Palliative care presentations Flashcards
1
Q
What are the symptoms of hypoactive delirium?
A
Lethargy
Slowness in everyday tasks
Uncommunicative
Slow speech
2
Q
What are the symptoms of hyperactive delirium?
A
Agitation
Restlessness
Aggression
Hallucinations
3
Q
What factors does the 4AT investigate?
A
Alertness
AMT 4 (Abbreviated mental test 4)
Attention
Acute change or fluctuating
4
Q
What does the 4AT investigate?
A
Delirium
5
Q
What are the causes of delirium?
A
PINCHME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
6
Q
What is the anticholinergic burden?
A
The cumulative effect on an individual of taking one or more medications with anticholinergic activity
Eg. antidepressants, Antihistamines, Anti-parkinsonism drugs, Antipsychotics, Urinary symptoms
7
Q
How is delirium managed?
A
- Use medication only if needed to relive symptoms
- No benzos as they can worsen
- 1:1 nursing
- Reverse underlying cause
8
Q
When is delirium most common?
A
At end of life
9
Q
What is the ROME criteria used for?
A
The diagnostic criteria for functional constipation and/or irritable bowel disease
10
Q
What does the ROME criteria contain?
A
- Straining
- Sensation of anorectal obstruction
- Loose stools are rarely present
- Lumpy or hard stools
- Manual manoeuvres
- Sensation of incomplete excavation
- > 3 spontaneous bowel movements per week
All at least 25% of the time
11
Q
What are some consequences of constipation?
A
Pain
Nausea
Reduced appetite
Overflow diarrhoea
Urinary retention
Haemorrhoids
Fissures
Confusion
Embarrassment
12
Q
What medications can be prescribed to treat constipation?
A
Softening (affect the water content in stool)
- Docusate sodium
- Macrogols (movicol/laxido)
- Lactulose
Stimulating (promote peristalsis)
- Senna
- Bisacodyl
Rectal interventions:
Suppositories or enema
13
Q
How can metoclopramide be used to treat constipation?
A
It’s pro-kinetic
14
Q
How can erythromycin be used to treat constipation?
A
It’s pro-motility
15
Q
What are some simple non-opioid analgesic used in palliative care?
A
- Paracetamol
- Anti-inflammatory medications (NSAIDs) Eg. Celecoxib, Naproxen
16
Q
What are some antidepressant adjuvant analgesics used in palliative care?
A
Amitripyline and Duloxetine
17
Q
What are some anti-epileptic adjuvant analgesics used in palliative care?
A
Gabapentin and Pregabalin
18
Q
What are some local anaesthetic adjuvant analgesics used in palliative care?
A
Lidocaine
19
Q
What are some less common adjuvant non-steroid analgesics used in palliative care?
A
Buscopan, Baclofen,Ketamine, Benzodiazepines (eg Clonazepam)
20
Q
Name some weak opioids
A
Codeine
Dihydrocodeine
Tramadol
21
Q
What are the uses of opioids in palliative care?
A
Diarrhoea
Pain management
22
Q
Name some commonly used strong opioids in palliative care
A
Morphine
Oxycodone
Transdermal Fentanyl
Transdermal Buprenorphine
23
Q
Name some less commonly used/specialist opioids used in palliative care
A
Diamorphine
Alfentanil
Transmucosal Fentanyl
Methadone
Hydromorphone
Pethidine
Tapentadol
24
Q
How is morphine excreted?
A
Renally
25
Where is oxycodone metabolised?
Liver CYP450
Eliminated renally so will accumulate in renal and/or hepatic failure
26
Name some brand names for oxycodone
Longtec
OxyNorm
27
Where is Fentanyl metabolised and excreted?
It's biosynthesised into inactive norfentonyl in the liver and excreted by the kidney unchanged
28
Which type of analgesic transdermal patch lasts the longest?
The buprenorphine patch
Lasts 7 days, fentanyl only lasts 3
29
Where is buprenorphine metabolised?
The CYP enzyme in the liver
Considered safe in renal failure
30
What are some side effects of opioids?
- Constipation: give laxatives
- Nausea: give antiemetics like Metoclopramide
- Drowsiness
- Pruritus: consider improving skin care or switching opioid
- Visual hallucinations: consider toxicity
- Myoclonic jerking: consider toxicity
31
What are the different types of breathlessnes?
- Breathlessness on exertion
Normal ‘physiological’ experience
- Breathlessness at rest
Intermittent/ “Episodic”- short /minutes or constant
- Terminal breathlessness
-Chronic breathlessness syndrome
breathlessness that persists despite optimal treatment of the underlying pathophysiology and that results in disability
32
Why do patient in palliative care get breathles?
- Related to underlying condition
Eg. lung metastases/PE’s
- Consequences of treatment
Eg anaemia
- Concurrent illness
Eg. Infection
- Associated factors
Eg. anxiety/ panic
33
What point are covered in an assessment of breathlessness in palliative care?
