Palliative care symptom management

Question 1

Death definition

Answer 1

permanent end of the life of a person or animal

Question 2

What palliative specific tools are there to predict dying?

Answer 2

palliative prognostic index
palliative prognostic score
feliu prognostic nonogram

Question 3

Clinical prognostic indicators in cancer

Answer 3

cachexia
anorexia
poor performance status
dyspnoea

Question 4

Prognostic factors in cancer (biomarkers)

Answer 4

CRP
lymphopenia
hypoalbuminaemia

Question 5

Symptoms at end of life

Answer 5

dyspnoea
pain
respiratory secretions/death rattle
confusion
nausea + vomiting
agitation
anxiety
insomnia

Question 6

Signs of dying or ‘terminal phase’

Answer 6

reduced appetite
increasingly fatigued
cold peripheries + reduced peripheral circulation
incontinence
secretions/death rattle
dyspnoea + irregular breathing
restlessness, delirium + agitation
mottled skin
pale/waxy skin
petechiae
oedema
weak pulse

Question 7

What causes death rattle?

Answer 7

caused by fluid collecting in the upper airways due to loss of awareness and loss of coordination/strength of swallow

comes from saliva, bronchial mucosa, pulmonary oedema, gastric reflux

Question 8

What is terminal agitation?

Answer 8

agitation in a patient who is close to death
likely in part a ‘hyperactive delirium’

Question 9

Define pain

Answer 9

unpleasant sensory and emotional experience associated with actual or potential tissue damage

Question 10

Causes of pain in cancer

Answer 10

cancer itself - soft tissue, bone, visceral, neuropathic

cancer treatment - oesophagitis, mucositis, scar pain, neuropathy

cancer-related debility - constipation, muscle spasm/tension, pressure sores

concurrent disorder - arthritis, angina, peripheral vascular

Question 11

Define nociceptive pain

Answer 11

nociceptors in tissues send pain signals to the CNS

Question 12

Define neuropathic pain

Answer 12

damage to the nerve itself causes typical pain symptoms

Question 13

Define breakthrough pain

Answer 13

a transitory exacerbation of pain experienced by the patient who has relatively stable and adequately controlled baseline pain

Question 14

What are the types of breakthrough pain?

Answer 14

spontaneous pain - idiopathic
incident pain - pain on movement, precipitated by involuntary act (eg. sneezing), procedural (eg. dressing change)

end of dose failure

Question 15

What is meant by total pain?

Answer 15

suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles

Question 16

Pain management in palliative care (general rules)

Answer 16

conservative - avoid precipitants, PT, education about limitations, psychological support
medical - analgesic ladder
surgical - radiotherapy, surgical options eg. nerve blocks, decompression

Question 17

What adjuvants can be used for pain relief in palliative care (co-analgesics) and what is each used for?

Answer 17

corticosteroids - nerve compression, spinal cord compression, bone pain

antidepressants - neuropathic pain eg. amitriptyline

antiepileptics - neuropathic pain eg. gabapentin, carbamazepine

NMDA receptor channel blockers - eg. ketamine

antispasmodics - cramping abdominal pain, visceral distension pain and colic eg. buscopan s/c

muscle relaxants - muscle spasms eg. diazepam/midazolam

bisphosphonates - zometa

chemo/radiotherapy

Question 18

How is SC morphine dose calculated?

Answer 18

SC dose is half of oral dose

Question 19

How is diamorphine dosed?

Answer 19

diamorphine dose is 1/3 of oral morphine equivalent

Question 20

How is oxycodone dosed?

Answer 20

1/2 of SC morphine dose

Question 21

Which opiate is best in hepatic failure?

Answer 21

morphine

Question 22

Which opiates can be used in renal failure?

Answer 22

eGFR 30-60 = oxycodone
eGFR<30 = alfentanil

Question 23

Side effects of opiate therapy

Answer 23

constipation
nausea
drowsiness
confusion
hallucinations
myoclonus
respiratory depression
tolerance, physical dependence, addiction

Question 24

What are the opioid rules in palliative care?

