Palliative Care Flashcards
What is the most appropriate management for hiccups in palliative care?
. Chlorpromazine- used in intractable hiccups
. Haloperidol, gabapentin are also used
. Dexamethasone is also used, particularly if there are hepatic lesions
If you are changing oral morphine to SC diamorphine/morphine then how should you change the dose?
Parental diamoprhine is approx 3x more potent as oral morphine, so the total daily dosage of morphine should be divided by three to obtain the 24hr subcut dose of diamorphine.
The oral to subcut potency ratio of morphine is between 1:2 and 1:3 (that is the subcut dose is one third to one half of the oral dose). In practice, most centres divide the oral dose by two and re titrate as necessary.
What are the most common tumours causing bone mets?
Prostate
Breast
Lung
(In descending order)
What are the most common sites for bone mets?
Spine Pelvis Ribs Skull Long bones
(In descending order)
What are the features of bone mets?
Bone pain
Pathological fractures
Hypercalcaemia
Raised ALP
What can opioid use in renal impairement lead to?
Can lead to opioid toxicity and therefore mimic active dying.
What drug can be used in palliative patients with mild renal failure and why?
Oxycodone (mainly metabolised in the liver- 19% renally excreted)
What opioids can be used in severe renal impairement?
Fentanyl
(Mainly metabolised in liver)
Alfentanil
Buprenorphine
What cancers is neoplastic spinal cord compression most common in?
Lung
Breast
Prostate
What are the features of neoplastic spinal cord compression?
Back pain= earliest and most common symptom, may be worse on lying down and coughing
Lower limb weakness
Sensory changes- sensory loss and numbness
Neurological signs- this really depends on the level of the lesion
Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level
Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness, tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion.
What investigation is needed for suspicious spinal cord compression due to neoplasm?
Urgent MRI- recommend a whole MRI spine within 24 hours of presentation
What is the management of spinal cord compression?
High dose oral dexamethasone
Urgent oncological Assesment for consideration of radiotherapy or surgery
What is superior vena cava obstruction?
It is an oncological emergency caused by compression of the SVC, it is commonly associated with lung cancer.
What are the features of SVCO?
Dyspnoea is the most common symptom
Swelling of the face, neck and arms- conjunctival and peri orbital oedema may be seen
Headache which is often worse in the mornings
Visual disturbance
Pulseless jugular venous distension
What are the causes of SVCO?
Common malignancies- small cell lung cancer, lymphoma
Other malignancies- metastatic seminoma, kaposis sarcoma, breast cancer
Aortic aneurysm
Mediastinal fibrosis
Goitre
SVC thrombosis
What is the management of superior vena obstruction?
In general- dexamethasone, balloon venoplasty, stenting
Small cell: chemo and radiotherapy
Non small cell: radiotherapy
What are the risk factors for developing Nausea and vomiting in chemo?
Anxiety
Age less than 50 years old
Concurrent use of opioids
The type of chemo used
What anti emetics can be used for cancer patients?
For patients at a low risk of symptoms then metoclopramide can be used first line
For high risk patients then 5HT3 receptor antagonists such an ondansetron are often effective, especially if combined with dexamethasone
If metastatic disease is found before the primary cancer, what investigations should be performed to help identify primary?
FBC, U and E, LFT, calcium, urinalysis, LDH
CXR
CT CAP
AFP and hCG
Following investigations should be performed for specific patients….
myeloma screen (if lytic bone lesions)
Endoscopy (directed towards symptoms)
PSA (men)
CA 125 (women with peritoneal malignancy or ascites)
Testicular US (in men with germ cell tumours)
Mammography (in women with clinical or pathological features compatible with breast cancer).
What are the two most common causes of nausea and vomiting in palliative care?
Gastric stasis
Chemical and metabolic disturbances
What are the signs that someone is in their final days of life?
Profound weakness More time in chair/bed Gaunt Reduced appetite Weight loss Loss of consciousness Poor concentration Increase in disease specific symptoms Cheyne stokes breathing pattern Skin colour changes Incontinence Reduced UO Temp change at extremities Agitation Raspy breathing
State the standard 4 drugs, doses and indications that are given for anticipatory prescribing in end of life care…
Morphine 2.5-5mg SC (opioid naive dose) PRN for pain and dyspnoea
Midazolam 2.5-5mg SC PRN for dyspnoea and agitation
Lansoprazole 2.5-5mg
Glycopyrronium 200mg SC PRN
What considerations need to be made for advanced care planning?
