Palliative medicine Flashcards
3 parts to palliative care
Physical
Psychosocial
Spiritual
3 reasons for Sx relief in palliative
Reduces QoL
Causes distress
Results in admissions
Name 3 causes of nausea and vomiting
Bowels - Mucositis, constipation, infection, obstruction
Brain 0 raised ICP
Biochemical - Medications, hypercalcaemia, uraemia, infection, hypomagnaesaemia
How do these places play a role in Nausea
Gut wall?
Chemoreceptor trigger zone?
limbic?
vestibular?
Gut wall: distension stimulates vagus - constipation, obstruction, chemo stimulates enterochromaffin cells
Chemo - uraemia, drugs, chemotherapy, hypercalcaemia
Limbic - emotion
Vestibular - motion sickess / vertigo
Name some antiemetics ///
Bowel only cause
Domperidone Hyoscine butylbromide
Bowel+brain
Haloperidol / metoclopramide
Brain
cyclizine / levopromazine
Why shouldn’t you prescribe cyclizine and metoclopramide
c - constipating
M - diarrhoea
Counteract each other in bowel
What is pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
Goals of Nx in pain
A good night’s sleep
Pain free at rest
Pain free on movement
When is the WHO pain ladder used
Cancer pain
3 Stages of pain ladder and Eg of 2 drugs in each
Simple
-Para / NSAIDs
Weak opiods
Codeine / tramadol
Strong
-Morphine, oxycodone, buprenophine, fentany, methadone, ketamine
When you move from weak opiods to strong do you continue the weak?
All have a CEILING EFFECT therefore REPLACE with strong opioid rather than add
Which do we prefer morphine or oxycodone?
Oxycodone - stronger + less SEs
Can get tablets and immediate release
-Deal with background and breakthrough pain
Common SEs with morphine?
Constipation, sedation, nausea, dry mouth
[-> Stimulant laxatives + PRN antiemetics]
Intresting Resp fact with opiates?
tend to reduce RR BUT increase tidal volume!
Which can you give if RR<8 AND SpO2 <92% due to opioids?
Naloxone
When would you use fentanyl ? How long does it take to work?
For STABLE opioid responsive pain
Indicated for poor oral route, or renal impairment
12 hours to reach analgesic concentration so not for acute pain (lasts 72 hours)
Good drug for pain+
Neuropathic pain?
muscle spasms?
compression sx?
bone pain?
Neuro
amitryptilline
pregabalin, gabapentin
Spasms
Baclofen / benzos
Compression
steroids
Bone
bisphos Eg zolendronic acid
Name 3 key things in terminal care - Is anything legally binding?
Advance care planning
- Advance statements
- Advanced refusal of treatment - THIS ONE IS LEGALLY BINDING
Power of attorney
DNACPR
3 things How to recognise dying
***CV changes (pulse, mottled skin, cool peripheries)
***Resp changes (noisy secretions, laboured breathing)
Weight loss and poor appetite
Fatigue
Poor mobility
Social withdrawal
Struggling with medications
What format do you communicate with dying patient and what do you need to do?
SBAR SBAR SBAR SBAR
document after
Name 2 things in advanced care planning
Preferred place
Medical interventions they would or wouldn’t want e.g. ADRT IV ABX, PEG, escalation
DNACPR
A bucket list for the patient
name 3 key Sx in dying
Pain Breathlessness Respiratory secretions Nausea and vomiting Distress/agitation
Mx of these Sx in dying
Pain Breathless secretions n+v agitation
Pain PRN morphine
Breathless
PRN opioid SC and SC benzodiazepines
Secretions
Hyoscine / buscopan
N+V - Haloperidol
Agitation - midazolam
Maxrogols and lactulose often poorly tolerated in mx of constipation so what is usually used in dying
A stool softener and stimulant laxative
Docusate and senna
If a pt is going to die in next few days
Name 3 priorities in care
Possibility is recognised and clearly communicated to patient
Sensitive communication occurs between staff and patient/family
Dying person/family involved in treatment and care planning
Needs of family are identified and actively explored
An individual plan of care including food and drink, symptoms and psychosocial/spiritual support is delivered
Good communication dramatically improves the bereavement process.
How is formal support offered?
as counselling, referral to GP, specialist psychological therapy
Palliative care emergencies mx ?
Malignant spinal cord compression
SVCO
Malignant hyperclcaemia
8mg IV dexamethasone BD + analgesia
dexamethasone 8mg BD
IV zoledronic acid and IV fluids
Name 2 DDX of confusion in dying
Hypercalcaemia, infection, brain metastasis
If someone lacks capcity and need to prevent them from leaving what do you use? acid test for this?
DOLS (MCA)
1) person under continuous supervision AND 2) is not free to leave AND 3) cannot consent to these arrangements
How can patient claim benefits in palliative care
DS1500 form
-filled by doctor / specialist nurse
