Symptom Management Flashcards
What is palliative care?
- Provides relief from pain and other distressing symptoms
- Integrates physical, psychological, social and spiritual care
- Affirms life and regards dying as a normal process
- Neither hastens nor postpones death
- Helps patients live as actively as possible until death
- Offers support to help family/carers during the patient’s illness and into bereavement
What may be included in formalised outcomes of advance care planning?
- Advance statement of wishes to inform subsequent best interest judgements
- Advance decisions to refuse treatment which are legally binding if valid and applicable
- Appointments of lasting powers of attorney for ‘Health and Wlfare’ and/or ‘property and affairs
What may pain be caused by in cancer patients?
- The disease itself e.g.bone invasion
- The treatment e.g. radiotheray induced oesophagitis
- The concurrent disease e.g. oesteoarthritis
How does bone pain clinical present in cancer patients? How do we treat it?
Presentation
- dull ache over a large area or
- well localised tenderness over the bone
- Worse on weight bearing or movement
Treatment
- NSAID e.g. diclofenac 50mg tds
- Radiotherapy and bisphosphonates e.g. pamidronate infusion
How does visceral pain commonly present in cancer patients? How do we treat it?
Presentation
- Dull, deep-seated
- Poorly localised pain
- Tenderness over particular organ (e.g. liver)
- Some visceral pain is spasmodic i.e. bladder or bowel colic
Treatment
- For constant: follow analgesic ladder
- Visceral stretch pain
How does a headache due to raised intracranial pressure present? Treatment?
Presentation
- Dull, oppressive pain
- Worse on waking, coughing, sneezing
- Associated with nausea and vomiting
Treatment
- Corticosterois to reduce oedema (e.g. 16mg dexamethasone daily, reduced to lowest effective dose)
- NSAIDs and paracetamol
How does neuropathic pain present? Treatment?
Presentation
- Pain in an area of abnormal sensation
- Localised to specific dematomes, or over wider, less defined area
- Altered sensation in area such as numbness or hyperaesthesia
- Autonomic changes: pallor or sweating
- May describe pain as ‘pins and needles’ or burning
Treatment
- Antidepressant Tricyclic (amitriptyline 10-75mg Nocte)
- Anticonvulsants (gabapenting 100-1200mg tds, pregablin 25-300mg bd)
- Compression of never may be helped by corticosteroids
What are causes of a dry mouth (xerostomia) in palliative medicine? What can a dry mouth result in?
- Reduced intake of oral fluids
- Adverse effect of drugs e.g. antiemetic, antidepressants
- Radiotherapy to head and neck
- A dry mouth can result in: loss of taste, anorexia, halitosis, dysphagia and oral infection
What is the presentation and treatment of oral thrush in palliative care?
- May be asymptomatic, cause altered taste, soreness or pain
- Treatment
- systemic antifungals (fluconazole 50mg o.d. 7 dyas
- Topical agents (nystatin 1ml q.d.s 7 days)
Drug treatments to alleviate anorexia as a symptoms?
- Dexamthasone 4mg o.d. may help effect sbu often wears off after 2-3 weeks
- Megestrol acetate 160mg o.d is effective but may cause fluid retention
What are the 4 causes of nausea and vomiting?
- Gastric stasis / irriation
- Toxic causes
- Cerebral causes
- Vestibular causes
What are the features of nausea and vomiting caused by gastric stasis / irritation? Caused by what in palliative care patients?
- Early satiety
- epigastric fullness
- hiccups
- heartburn
- often minimal nausea between vomits
- may be caused by tumour, hepatomegaly, ascites (‘squased tummy’) and dsymotility (drugs, autonomic failure)
What is the treatment of nausea and vomiting caused by gastric stasis / irritation?
- Metoclopramide 10-20mg po/sc 30 minutes before meals or30-60mg SC over 24hours
- Stop any causative drugs if possible
- Consider proton pump inhibitor if gastric irritation
What are the features of nausea and vomiting caused by ‘toxic’ causes? What are some of the ‘toxic’ causes of nausea and vomiting?
Features:
- Persistent or intermitten nausea
- small vomits = “possets”
- retching
Causes:
- Drugs (opioids, digoxin, antiepileptics)
- Hypercalcaemia
- uraemia and infections (UTI and pneumonia)
What is the treatment of nausea and vomiting caused by toxic causes?
- Haloperidol 1.5-5mg po/sc nocte
What are the cerebral causes of nausea and vomiting? Features of each?
- Raised Intracranial pressure
- Early morning headache
- vomiting
- may be little nausea
- associated with neurological symptoms/signs
- Anxiety, anticipatory nausea and vomiting
- specific precipitant such as certain situations
- overly anxious or depressed
- Indeterminate
What is the treatment of nausea and vomiting caused by raised intracranial pressure?
- Dexamethasone 8-16mg po od (reduced if possible) plus Cyclizine 50mg TDS po/sc or 150mg SC/24hrs
What is the treatment of nausea and vomiting caused by anxiety?
- Benzodiazepines
- CBT
- Complementary therapies
Why is constipation common in palliative medicine?
- Immobility
- reduced food and fluid intake
- drugs e.g. opioids
- bowel pathology
- hypercalcaemia
What are the different types of laxatives that can be given? What do most patients in palliative care require?
- Bulk forming (rarely appropriate in palliative care setting)
- Stool softerners
- Movicol
- Lactulose
- Sodium docusate
- Stimulants
- Senna
- Dantron
Mosy patients in palliative care require a softener and a stimulant
What drugs are commonly chosen to treat opioid induced constipation?
Laxatives
- Co-danthrusate = dantron + docusate
- Co-danthramer
- Movicol
What type of cancer causes a high incidence of intestinal obstruction?
- Ovarian cancer
- Bowel cancer
What are the symptoms of intestinal obstruction?
- Nausea and vomiting
- Colicky pain
- Abdominal distension
- Dull aching pain
- Diarrhoea and/or constipation
What is the management of intestinal obstruction in a paliiative care setting?
- Surgical intervention depends on:
- patients disease status
- co-mobidity
- level of obstruction + co-existing symptoms
- IV fluids and NG tubes may be appropriate in short-term intervention
- Oral intake of foot and drink can continue for patient’s enjorment and is often surprisingly well tolerated
- patient decideds whether risk of vomiting outweights the pleasure of eating
- medication given SC infusion continues
- combination of antiemetics, analgesics and antispasmodics
- colic a feature: stumulant laxatives and prokinetic drugs (metoclopramide) stopped and antispasmodics prescribeds
What is the non-pharmacological treatment of dyspnoea?
- Discussion of fears and explanation vital
- Modification of lifestyle: breathing retraining and relaation beneficial
- Oxyen can help acute dyspnoea -not always helpful in palliative care setting
- Fan directed onto face
What is the pharmacological management of dyspnoea?
Opioids
- they decrease respirratory effect and therefore breathlessness
- oramorph 2.5mg four hourly -gradually titrate dose upwards according to response
Benzodiazepines
- Lorazepam (0.5-1mg sub-lingual) may help anxiety associated with breathlessness or give relief during panic attacks
- Midazolam (2.5-5mg SC) may benefit patients who can’t tolerate oral/sub-lingual route
What is the management of a cough in palliative care?
- Treat underlying cause
- If patient has difficulty expectorating = trial of saline nebulisers may be helpful
- Cough is dry and irritating then simple lincuts may help
- Alternatively opioids are cough suppressants