Resus Psychosocial needs and fears Spiritual and religious needs Ongoing symptom management Anticipatory prescribing Mouth care Food and drink- clinically assisted nutrition and hdyration Good after death care Ceiling of care agreed Referal when complex symptoms Preferred place of death
What can cause pain in cancer?
Concurrent disease (pain unrelated to the cancer) - OA, spinal cord stenosis, peripheral neuropathy, unkown cause
Cancer invading bone, nerves, viscera and soft tissue
Treatment - chemo, radiotherapy, surgery
Cancer related debility- mucositis, neuropathy
What can exacerbate pain at the end of life of cancer?
. Anger . Anxiety . Boredom . Discomfort . Imnsomnia . Social isolation
What non pharmalogical approaches can reduce pain at end of life?
Acceptance Relaxation Mood elevation Relief of other symptoms Sleep Explanation
What is the difference between nociceptive and neuropathic pain?
Neuropathic pain is where there is a malfunctioning in the nervous system and the nerves are damaged
Nociceptive is where there is a normal nervous system, an identifiable lesion is causing tissue damage.
What NSAIDS can be given for a patient with CVS risk?
Naproxen or ibruprofen
You should avoid diclofenac
When should NSAIDS be used with caution?
. GI risk . CVS risk . Renal failure (exacerbates) . Heart failure (exacerbates) Give PPI with All- lansoprazole
What drugs can be used for neuropathic pain?
Amitriptylline
Pregabalin
Gabapentin
They take around 5 days to work
What drug is particularly good for bony pain?
Bisphosphonates
Give examples of bisphophonates?
Alendronic acid PO
Zoledronic acid IV
How do bisphosphonates work?
They work by slowing down the cells which break down bone (osteoclasts) therefore they slow down bone loss, allowing the bone building (osteoblasts) to work more effectively.
Give examples of weak opioids…
Co codamol
Codeine phosphate
Tramadol
Dihydrocodeine
Give examples of strong opioids….
Morphine
Fentanyl
Diamorphine
Oxycodone
What are the side effects of opioids?
Confusion Constipation N+V Dry mouth Drowsiness
What dose of morphine should be given PRN for breakthrough pain?
TDD/ 6
How are opioids excreted?
Most are excreted renally, therefore you should be careful in renal failure
Fentanyl and alfentanyl are excreted by the liver
What is the strength of morphine, relative to codeine?
Codeine is 1/10th the dose of morphine
Give examples of slow release and immediate release morphines…
Slow release= zomorph capsules
Immediate= oramoprh liquid or sevredol tablets
How do you calculate the dose titrations for opioids?
Calculate total daily dose (background BD and PRN doses)
Then do TDD/2
Give this as BD slow release dose
Then do TDD/6 and five this as PRN immediate release dose
Principle is the same for syringe drivers but half the dose because its twice as strong via. Syringe driver because it bypasses the liver
How does impaired gastric emptying occur and what causes it at EOL?
Epigastric pain, reduced appetite, nausea gets better with vomiting large volumes, feeling full and bloating
Causes:
Cholinergic or autonomic neuropathy
Morphine
Locally advanced disease
How should impaired gastric emptying be managed?
Domperidone or Metoclopramide for symptomatic relief
Treat the cause if possible
How is chemical/metabolic disturbances causing N and V managed?
Haloperidol or metoclopramide
Correct the cause
What is a key feature in terms of N and V which would lead you to think of it being caused by chemical/metabolic disturbance?
If the nausea is not getting better with vomiting
How does raised ICP causing N and V present and how is it managed?
Presents with projectile vomiting
Headaches, visual changes
Worse with head movements/coughing/sneezing etc
Treat cause
Give cyclizine and/or dexamethasone
How is N and V caused by radiotherapy?
Caused by serotonin release
Treat with ondansetron
What drugs are good for managing N and V due to malignant bowel obstruction?
Cyclizine or dexamethasone
What drugs are good to manage N and V associated with chemo?
. Aprepitant
. Hypnosis and acupuncture also have a good evidence
How should N and V due to constipation be managed?
Laxatives
What antiemetic is a good all rounder and can be used 2nd line for all causes?
Levomepromazine
Can also try combining different antiemetics, giving them SC and regularly
How do metoclopramide and haloperidol work?
