver housekeeping
- The contents of the syringe driver should be checked at regular intervals for
signs of degradation - Infusions should not run for longer than 24 hours
- Giving sets should be protected from light, particularly if containing
levomepromazine - Ensure the syringe driver is placed above the covers if a patient is in bed to
minimise the effect of temperature
what drugs are common prescribed for pain in syringe driver?
Diamorphine, morphine, oxycodone, methadone, clonazepam,
alfentanil
what drugs are common prescribed for n+v in syringe driver?
Haloperidol, metoclopramide, hyoscine butylbromide,
levomepromazine
what drugs are common prescribed for restlessness + agitation in syringe driver?
Haloperidol, levomepromazine, midazolam
what drugs are common prescribed for terminal secretions +/or colic in syringe driver?
Hyoscine butylbromide, glycopyrronium
bromide
what drugs are common prescribed for bowel obstruction in syringe driver?
Hyoscine Butylbromide, octreotide
for which drugs do you have to use 0.9% saline instead of water to mix up the drugs for a syringe driver?
- Ketamine
- Ketorolac
- Ondansetron
- Octreotide
- Granisetron
converting 120mg morphine to a fentanyl patch
37 microgram/hour
performance status in cancer
zubrod scale
0 = normal
1 = symptomatic and ambulatory, cares for self
2 = ambulatory >50%, ocassional assistance
3 = ambulatory =50% of the time, nursing care needed
4 = bedridden
karnofsky scale
100 = normal
90 = able to perform with only minor symps
80 = normal activity with effort, some symps
70 = able to care for self but unable to do normal activities
60 = requires occasional assistance, cares for most needs
50 = requires considerable assistance
40 = disabled, requires special assistance
30 = severely disabled
20 = very sick, requires active supportive treatment
10 = moribund
for patients nearing the end of life what can you tell them to complete to ensure they have thought of everything
Conversation Project -ConvoStarterKit
what is a power of attorney
A lasting power of attorney (LPA) is a legal document that lets you (the ‘donor’) appoint one or more people (known as ‘attorneys’) to help you make decisions or to make decisions on your behalf.
This gives you more control over what happens to you if you have an accident or an illness and cannot make your own decisions (you ‘lack mental capacity’).
why shouldnt you prescribe cyclizine and metoclopromide?
Metoclopramide (D2) is a prokinetic and can cause diarrhoea
Cyclizine (H1, antiMusc) is constipating
The 2 counteract each other in the bowels
what would you prescribe for muscle spasms
baclofen
prescribe for compression symptoms
dexamethasone
prescribe for spasms
diazepam and clonazepam
prescribe for bone pain
bisphos eg zolendronic acid
terminal care key concepts to consider
formal advanced care planning
DNACPR - inform
symptoms of dying
Weight loss and poor appetite
Fatigue
Poor mobility
Social withdrawal
Struggling with medications
CV changes (pulse, mottled skin, cool peripheries)
Resp changes (noisy secretions, laboured) - the death rattle
5 key symptoms: what to prescribe for each
Pain
PRN morphine on syringe driver, continue patch medication
breathlessness
PRN opioid SC and SC benzodiazepines
secretions
PRN hyoscine hydro/butylbromide (buscopan) also good for colicky pain 20mg sc PRN hourly
n+v Haloperidol D2 (also?domperidone/metoclopramide) 0.5 - 1.5mg sc PRN 4 hourly (also for agitation/delirium)
agitation
Midazolam 1.25 -2.5mg SC PRN hourly
constipation in palliative care what to prescribe
A stool softener and stimulant laxative
Docusate and senna
5 priorities of care when the patient may die in the next few hours
- Possibility is recognised and clearly communicated to patient
- Sensitive communication occurs between staff and patient/family
- Dying person/family involved in treatment and care planning
- Needs of family are identified and actively explored
- An individual plan of care including food and drink, symptoms and psychosocial/spiritual support is delivered
palliative care emergencies what are they
malignant spinal cord compression
superior vena cava
malignant hypercaalcaemia
opioid overdose/tox
acute bleeding
ddx for confused dying patient and decreased AMT
Hypercalcaemia, infection, brain metastasis
palliative care patient lacks capacity and want to prevent them from leaving
DOLS is a part of the MCA
Acid test is 1) person under continuous supervision AND 2) is not free to leave AND 3) cannot consent to these arrangements
