Palliative - Intro and Symptoms Managment Flashcards
what is the criteria for referral to hospice
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
is palliate end of life
no
quick palliative treatment has actually been shown to improve and increase life expectancy
why is it important for family to recognise EoL
Planning
Support the patient
Prepare for the future
start grieving
Relieves anxiety
address unresolved issues
can seek support
what is death
permanent loss of consciousness, cardiac output and brainstem function
what are some tools to predict death for different specialties
Emergency Departments
Cardiology
Gastroenterology
Respiratory
Emergency Departments (CARING Criteria, PREDICT)
Cardiology (GRACE, EuroSCORE)
Gastroenterology (Child-Pugh, Rockall score, MELD Score)
Respiratory (ADO index, BODE Index, pneumonia severity index)
what are some indicators of advanced disease and death
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.
what are the most common symptoms of end of life
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%)
what happens to appetite and thirst as we die and why
both reduced
cytokine release acting on the hypothalamus and skeletal muscle - anorexia
treatment for appetite and thirst
progesterone and dexamethasone
what happens to sleep as we die
both insomnia and sleepy
common to approach a coma at the end of life
what happens to our temperature as we die
cold peripheries and reduced peripheral circulation
what happens to our renal and gastro systems as we die
not uncommon to become incontinent of faeces and urine
- do not allow constipation as this can cause discomfort
what happens to breathing as we die
dyspnoea
irregular breathing is very common at end of life
cheyne-strokes
several quick breath in followed by no breathing
give anti-muscarinic
what happens to cognition as we die
agitation, delirium VERY common
- hyperactive delirium no obvious physical reason
give antipsychotic and benzodiazepines
what can cause pain in cancer
the cancer itself
cancer treatment - chemo
chancer-related issues - constipation, pressure sores
another disorder - arthritis etc
what is the difference between nociceptive pain and neuropathic pain
nociceptive - tissues send pain signal to CNS
neuropathic - damage to a nerve causes pain signal
what causes breakthrough pain (AKA pain flare, episodic pain)
movement
inadequate regular analgesia
unpredictable pain
how do you treat breakout pain
1/6th the 24 hr dose of morphine
what meication do you give for cord compression
dexamethasone
corticosteroids
at what dose is paracetamol toxic
4g/24hrs (normal adult)
causes renal damage and hepatotoxicity
how fast does oral morphine take to work
15-60mins
when in a buprenorphine patch most useful
can be given to people with eGFR<30
what are the most common side effects of opioids
Constipation
Nausea
Drowsiness
Confusion
Hallucinations
Myoclonus
Respiratory depression
Tolerance, physical dependence, addiction
what is equivalent dosing
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
what should you do starting opioids on an opioid naive person
start low
give counselling
advise
plan a review and advise on health
what are the starting doses for morphine
2.5-5mg PO, PRN, 2-4 hourly
what are the starting doses for oxycodone
1.25-2.5mg PO PRN, 2-4 hourly
what are the starting doses for alfentanil
125-250mcg s/c PRN, 2 hourly
what should you prescribe along with an opioid
laxative
anti-emetic
regular review and change dose accordingly
what 3 drugs can be given for neuropathic pain
amitriptyline
gabapentin
Pregabalin
what medication would you prescribe for a patient with nausea of no specific cause
levomepromazine
what anti-emetic would you give to someone with breast cancer on chemo
ondansetron
what anti-emetic would you give to someone with prostate cancer and opiod constipation
metoclopramide
what antiemetic would you give to someone with SCC lung and hyperclacaemia
haloperidol
what anti-emetic would you give to someone unconscious with multifactoral nausea
levomepromazine
what anti emetic would you give for someone with brain cancer (glioblastoma multiforme)
cyclizine
raised intracranial pressure
what is a consideration/side effect of hyoscine hydrobromide
it crosses BBB
