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Placement > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

ACP

A

Advanced Care Plan - voluntary conversation and opportunity to patient to plan (w or w/o family) their future care whilst they still have capacity

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2
Q

ADRT

A

advanced decision to refuse treatment

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3
Q

Which supersedes the other - LPA or ADRT

A

If the ADRT is made before the LPA, then the LPA supersedes. If the ADRT is made after the LPA, it is a legally binding document

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4
Q

cheyne-stokes breathing

A

rapid breathing then period of apnoea, can be sign of dying

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5
Q

Diagnosing Death

A

Confirm irreversible cessation of neurological (pupillary), cardiac and resp activity.
Drs (and some trained nurses) role
No pulses, absent breath and heart sounds
pupils fixed and dilated, no corneal reflex
no motor response to supraorbital pressure

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6
Q

who can sign a death certificate

A

seen the person within the last 14 days before they died (covid now 28 days), not necessary to have seen the body after death as long as death certified by a competent person.

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7
Q

When to refer to the coroner

A

unknown cause of death
sudden or unexpected death (<24hrs after admission to hospital)
Deceased person has not seen a dr within the 14 days before death
suspicious, unnatural or violent
accident,
infant death, self-neglect or neglect
prior employment
adue to an abortion
occured during opperation or before recovery from anaesthetic
during or shortly after police custody
suicide

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8
Q

writing a death certificate

A

Part 1 - cause of death.
1a - the disease(/s) or condition that led directly to death
1b - any disease(/s) that lead to 1a
1c - any disease(/s) that lead to 1b
Part II - any other conditions that were not part in the main cause of death, but may have had an impact in hastening it (NOT entire PMH)
Box A -write in initial if have reffered to coroner
Box B - initial if may have more information in the future (e.g. lab results arent back yet)

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9
Q

who can sign cremation certificate

A

3 parts - dr caring for patient, independant dr, crem officer.
1st Dr must talk to 2nd dr, 2nd dr would talk to 3rd party (staff member or next of kin) to confirm details.
Both Drs must have seen the body after death

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10
Q

when do you need consent to do an autopsy

A

need consent from next of kin if being done for research or to better understand cause of death. if death has to be reffered to the coroner, then consent does not need to be given. However consent is needed if tissues are to be removed or retained.

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11
Q

CD4 count for AIDS

A

200

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12
Q

AIDS defining illness

A

resp - recurrent bacterial pneumonia, TB, PCP (pneumocystis jirovecii, fungus)
CNS - toxoplasmosis, cryptococcal meningitis, primary cerebral lymphoma (associated with EBV)
skin - karposi sarcoma (Human herpes virus 8). in mouth = bad prognostic indicator)
GI - bacterial, CMV (can also effect eyes), cryptosporidium, microsporidia, mycobacterium avium intracellulare (rare form of TB)
Lymph - NHL, diffuse large B cell, Burkitts

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13
Q

what does toxoplasmosis look like on CT

A

adscess, effect basal ganglia, associated with severe oedema, ring enhancing

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14
Q

blood test to monitor HIV

A 
CD4 count (normal >500) 
Viral load (undetectable (<20/40 copies per ml)
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15
Q

mechanism of NRTI (nucleoside reverse transcriptase inhibitors)

A

stop viral RNA being converted to DNA by competing for binding sites

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16
Q

mechanism of NNRTI (non nucleoside reverse transcriptase inhibitors)

A

stop viral RNA being converted to DNA by blocking binding sites

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17
Q

protease inhibitor mechanism

A

stop new copies of HIV being produced by preventing productions of units needed for capsule formation

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18
Q

integrase inhibitors mechanism

A

stop viral DNA integrating into host cell DNA

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19
Q

NRTI example

A

tenofovir, stavudine, emitricitbine, lamivudine, zidovudine

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20
Q

NRTI side effects

A

N&V, fatigue, headache, myelosuppressinon (Aneamia, bone marrow), panreatitis, neuropta

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21
Q

Analgesic Ladder

A

Step 1: non-opioid +/- adjuvant.
1. paracetamol
2. ibuprofen
3. Paracetamol and ibuprofen
4. paracetamol + alternative NSAID
Step 2: weak opioid (tramadol, codeine, co-proxamol, co-codamol, dihydrocodeine)
Step 3: strong opioid (morphine) +non-opioid +/- adjuvant