Answer 24

if on an opioid and tolerating it and no reason for change - don’t

total all of your opioid and make the PRN dose 1/6th of the total opioid dose

if on a patch + dying - keep patch on (unless clear reason to remove) - include when calculating dosing - syringe driver may be added in addition

if on syringe driver already - remember to calculate the correct total opioid dosing when calculating PRNs

increase in total opioid dose by 1/3-1/2 if there is high PRN use in prev 24h and no signs of toxicity

Question 25

How should opioids be initiated in an opioid naive patient?

Answer 25

generally best to use PRN immediate release opioid 2-4 hourly
if in hospital - consider regular + PRN
consider low dose modified release if the patient prefers to prevent pain

Question 26

Starting dose of morphine/oxycodone/alfentanil for someone on no other opioids

Answer 26

morphine = 2.5-5mg PO, as required, 2-4 hourly

oxycodone = 1.25-2.5mg PO as required, 2-4 hourly

alfentanil = 125-250mcg sc as required, 2 hourly

Question 27

What other medicines should be considered to prescribe alongside opioids?

Answer 27

laxatives
anti-emetic

Question 28

How should a modified release opioid dose be calculated?

Answer 28

if a patient already on immediate release - add up total use to calculate 24 h dose

divide 24h dose by 2 and prescribe BD MR formulation (or patch)

Question 29

What should PRN opioid dose be in palliative care?

Answer 29

2 hourly PRN
keep in line with dose titrations - dose should be 1/6 of background dose

Question 30

How long do opiate patches take to work?

Answer 30

up to 12 hours

Question 31

What medications can be used for neuropathic pain?

Answer 31

antidepressants: duloxetine, amitriptyline

gabapentinoids: gabapentin, pregabalin

trigeminal neuralgia: carbamazepine

other antiepileptics

Question 32

Why are opioids switched in the palliative care setting?

Answer 32

side-effects
lack of efficacy
change of route
compliance
opioid induced hyperalgesia
change in physiology - eg. renal/hepatic failure

Question 33

Non-pharmacological pain treatments

Answer 33

rest/immobilisation
radiotherapy
acupuncture
TENS
surgery
spinal analgesia
nerve blocks
heat pads/wheat bags/cold packs
distraction/psychological support

Question 34

What are anticipatory medications?

Answer 34

medications prescribed in anticipation of a patient’s decline as they approach death
avoids delays in them receiving medication when they need it for symptom control

Question 35

Why are anticipatory medications usually given SC?

Answer 35

poor venous access
less invasive
good clinical experience
parenteral/absorption

Question 36

How are SC medications given at the end of life?

Answer 36

syringe driver

Question 37

How can delirium be treated in palliative care?

Answer 37

more likely to be accompanied by confusion/hallucinations/disorientation

responds better to antipsychotics (eg. haloperidol, levomepromazine)

ensure no contraindications (eg. lewy body dementia, Parkinson’s)

Question 38

How is terminal agitation treated?

Answer 38

benzodiazepines eg. midazolam

Question 39

If midazolam doesn’t work for agitation in a palliative care pt, what should you do?

Answer 39

correct reversible causes
increase syringe driver doses
trial of levomepromazine
specialist input - consider high doses in syringe driver

Question 40

How to treat nausea in palliative care pt

Answer 40

choose right antiemetic for right cause
broad spectrum if no anticipated specific cause (eg. levomepromazine)
treat reversible causes

vestibular system = cyclizine or levomepromazine
intracerebral = cyclizine, consider steroids
gastric stasis = metoclopramide
bowel obstruction = levomepromazine

Question 41

Death rattle management

Answer 41

anti-muscarinic medications

eg. glycopyrronium SC
hyoscine butlybromide (buscopan) SC
hyoscine hydrobromideSC