Palliative Care and Pain Management Flashcards
Give 5 situations in which a patient could be described as approaching the end of life
patient whose death is imminent,
patient with advanced incurable condition/s,
patients at risk of dying from a sudden acute crisis of their condition,
patients with life-threatening acute conditions caused by sudden catastrophic events
patients with general fraility and co-existing conditions that mean they are expected to die within 12 months
How would you define ‘a patient who is approaching the end of their life’?
likely to die within 12 months
List 5 long-term conditions other than cancer which may result in palliative care needs
cardiovascular disease,
AIDs,
kidney failure,
dementia,
multiple sclerosis
List some common symptoms in patients with advanced illness
Loss of appetite, reduced food and fluid intake
Weight loss
Fatigue
Pain
Low mood
Incontinence
Insomnia
Give some common changes that are seen in a patient’s final days
Loss of appetite
Changes to breathing
Changes to skin
Needing more sleep / Restlessness
Losing control of bladder or bowels
How can agitation and confusion be managed in palliative care?
Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication.
If specific treatments fail then the following may be tried:
first choice: haloperidol
other options: chlorpromazine, levomepromazine
How is agitation / restlessness in the terminal phase best managed?
midazolam
How can hiccups be managed in palliative care?
chlorpromazine is licensed for the treatment of intractable hiccups
haloperidol, gabapentin are also used
dexamethasone is also used, particularly if there are hepatic lesions
What are the six broad nausea and vomiting syndromes in palliative care?
Reduced gastric motility
May be opioid related
Chemically mediated
Secondary to hypercalcaemia, opioids, or chemotherapy
Visceral/serosal
Due to constipation/ oral candidiasis
Raised intra-cranial pressure
Usually in context of cerebral metastases
Vestibular
Related to activation of acetylcholine and histamine (H1) receptors
Most frequently in palliative care is opioid related
Can be motion related, or due to base of skull tumours
Cortical
May be due to anxiety, pain, fear and/or anticipatory nausea
how can N+V due to reduced gastric mobility be managed?
Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis
first-line medications include metoclopramide and domperidone
metoclopramide should not be used when pro-kinesis may negatively affect the GI tract, particularly in complete bowel obstruction, perforation, or immediately following gastric surgery
how can chemically mediated N+V be managed?
the chemical disturbance should be corrected first
Key treatment options include ondansetron, haloperidol and levomepromazine
How can visceral/serosal causes of N+V be managed?
Cyclizine and levomepromazine are first-line
Anti-cholinergics such as hyoscine can be useful
How can N+V due to raised ICP be managed?
cyclizine for nausea and vomiting due to intracranial disease
Dexamethasone can also be used
Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours
How can vestibular causes of N+V be managed?
cyclizine is first-line
Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine
How can cortical causes of N+V be managed?
If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful
If benzodiazepines are not ideal, BMJ best practice recommends use of cyclizine
What is the preferred route of administration for antiemetics in palliative care?
oral anti-emetics should be used if possible
Situations where use of oral medications may not be possible include if the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis
If the oral route is not possible the parenteral route of administration is preferred
The intravenous route can be use if intravenous access is already established
Headache caused by raised intracranial pressure due to brain cancer (or metastases) can be palliated with what?
dexamethasone
What is the first line for pain relief in palliative care?
regular oral modified-release (MR) or oral immediate-release morphine, with oral immediate-release morphine for breakthrough pain
if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
What should be considered on initiation of pain relief in palliative care?
laxatives should be prescribed for all patients initiating strong opioids
patients should be advised that nausea and drowsiness are often transient
What is the breakthrough dose of morphine?
one-sixth the daily dose of morphine
What is preferred to morphine in palliative patients with renal impairment?
mild-moderate renal impairment = oxycodone
more severe renal impairment = alfentanil, buprenorphine and fentanyl
How should you increase opioid dose?
the next dose should be increased by 30-50%
In addition to strong opioids, bisphosphonates and radiotherapy, what may be used for bone pain?
denosumab
Which opioid side effect often persists?
constipation
How do you convert from oral codeine to oral morphine?
Divide by 10
How do you convert from Oral tramadol to Oral morphine?
Divide by 10
What is the equivalent strength of the 2 common transdermal opioid prescriptions?
a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.
Give some features of opioid toxicity
reduced conscious level, slow respiratory rate, myoclonic jerks, and pinpoint pupils
What is the conservative mx of secretions?
Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
Educating the family that the patient is likely not troubled by secretions
What is the medical mx of secretions?
hyoscine hydrobromide or hyoscine butylbromide is generally used first-line
glycopyrronium bromide may also be used
When should syringe drivers be considered in palliative care?
when a patient is unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma
What are the 2 main types of syringe driver used in the UK?
Graseby MS16A (blue): the delivery rate is given in mm per hour
Graseby MS26 (green): the delivery rate is given in mm per 24 hours
Which drugs can be given via syringe driver for excess secretions and bowel colic?
hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide
Which drugs can be given via syringe driver for agitation/restlessness?
midazolam, haloperidol, levomepromazine
Which is the preferred opioid for delivery via syringe driver?
diamorphine
cyclizine is incompatible with a number of drugs including:
clonidine, dexamethasone, hyoscine butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, sodium chloride 0.9%
What are the 3 steps to the WHO analgesic stepladder?
Step 1: Non-opioid medications such as paracetamol and NSAIDs
Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine
What are the key side effects of NSAIDs?
Gastritis with dyspepsia (indigestion)
Stomach ulcers
Exacerbation of asthma
Hypertension
Renal impairment
Coronary artery disease, heart failure and strokes (rarely)
What are the key side effects of opioids?
Constipation
Nausea
Skin itching (pruritus)
Altered mental state (sedation, cognitive impairment or confusion)
Respiratory depression (usually only with larger doses in opioid-naive patients)
naloxone used to reverse resp depression
Adequate analgesia in the post-operative period is vital to encourage the patient to:
Mobilise
Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
Have an adequate oral intake