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22
Q

Mechanism of paracetamol

A

inhibit Cox in CNS

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23
Q

what type of pain are NSAIDs good for

A

inflammatory, bone pain, NOT neuropathic pain

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24
Q

side effects of NSAIDs

A

gastric irritation (dyspepsia, ulceration)
Brocnhospasm in asthmatics
May precipitate renal failure

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25
Q

dose of codein phosphate

A

30-6omg 4-6hrly, max dose 240mg in 24hrs

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26
Q

side effects of codeine

A

nausea and conspitation

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27
Q

compound preparations of codeine available

A

cocodamol 8/500 (8mg codeine, 500mg paracetamol) or 30/500 (30mg codeine…)

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28
Q

Methods of giving morphine

A

oral, subcut

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29
Q

peak plasma levels and suration of analgesia for oromorph (oral immediate release)

A

1 hr

4 hrs

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30
Q

peak plasma conc and duration of analgesia for Zomorph (oral controlled release)

A

2-4hrs

12hrs

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31
Q

peak plasma conc of parenteral (s/c) morphine or diamorphine

A

15-30mins

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32
Q

side effects of morphine

A

drowsiness (particularly common in beginning of treatment)
N&V (occur in 2/3 patients, usually resolves, prescribe anti-emetic cover)
Constipation (prophylactic laxative)

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33
Q

what to administer when converting to strong opioids

A

morphine, immediate release (5mg if opioid naive, 2.5mg if frail or elderly, 10mg if patient on max weak opioid and still in pain) 4hrly with same dose as prn

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34
Q

How to convert from immediate to controlled release morphine

A

work out total daily dose of immediate release morphine (regular + prn)
divide by 2 to give bd dose
breakthrough dose = total daily dose /6

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35
Q

how to know when to adjust controlled release dose

A

after 24hrs, check the number of breakthrough doses needed. if 2 or more, add total daily requirement and divide by 2 to get the new bd dose. remember to adjust breakthrough dose (new MST total daily/6)

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36
Q

converting oral to s/c morphine/diamorphine

A

work out total daily requirement of oral morphine. divide by 2 to convert to s/c morphine dose. divide by 3 to convert to s/c diamorphine dose.
breakthrough dose = total daily requirement/6

37
Q

options other than morphine if bad side effects (e.g. nightmares/hallucination)

A

oxycodone

alfentanyl

38
Q

how do fentanyl patches work

A

lipophylic, so transcutaneous administration

39
Q

how long does a fentanyl patch work

A

72hrs, doesnt matter what dose

40
Q

why isnt a fentanyl patch suitable to give to a patient first starting on opioids

A

short half life - but build up in reservoir under the skin

41
Q

adjuvant analgesics

A

Group of medications which relieve pain in specific circumstances
neuropathic pain - tricyclic antidepressants (e.g. amiltryptiline) or anti-convulsant (e.g. gabapentin, pregabalin, carbamazepine)
Bone pain - bisphosphinates

42
Q

non-medical methods of pain relief

A 
heat
radiotherapy (bone mets) 
fracture stabilisation 
TENS (transcutaneous electrical nerve stimulation) 
nerve block 
Spinal analgesia
43
Q

controlled drugs symbol

A

controlled drugs are shown in the BNF with ‘CD’

specific requirements govern the prescription of these drugs

44
Q

metoclopramide - receptor antagonist

A

Dopamine

45
Q

metoclopramide - site of action

A

peripheral (gut)

CTZ

46
Q

metoclopramide - when to use/actions

A

Prokinetic

gastric stasis

47
Q

metoclopramide - side effect

A

Colic in obstruction

extra-pyramidal side effects

48
Q

receptor on the vomiting centre

A

muscarinic

49
Q

receptor on the chemoreceptor trigger zone

A

dopamine and 5-HT

50
Q

where are the vomiting centre and the CTZ

A

medulla

CTZ - outside the blood-brain barrier

51
Q

cause of motion sickness

A

vestibule in the labrinth is responsible for balance. when problems occur signals are sent along to vestibular cochlear nerve to the brain stem, (vestibular nuclei, located in the pons)

