Palliative medicine Flashcards
What is meant by titration in pain medicine?
When a patient uses more frequent “as required” doses on top of their daily dose, the following day the “as required” is added onto their daily dose.
this keeps occurring until the symptoms settle and a balance is met
What are some signs of opioid toxicity?
Confusion Drowsiness myoclonus nightmares hallucination
What drugs can be used for N&V in patients?
Start with things such as metoclopramide *avoid in bowel obstruction due to the promotility effects
Ondansetron - 5HT3 antagonist can be used for severe
What is the conversion from oral codeine to oral morphine?
divide by 10
What is the conversion from oral morphine to subcut morphine?
Divide by 2
What is a useful mechanism to aid shortness of breath in a terminally ill patient?
Hand fan over the patient
- due to temperature change of air stimulates reflexes to slow breathing
What is an effective tool that can be used to aid the treatment received in hospice into a hospital setting?
Liverpool care pathway
- 4 step approach
What are some common symptoms of palliative care?
Dry mouth
Excessive Respirations
Restlessness
Nausea and vomiting
What drugs can be used for excessive respiratory secretions?
Hyoscine butylbromide
Glycopyrronium bromide
What drugs are used for nausea in palliative medicine??
Metoclopramide
Haloperidol
What drugs can be used for intractable hiccups?
Chlorpromazine
or
Haloperidol
What medication can be used for bowel obstruction pain?
Hyoscine Butylbromide
What can be used for respiratory secretions?
Hyoscine hydrobromide
**remember secretions with “hydro”
What dose should be given when changing from oral morphine to SC diamorphine?
divide by 3
Which drugs are ideal to use in severe kidney disease for pain relief?
Fentanyl
Alfentanil
Buprenorphine
If you are switching someone from oral codeine to oral morphine, what dose should you give?
Divide by 10
What does metastatic bone pain respond too?
Analgesia
Bisphosphonates
Radiotherapy
Confusion in a palliative patient, what is the management?
Look for reversible causes:
- hypercalcaemia
- infection
- urinary retention
1st line: Haloperidol
2nd line: Chlorpromazine
Which drug is good for increased ICP pain?
Dexamethasone
Between morphine and oxycodone, which is safer to prescribe in renal failure?
Oxycodone
preferred over morphine in CKD
What is the treatment for constipation?
Hydration
Ensure privacy access to toilet
Senna - stimulant
Macrogol - osmotic
Phosphate enemas
glycerol suppositories
How is breathlessness managed?
Remove causes
- infection
- effusion
- arrhythmias etc
Low dose opioids for distress
+/-
Benzodiazepine for stress
What are some approaches to dealing with a patients spiritual pain?
Remember the whole person when treating them
Provide companionship
- palliative teams
- Macmillan nurses
- Chaplains
Remember spiritual pain can be exacerbated by physical pain
- look to sort these first
What are some core features of the final days towards death?
Bed bound
Semi - comatose
Unable to take tablets
Only able to take small sips of water
When a patient is entering the dying days, how should your general management change?
Focus treatment on symptom control
Stop carrying out daily investigations
Only treat reversible problems as appropriate towards symptoms - urinary retention
Rationalise medications
What specific things are done as a person enters their last days of life?
Prescribe PRN end of life drugs
Start a syringe driver
Manage Agitation
- diazepams
Manage secretions
- reposition
- suction
- hyoscine hydrobromide
Hydration
Plan for death
- DNACPR
- Die at home? - arrange with district nurses
Respond to changes in clinical situation
Communicate
Which types of drugs can be put through a syringe driver?
Pain
- Morphine
Anxiety/ Agitation/ Delirium
- Midazolam
- Haloperidol
N&V
- Cyclizine
- Haloperidol
- Levomepromazine
Respiratory secretions
- Hyoscine Hydrobromide
- Glycopyrronium
Seizures
- Midazolam
What are the red flags for back pain?
<20 years old, >55 years old Weight loss / Fever Taking steroids History of malignancy Disturbance of continence Saddle anaesthesia Thoracic spine tenderness Night pain
Name some oncological emergencies:
Neutropenic sepsis
Spinal cord compression
Tumour lysis syndrome
Malignancy associated hypercalcemia
Superior Vena cava syndrome
Raised ICP
What are some side effects of opioids:
N&V Constipation Drowsiness/ sedation Dry Mouth Hypotension - vasodilatory properties Respiratory depression
In renal failure, what is the danger of using morphine?
Build up of toxic metabolites, especially:
- M6G
- M3G
M6G is the active form and will lead to the overdose.
usually first seen with myoclonus.
Symptoms of hypercalcemia?
Tiredness Confusion Depression Anorexia Polydipsia Polyuria Constipation \+/- Bone pain \+/- Renal pain
What is the calculation of oral morphine to subcut?
divide by 2
What is the calculation of oral morphine to diamorphine
subcut?
Divide by 3
What is the calculation of oral codeine to oral morphine?
Divide by 10
In a cancer patient, list several causes of symptoms of nausea:
Drugs:
- morphine, chemotherapy
ICP
- metastasis to brain
Pain
- induces feeling of nausea
Metabolic changes
- hypercalcemia
Gastric:
- stasis
- obstruction
What is the calculation for working out the daily dose of modified release opioid?
Calculate the total daily dose + PRN.
the Following day the PRN should be added to the previous dose.
Divide into two 12 hour Modified release MST
What should the dose of PRN be?
1/6 of the total daily dose
What should be prescribed along with opioids?
Laxative
Antiemetic
What are some of the complications with a PICC line/ Hickmann Line?
Infection
Thrombosis
Electrolyte imbalances
Osmotic changes
Vitamin deficiencies
Refeeding syndrome
What are the types of pain experienced by people?
Biological
Social
Psychological
Spiritual
What drugs can be given for itch?
Hepatic: Cholestyramine
Uraemia: Gabapentin
Unknown: Chlorpheniramine
What drugs should be avoided in end stage liver disease:
NSAIDs
Codeine
Dihydrocodeine
What things should be thought about when planning for death:
Speaking to family
Welfare and power of attorney
DNACPR
Prescribing anticipatory medicines - Just incase medicines
Contact with palliative care
What are some reversible causes of deterioration in the dying patient?
Dehydration
Opioid toxicity
Hypercalemia
Delirium
Infection
Glucose levels - hypo/ hyper
When are syringe pumps indicated and how are the medications delivered?
Persistent N&V
NIl by mouth
Gastric obstruction
Excessive medication load
- too much to continually inject or give orally
End of life days
**given Subcut
What are some just incase medications that are commonly prescribed?
Opioids for pain
Antiemetics
Anti - Anxiolytics
Anti- secretory