They are dopamine receptor antagonists
(Act at chemoreceptor trigger zone, which responds to toxins in blood)
Metoclopramide also has some action at the serotonin receptor
How does levomepromazine work?
Also is a dopamine receptor antagonist (acting at the chemoreceptor trigger zone) which responds to toxins in blood
Also inhibits mACH receptor at the vomiting centre which is why its so versatile
How does hyoscine work?
Inhibits mACH receptor at the VIII nucleus (acts on CTZ and vomiting centre)
How does ondansetron work?
Serotonin receptor antagonists
Acts at vomiting centre which responds to chemoreceptor trigger zones, higher centres, autonomic afferents
How does cyclizine work?
Inhibits histamine receptor at the 8th nucleus and vomiting centre
What causes constipation at end of life?
Diet
Immobility
Fluid depletion- vomiting, sweating, fistulae, poor intake
Weakness- can’t poo
Obstruction
Medications (opioids, diurectics, anticholinergics, SSRIS)
Biochemical disturbances (hypercalcaemia, hypokalaemia)
Give an example of a stimulant and a stimulant/softener?
Stimulant: senna or bisacodyl
Both: sodium picosulphate
Give an example of a softener…
Docusate
Give an example of an osmotic agent?
Lactulose
Movicol
Laxido (macrogol)
What drugs are good at palliating bowel obstruction?
Octeride and buscopan- reduce GI secretions and hence volume of vomiting as well as reducing peristalsis.
Give 5 treatable causes of breathlessness that are common in EOL care?
PE Anaemia Pleural effusion Pericardial effusion COPD CCF SVCO Anxiety Pneumonia
How do you treat breathlessness at EOL, if there are no specific causes for it?
. Sit them up
. Open window/ fan
. Oxygen if they are hypoxic
. Morphine (1-2mg SC/PO or 5-10mg/ day SC driver)
. Benzos- lorazepam 0.5-1mg SL PRN, midazolam 2.5mg SC PRN
How can insomnia at end of life be relieved?
Appropriate room temp
Blackout blinds
Give steroids in the morning (dont give them after 12)
Avoid waking them at night
Discuss psychosocial issues
Zoplicone or benzos can help establish normal sleep wake cycles but can also cause delirium
How do patients describe nociceptive pain?
Somatic= sharp, throbbing, easy/well localised
Or
Visceral= diffuse ache, difficult to localise (irritation of the pleura, localised)
How do patients describe neuropathic pain?
Neuropathic= shooting, stabbing, burning, stinging, allodynia, numbness, hypersensitivity
What should you find our as part of the pain assesment?
The impact of the pain on all areas of the patients life
Their understanding of the pain- what does it mean to them?
Any concerns they have about the treatment of the pain
What NSAIDS would you presribe for someone who
A) had no CV or GI risk
B) GI risk but no CV risk
C) CV risk but less GI risk
A) ibuprofen, diclofenac or naproxen
B) GI risk but no CV risk (cox2, celecoxib)
C) naproxen or low dose ibuprofen
What are adjuvants/ co analgesics?
Drugs whose primary indications are not for pain
Consider for pain that is only partially response to opioid analgesia
Can have a significant opioid sparing effect
Give examples of adjuvant/co analgesics…
Antidepressants- amitriptyline, duloxetine Anticonvulsants- gabapentin, pregabalin Benzodiazepines- diazepam, clonazepam Steroids- dexamethasone Bisphosphonates- for bony pain
What types of pain have
A) good response
B) poor response
To opioids?
A) soft tissue, visceral
B) neuropathic, bone
What do bone mets respond to in terms of pain?
NSAIDS, RT, surgery
What does liver pain respond well to?
Steroids/NSAIDS
How does soft tissue and visceral differ?
Visceral= poorly localised, deep ache, colicky and episodic, may be referred
Soft tissue= localised ache, throbbing, gnawing
What are the potential anxieties a patient may have when commencing morphine?
They may believe its the end of the road
They may be worried they might become addicted
They may be worried that they will develop tolerance
Last resort
Severe side effects
What should you always prescribe alongside opioids?
Write up laxatives and anti emetic
What are the signs of opioid toxicity?
Pinpoint pupils, hallucinations, drowsiness, vomiting, confusion, myoclonic jerks, resp depression
What are the causes of opioid toxicity?
Dose has been escalated too quickly
Renal impairement