52
Q

what kind of receptors do vestibular nuclei have

A

Histamine 1

muscarinic

53
Q

which area is effected in morning sickness

A

labrinth/ vestibular nuclei

54
Q

where is promethazine site of action and what is it used for

A

H1 receptor antagonist in the Vestibule (labrinth). used for morning sickness and motion sickness

55
Q

examples of 5-HT receptor antag

A

end in setron, e.g. oldansetron

56
Q

main types of antiemetic

A

5HT3 receptor antagonist
H1 receptor antagonist
Muscarinic receptor antagonist
D2 receptor antagonist

57
Q

example of muscarinic receptor antagonists and where they work

A

hyosine

vomiting centre in the medulla

58
Q

metoclopramide - Dose

A

10mg TDS PO/Sc/IV

30-80mg sc over 24hrs

59
Q

Domperidone - receptor antagonist

A

Dopamine

60
Q

Domperidone - site of action

A

Peripheral (does not cross blood brain barrier)

61
Q

Domperidone - when to use

A

as metoclopramide (prokinetic, gastric stasis)

62
Q

Domperidone - dose

A

20mg TDS

no driver option

63
Q

Cyclizine - receptor antagonist

A

histamine

anti-cholinergic (muscarinic)

64
Q

Cyclizine - site of action

A

Labrinth/vestibular

65
Q

Cyclizine - when to use

A

increased ICP

66
Q

Cyclizine - side effects

A

constipation
irritant if sc
dry mouth

67
Q

Cyclizine - dose

A

50mg TDS PO/sc/IV

100-150mg over 24hrs

68
Q

Haloperidol - receptor antagonist

A

dopamine

69
Q

Haloperidol - site of action

A

CTZ

70
Q

Haloperidol - when to use/action

A

Metabolic (hypercalcaemia), drug induced

71
Q

Haloperidol - side effects

A

sedation
extra-pyramidal
contra-indicated in parkinsons

72
Q

Haloperidol - dose

A

1.5mg ON PO/SC 2.5mg-5mg over 24hrs

73
Q

Levomepromazine - receptor antagonist

A

5HT2
Dopamine
Ach M
Histamine

74
Q

Levomepromazine - site of action

A

VC

CTZ

75
Q

Levomepromazine - when to use/actions

A

hits all receptors to useful if others have failed

76
Q

Levomepromazine - side effects

A

sedation

reduce in renal failure

77
Q

Levomepromazine - dose

A

6mg PO
5-10mg sc ON
25mg over 24hrs

78
Q

ondansetron - receptor antagonist

A

5HT3

79
Q

ondansetron - site of action

A

Central - CTZ

Peripheral - gut

80
Q

ondansetron - when to use

A

chemo

after surgery

81
Q

ondansetron - side effects

A

constipation

82
Q

ondansetron - dose

A

4-8mg TDS PO/IV

83
Q

Main palliative care drugs for pain/breathlessness

A

diamorphine or morphine

84
Q

main palliative care meds for N&V

A

Haloperidol and/or cyclizine
prokinetic - metoclopromide
second line - levomepromazine

85
Q

palliative care drugs for Agitation and anxiety

A

midazolam

86
Q

palliative care drugs from anxiety and hallucinations or confusion

A

haloperidol, levomepromazine

87
Q

palliative care drugs for noisy breathing due to resp tract infections

A

Glycopyrronium bromide
hyoscine butylbromide
hyoscine hydrobromide

88
Q

management of breathlessness in pall care setting

A

reverse the reversible: bronchospams, pleural effusion, pericardial effusion, pain, anaemia, infection, airway obstruction (stent, steroids, laser radiotherapy), SVCO, lymphangitis CCF, COPD, arrhythmias
set realistic goals/expectations
conservative: acknowledge fears and explore reasons, reassurance, breath retraining, panic management, physio, OT.
medical: opioids, benzodiazepines (lorazepam, sublingual). Oxygen (for hypoxia), steroids, CPAP
surgical: any reversible e.g. lobectomy for emphysema
indwelling pleural drainage - pleurex catheter

89
Q

medications for terminal breathlessness

A

opioids, benzo

note: need to explain ti patient and family. will make more drowsy but much more comfortable

Placement (10 decks)

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