Pallitative Care Flashcards
What is Palliative care? and give cases of where it might be available
The active holistic care of patients with advanced progressive illness
Management of pain, and other symptoms and provision of psychological, social and spiritual support is paramount
Goal of palliative care is achievement of the best quality of life for patients and their families
Available in patients with COPD, heart failure, HIV
Making quality of life best they can
Supporting family to get the best quality of life with limited amount of time
Who normally delivers palliative care?
Nurse specialists Day hospice Hospice at home Outpatients Inpatient units/ SPCUs MDT pharmacists, psychologists, OT, physio, chaplain, social workers, nursing staff, medical staff, complementary therapists, volunteers
How would you symptomatically manage pain
Pain WHO pain ladder
Paracetamol and opioids
Malignant bone pain (bisphosphonates- prevent bone breakdown which may cause pain, denosumab)
Neuropathic pain- anti-epileptics (gabapentin and pregabalin), anti-depressants
Skeletal muscle spasm (baclofen, benzodiazepines- watch out for addictive effect)
How would you symptomatically manage nausea
Haloperidol- affects area posterma, then vomiting centre, then stomach gastric stasis (can be used for opioid sickness)
Cyclizine- affects vomiting centre, then stomach gastric stasis
Pro kinetics like metoclopramide, domperidone- affects stomach gastric stasis (constipation sickness)
Laxative can be used to deal with constipation too
Describe why we use syringe drivers in the first place and what they are
Patient is unable to use oral route- oral cancer or reduced absorption
Better control of symptoms- constant blood levels over 24 hours
End of life patient
Consider compatibilities, diluent- syringe driver, PCF, unlicensed medications made
A continuous subcutaneous infusion in palliative care
Why do syringe drivers need to be at a specific concentration like 0.95mg/mL
To make sure it doesn’t precipitate to cause chemical non-compatibility
What is the role of the pharmacist in palliative care
Polypharmacy- try to avoid for as long as possible
- Interactions
- Drug induced vs disease induced symptoms
- Drug handling- co-morbidities
- Review of long term medications
Patients beliefs about medication
- Use of opioids
- Dependence (opioids), tolerance
- Might not work if used too early
- Alternative treatments- herbal, chinese, homeopathic
- Patient counselling
Concordance
- Large number of medications
- Complex regimes- try to keep it simple for patient
- Formulations- liquids, crush tablets (becomes unlicensed) and medicines enter down enteral tube
Supplying end of life medication for patients at home
- Available in community
- Morphine, modazolam, haloperidol
Provide information to
Drs, nurses, other pharmacists
Use of medication via subcutaneous route like sodium valproate
Policies, guidelines, medicines management group
More symptoms experienced as they become unwell
Could be on drugs like: Opioids, laxatives, Amitriptyline, cyclizine
What are unlicensed drugs and uses of them
Routes-
subcutaneous haloperidol
Sublingual modazolam to calm patient down
Uses- lidocaine patches, cutting fentanyl patches
Drug- ketamine oral solution
Combining medicines in syringe drivers- mixing together is outside product license
When do controlled drug regulations apply
Use in hospice and hospital
Accountable officer
CD prescribing
What do macmillan offer?
Provision of information
Offer support, listening ear and friendly face
Living with and beyond cancer information day
Signposting
CAB, relationship counselling, physical activity, psychological support
Decision making
Choice between chemo or radiotherapy
Dietary advice based on culture
Money for patients
What are the complementary therapy offered to support patients with cancer
Acupuncture- helps with induced nausea and vomiting, anxiety, fatigue, dry mouth, depression, stress, increased quality of life, decrease fatigue
Taichi- gentle exercises, movement, reduce inflammation and pain management
Mindfulness of medication
Reduces stress, anxiety, depression
What is the look good feel better campaign
Helps women and teenagers with 2 hour workshops on how to draw back on eyebrows and it is a support group
What is the pharmacists role in palliative care emergency
Advise and/or prescribe medication to manage symptoms
Have awareness of diagnostic signs and symptoms of incipient palliative care emergencies
Advise on anticipatory prescribing for patients discharged to community setting
Describe what malignant spinal cord compression is and what are some symptoms?
A cancerous vertebrate pushing on spinal cord suppressing it
Bone metastases pushing on spinal cord on epidural space
Affects 5% of cancers in final 2 years of life
Impacts patients quality of life and survival
Involves rapid referral and quick medical review
Symptoms: Severe back pain, nerve pain, pain worst when laying down when they do straight leg raises
What are the clinical features of malignant spinal cord compression?
Pain
Motor deficits
Sensory deficits loss of touch, movement, general body awareness and less aware of their surrounding
Automatic deficits urinary retention
Investigate via MRI
How do you treat malignant spinal cord compression?
Corticosteroids: Dexamethasone 16mg daily as soon as suspected MSCC 2mg Dexamethasone = 15mg prednisolone - Need to see if PPI needed - Reduced oedema - Inhibit inflammatory response - Stabilise vascular membranes - Delay onset of neurological dysfunction
Analgesia
WHO ladder
Optimise opioids +/- NSAIDs +/- neuropathic agents
Radiotherapy used until tumour becomes sensitive to it
Surgery
What is malignant hypercalcaemia and the symptoms
Adjusted serum calcium >2.6mmol/L
Incidence: 10-20% of all cancer patients
Indicate disseminated disease
Poor prognosis- 4 to 5 die within 1 year
Symptoms:
- Anorexia
- N and V
- Constipation
- Fatigue
- Polyuria
- Pain escalation, mood disturbance, delirium, coma/death
Adjusted calcium of >4mmol/L is a clinical emergency and may result in seizures or arrhythmias
How do you manage malignant hypercalcaemia?
Review medication- high calcium and still taking adcal D3?
Thyroxine, lithium and gaviscon
Alleviate symptoms
Assess fluid status and renal function
Pre hydration
IV bisphosphonates- zoledronic acid 4mg- takes 3 days to have an effect and lasts 4 weeks
Disodium Pamidronate (30, 60, 90mg) depends on calcium level- it is nephrotoxic so need to assess renal function or we would give it slower to them (pre hydration to protect kidneys)
What is neutropenic sepsis
When neutrophil count is less than 0.5 x 109/L and temperature of 38 degrees- result of chemotherapy- must monitor white cell count and platelets and 38 degrees= organ failure
Medical emergency- can occur in any patient who has received chemotherapy within last 4 weeks
Symptoms can progress rapidly to shock and death- rapid referral necessary
How do you manage neutropenic sepsis (treatment) and monitoring
Broad spectrum of antibiotic IV within one hour
- Tazocin 4.5g TDS + Gentamicin 5mg/kg OD
Monitor: Urea and electrolytes Full blood count Liver function tests CRP Blood cultures- see what antibiotics are more sensitive Urine and sputum cultures Chest X ray Look for infection focus- is it fungal infection?
