Palliative care symptom management Flashcards
Death definition
permanent end of the life of a person or animal
What palliative specific tools are there to predict dying?
palliative prognostic index
palliative prognostic score
feliu prognostic nonogram
Clinical prognostic indicators in cancer
cachexia
anorexia
poor performance status
dyspnoea
Prognostic factors in cancer (biomarkers)
CRP
lymphopenia
hypoalbuminaemia
Symptoms at end of life
dyspnoea
pain
respiratory secretions/death rattle
confusion
nausea + vomiting
agitation
anxiety
insomnia
Signs of dying or ‘terminal phase’
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
What causes death rattle?
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
What is terminal agitation?
agitation in a patient who is close to death
likely in part a ‘hyperactive delirium’
Define pain
unpleasant sensory and emotional experience associated with actual or potential tissue damage
Causes of pain in cancer
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
Define nociceptive pain
nociceptors in tissues send pain signals to the CNS
Define neuropathic pain
damage to the nerve itself causes typical pain symptoms
Define breakthrough pain
a transitory exacerbation of pain experienced by the patient who has relatively stable and adequately controlled baseline pain
What are the types of breakthrough pain?
spontaneous pain - idiopathic
incident pain - pain on movement, precipitated by involuntary act (eg. sneezing), procedural (eg. dressing change)
end of dose failure
What is meant by total pain?
suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles
Pain management in palliative care (general rules)
conservative - avoid precipitants, PT, education about limitations, psychological support
medical - analgesic ladder
surgical - radiotherapy, surgical options eg. nerve blocks, decompression
What adjuvants can be used for pain relief in palliative care (co-analgesics) and what is each used for?
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
How is SC morphine dose calculated?
SC dose is half of oral dose
How is diamorphine dosed?
diamorphine dose is 1/3 of oral morphine equivalent
How is oxycodone dosed?
1/2 of SC morphine dose
Which opiate is best in hepatic failure?
morphine
Which opiates can be used in renal failure?
eGFR 30-60 = oxycodone
eGFR<30 = alfentanil
Side effects of opiate therapy
constipation
nausea
drowsiness
confusion
hallucinations
myoclonus
respiratory depression
tolerance, physical dependence, addiction
What are the opioid rules in palliative care?
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
How should opioids be initiated in an opioid naive patient?
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
Starting dose of morphine/oxycodone/alfentanil for someone on no other opioids
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
What other medicines should be considered to prescribe alongside opioids?
laxatives
anti-emetic
How should a modified release opioid dose be calculated?
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)
What should PRN opioid dose be in palliative care?
2 hourly PRN
keep in line with dose titrations - dose should be 1/6 of background dose
How long do opiate patches take to work?
up to 12 hours
What medications can be used for neuropathic pain?
antidepressants: duloxetine, amitriptyline
gabapentinoids: gabapentin, pregabalin
trigeminal neuralgia: carbamazepine
other antiepileptics
Why are opioids switched in the palliative care setting?
side-effects
lack of efficacy
change of route
compliance
opioid induced hyperalgesia
change in physiology - eg. renal/hepatic failure
Non-pharmacological pain treatments
rest/immobilisation
radiotherapy
acupuncture
TENS
surgery
spinal analgesia
nerve blocks
heat pads/wheat bags/cold packs
distraction/psychological support
What are anticipatory medications?
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
Why are anticipatory medications usually given SC?
poor venous access
less invasive
good clinical experience
parenteral/absorption
How are SC medications given at the end of life?
syringe driver
How can delirium be treated in palliative care?
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)
How is terminal agitation treated?
benzodiazepines eg. midazolam
If midazolam doesn’t work for agitation in a palliative care pt, what should you do?
correct reversible causes
increase syringe driver doses
trial of levomepromazine
specialist input - consider high doses in syringe driver
How to treat nausea in palliative care pt
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
Death rattle management
anti-muscarinic medications
eg. glycopyrronium SC
hyoscine butlybromide (buscopan) SC
hyoscine hydrobromideSC