SOCRATES
Distress?
Impact on QoL
Coping strategies
34
What is refractory breathlessness?
Breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causes
35
How is breathlessness in palliative care treated?
1. Treat cause where possible
History & examination and investigations as appropriate
2. General skills
3. Non-pharmacological management4. 4. Pharmacological management
36
What are some non-pharmacological interventions for breathlessness in advanced stage disease?
High strength of evidence
- neuro-muscular electrical stimulation chest wall vibration
Moderate strength
- walking aids
- breathing training
Low strength
- acupuncture/acupressure
Not enough data to judge the evidence
- distractive auditory stimuli (music)
- relaxation
- fan
- counselling and support
- counselling and support with breathing-relaxation training
- case management and psychotherapy
37
What is deep/diaphragmatic breathing?
STEP ONE: Relax. Start by relaxing your shoulders. Try sitting comfortably in an easy chair
STEP TWO: Place your hands lightly on your abdomen
STEP THREE: Breathe in slowly through your nose. You want to feel your abdomen rise out under your hands
STEP FOUR: Breathe out slowly through your mouth. Your abdomen should fall inward
38
What are some options for pharmacological management of breathlessness in palliative care?
Opioids
Benzodiazepines
Oxygen
Steroids
39
What sis the difference between nausea, retching, and vomiting?
Nausea – an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms, e.g. pallor, cold sweat, salivation and tachycardic
Retching – rhythmic, laboured, spasmodic movements of the diaphragm and abdominal muscles, usually occurring in the presence of nausea and not always culminating in vomiting
Vomiting – forceful expulsion of gastric contents through the mouth
40
What are the GI tract causes of vomiting?
* Gastric irritation (tumour, gastritis, ulcer, drugs)
* Gastric distension (tumour, diabetic autonomic neuropathy)
* Bowel obstruction
* Oedematous gut
* Constipation
* Stretched liver capsule
41
What are the intracranial causes of vomiting?
* Raised intracranial pressure (GBM, mets, haemorrhage)
* Vestibular disturbance
* Base of skull tumour
42
Which drugs cause nausea and vomiting?
* Opioids
* Antibiotics
* Iron
* Digoxin
* Antidepressants
43
What are some metabolic causes of nausea and vomiting?
* Hypercalcaemia
* Uraemia
* Hyponatraemia
44
What type of toxins cause nausea and vomiting?
* Chemotherapy
* Radiotherapy
* Infection
45
What are some cortical causes of nausea and vomiting?
* Fear
* Anticipatory nausea
* Pain
* Anxiety
46
How is a patient assessed for causes of nausea and vomiting in palliative care?
History
- Clarify terms, time of onset, pattern, relation to meals, relief, bowel movements, early satiety, contents, recently prescribed drugs, opioids
Examination
- Hydration, abdominal examination, PR – constipation/faecal impaction, CNS examination – brain mets/raised ICP
Investigations
- Bloods: biochemistry
- Cr, Ur, Ca2+, digoxin levels
- AXR- CT abdomen to identify transition point and cause of bowel obstruction
- CT/MRI head - if brain mets suspected
47
What is the treatment for raised Ca2+?
Bisphosphonates
48
What is the treatment for raised ICP?
steroids
49
How is ginger related to nausea and vomiting?
Shown to reduce chemotherapy-induced nausea and vomiting and anticipatory nausea
50
What are the main receptors involved in nausea and vomiting?
Dopamine receptors
5HT receptors
Histamine receptors
Cholinergic (muscarinic) receptors
51
Give examples of antiemetics
Metoclopramide
Domperidone
Cyclizine
Hyoscine
Haloperidol
Ondansetron
Levompromazine
Benozodiazepines
Aprepitant
52
Which antiemetic should be prescribed if the suspected cause of nausea is gastric stasis?
Metoclopramide or Domperidone
53
Which antiemetic should be prescribed if the suspected cause of nausea is biochemical/drugs?
Haloperidol
54
Which antiemetic should be prescribed if the suspected cause of nausea is cerebral oedema?
Steroids or cyclizine
55
Which antiemetic should be prescribed if the suspected cause of nausea is vestibular?
Hyoscine hydrobromide or cyclizine
56
What does vestibular mean?
Relating to the inner ear and balance
57
Which antiemetic should be prescribed if the suspected cause of nausea is anticipatory?
Benzodiazepines +/- psychology
58
What are the 2nd line combinations of broad-spectrum antiemetics available?
Combinations: cyclize + Haloperidol
Broad-spectrum: levomepromazine
59
How does Metoclopramide work?
D2 antagonist and 5HT4 agonist
Peripheral action: prokinetic ( it increases gastric motility through release of ACh)
Blocked by Cyclizine
Can't be used in bowel obstruction or perforation
It crosses the blood-brain barrier so can causse extrapyramidal side effects like Parkinsonism and oculogyric crisis
60
How does Haloperidol work?
