Palliative - Intro and Symptoms Managment

Question 1

what is the criteria for referral to hospice

Answer 1

for final 2 weeks of life
difficult to manage symptoms - but stable

nursing care need for EoL that cant be met elsewhere

need for symptom management

Question 2

is palliate end of life

Answer 2

no
quick palliative treatment has actually been shown to improve and increase life expectancy

Question 3

why is it important for family to recognise EoL

Answer 3

Planning
Support the patient
Prepare for the future
start grieving
Relieves anxiety
address unresolved issues
can seek support

Question 4

what is death

Answer 4

permanent loss of consciousness, cardiac output and brainstem function

Question 5

what are some tools to predict death for different specialties
Emergency Departments
Cardiology
Gastroenterology
Respiratory

Answer 5

Emergency Departments (CARING Criteria, PREDICT)
Cardiology (GRACE, EuroSCORE)
Gastroenterology (Child-Pugh, Rockall score, MELD Score)
Respiratory (ADO index, BODE Index, pneumonia severity index)

Question 6

what are some indicators of advanced disease and death

Answer 6

Albumin <25g/l
Wt loss >10% in 6 months
Performance scores (various) – help with >50% activities of daily living
NYHA 4 Heart Failure
FEV1 <30% predicted
Fulfils criteria for LTOT
>6 weeks steroids /year for COPD
Development of dysphagia in dementia
Barthel score in dementia, development of incontinence
Unable to walk in dementia
Multiple hospital admissions
Persistent low conscious level after stroke.

Question 7

what are the most common symptoms of end of life

Answer 7

Dyspnoea (56.7%)
Pain (52.4%)
Respiratory secretions/death rattle (51.4%)
Confusion (50.1%)
Nausea and vomiting (19.4%)
Agitation (20.8%)
Anxiety (10.8%)
Insomnia (9%)

Question 8

what happens to appetite and thirst as we die and why

Answer 8

both reduced
cytokine release acting on the hypothalamus and skeletal muscle - anorexia

Question 9

treatment for appetite and thirst

Answer 9

progesterone and dexamethasone

Question 10

what happens to sleep as we die

Answer 10

both insomnia and sleepy
common to approach a coma at the end of life

Question 11

what happens to our temperature as we die

Answer 11

cold peripheries and reduced peripheral circulation

Question 12

what happens to our renal and gastro systems as we die

Answer 12

not uncommon to become incontinent of faeces and urine
- do not allow constipation as this can cause discomfort

Question 13

what happens to breathing as we die

Answer 13

dyspnoea
irregular breathing is very common at end of life

cheyne-strokes
several quick breath in followed by no breathing

give anti-muscarinic

Question 14

what happens to cognition as we die

Answer 14

agitation, delirium VERY common
- hyperactive delirium no obvious physical reason

give antipsychotic and benzodiazepines

Question 15

what can cause pain in cancer

Answer 15

the cancer itself

cancer treatment - chemo

chancer-related issues - constipation, pressure sores

another disorder - arthritis etc

Question 16

what is the difference between nociceptive pain and neuropathic pain

Answer 16

nociceptive - tissues send pain signal to CNS

neuropathic - damage to a nerve causes pain signal

Question 17

what causes breakthrough pain (AKA pain flare, episodic pain)

Answer 17

movement
inadequate regular analgesia
unpredictable pain

Question 18

how do you treat breakout pain

Answer 18

1/6th the 24 hr dose of morphine

Question 19

what meication do you give for cord compression

Answer 19

dexamethasone
corticosteroids

Question 20

at what dose is paracetamol toxic

Answer 20

4g/24hrs (normal adult)
causes renal damage and hepatotoxicity

Question 21

how fast does oral morphine take to work

Answer 21

15-60mins

Question 22

when in a buprenorphine patch most useful

Answer 22

can be given to people with eGFR<30

Question 23

what are the most common side effects of opioids

Answer 23

Constipation
Nausea
Drowsiness
Confusion
Hallucinations
Myoclonus
Respiratory depression
Tolerance, physical dependence, addiction

Question 24

what is equivalent dosing

Answer 24

if you change opioid you need to convert the dose
e.g. 100mg PO codeine = 10mg oral morphine = 5mg IV morphine = 6.6mg PO oxycodone

Question 25

what should you do starting opioids on an opioid naive person

Answer 25

start low
give counselling
advise
plan a review and advise on health

Question 26

what are the starting doses for morphine

Answer 26

2.5-5mg PO, PRN, 2-4 hourly

Question 27

what are the starting doses for oxycodone

Answer 27

1.25-2.5mg PO PRN, 2-4 hourly

Question 28

what are the starting doses for alfentanil

Answer 28

125-250mcg s/c PRN, 2 hourly

Question 29

what should you prescribe along with an opioid

Answer 29

laxative
anti-emetic
regular review and change dose accordingly

Question 30

what 3 drugs can be given for neuropathic pain

Answer 30

amitriptyline
gabapentin
Pregabalin

Question 31

what medication would you prescribe for a patient with nausea of no specific cause

Answer 31

levomepromazine

Question 32

what anti-emetic would you give to someone with breast cancer on chemo

Answer 32

ondansetron

Question 33

what anti-emetic would you give to someone with prostate cancer and opiod constipation

Answer 33

metoclopramide

Question 34

what antiemetic would you give to someone with SCC lung and hyperclacaemia

Answer 34

haloperidol

Question 35

what anti-emetic would you give to someone unconscious with multifactoral nausea

Answer 35

levomepromazine

Question 36

what anti emetic would you give for someone with brain cancer (glioblastoma multiforme)

Answer 36

cyclizine
raised intracranial pressure

Question 37

what is a consideration/side effect of hyoscine hydrobromide

Answer 37

it crosses BBB