Specific D2 receptor antagonist
Helps with hiccups
Often used 1st line in palliative care
Side effects: prolongation of QT interval, extrapyramidal symptoms, worsen narrow angle glaucoma and increase the risk of seizures
61
How does Ondansetron work?
5HT3 receptor antagonist
Licensed for post-operative (anaesthetic) and chemotherapy and radiotherapy-induced N&V
Limited use in palliative care because it can cause constipation, headache, doe-dependent QT interval prolongation
62
How does Cyclizine work?
Antimuscarinic and antihistamine
Acts in the vestibular nucleus and vomiting centre
Useful for motion sickness and raised ICP
Can cause mild drowsiness, avoid in cardiac failure (due to side effect of tachycardia)
63
How does Levomepromazine work?
Broader spectrum (D2, H1, mACh, 5HT2 receptor blocker)
- Used second line for nausea (used for sedation as well so may be beneficial when both effects needed)
Long half life (~20 hours)
Side effects: sedation, hypotension, anticholinergic, potential prolongation of the QT interval
64
How is Buscapan used in palliative care?
AKA Hyoscine N-Butylbromide
Used to treat chest secretion causing the death rattle
65
What is Glycopronium?
Used 2nd line for chest secretions instead of Buscapan
66
What are the symptoms of dying?
-Death rattle
-Sudden burst of energy
-Mottled and blotchy skin
-Low BP
-Less urine.
-Restlessness
-Difficult breathing
-Congested lungs
67
What is the definition of death?
The irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe
68
How is death confirmed?
Check the identity of the patient with the ward/nursing staff, and ensure this matches the identity of the patient by checking their wristband.
Assess the patient’s response to verbal stimuli response to verbal stimuli
For a minimum of five minutes, confirm the absence of:
-Central pulse on palpation (carotid artery)
-Heart sounds on auscultation
-Respiratory sounds on auscultation
-Signs of life (e.g. movement and respiratory effort
- Then look for absence of pupillary reflex with a pen torch, check for corneal reflexes with a piece of paper, and check for motor responses to supraorbital pressure
69
What is meant by the dying phase?
Lasts about 3 days, it's when everything slows down before the person actually dies
70
What is terminal agitation?
AKA terminal restlessness, terminal anguish, confusion at the end of life, or terminal delirium
Caused by pain, medication, and emotions about dying
71
What is the Lazarus sign?
When the patients arm raises and then drops, it's seen in brain-dead or bloodstream failure patients often about 10 mins after CPR has finished
Can be confused as a sign of life
72
What is included in care after death?
Washing, positioning, dressing the body, and tending to any medical equipment
Done as soon as possible before rigor mortis to prevent any tissue damage or disfigurement
73
What are some symptoms of organ failure?
- Weakness, faintness or fatigue
- Drowsiness or loss of consciousness
- Difficulty concentrating, confusion
- Loss of appetite
- Nausea and vomiting
- Fast, shallow breathing
- Fast or irregular heartbeat
- Fever, chills
- Swelling in your extremities or in your abdomen.
- Persistent chest pain or abdominal pain
74
What are some conditions that cause progressive neurological deterioration?
Multiple sclerosis (MS)
Motor neurone disease (MND)
Parkinson's and the atypical Parkinsonism's of multiple system atrophy (MSA)
Progressive supranuclear palsy (PSP)
- Caused by damage to nerve cells in areas of the brain that control thinking and body movements
Corticobasal degeneration (CBD)
- A type of frontotemporal degeneration, a dementia that involves the loss of cognitive functions
75
What is the first-line drug treatment for hypercalcaemia caused by malignancy?
Pamidronate disodium (a bisphosphonate)
76
What is the 1st line anti-emetic for chemotherapy induced nausea and vomiting?
Ondansetron
77
Which antibiotic is 1st line for neutropenic sepsis?
Tazosin (piperacillin/tazobactam)
78
Which steroid is 1st line for tumour related brain swelling?
Dexamethasone
79
Which antiemetic can be used alongside dexamethasone in tumour related brain swelling?
Cyclizine given IV
80
What is the 1st line antiemetic used in Parkinsons disease?
Domperidone
It's unable to cross the blood brain barrier so its anti-dopaminergic effects occur peripherally
81
What is the 1st-line symptomatic treatment for lung cancer related dyspnoea?
Morphine (low dose)
82
How is diabetes treated in palliative care?
Keeping BM in normal ranges isn't a priority
- Focus on symptoms of hyperglycaemia and DKA
83
What is the drug Riluzole used for?
A neuroprotective drug used in amyotrophic lateral sclerosis (ALS) to prolong time until a tracheostomy is needed
It inhibits the release of glutamic acid, to prevent excitotoxicity and therefore deterioration
84
What is Hyocine betylbromide used in palliative care?
For symptomatic relief of GI smooth muscle pain and chest secretions
