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DPD > The dying cancer patient > Flashcards

The dying cancer patient Flashcards

1
Q

what are the principles of palliative care and when its used

A

accessible throughout journey
applicable early in course of illness in conjunction with active therapy
symptom control
enchances QOL, may positively influence the course of illness
alternative to disease modifying or life sustaining treatment of
questionable value at end of life

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2
Q

how did palliative care originate

A

• Origins in the hospice movement – care of the dying pt right at the end of their lives

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3
Q

features of palliative care

A

• Recognition and relief of pain and other symptoms
• Recognition and relief of psychosocial suffering, including
appropriate care and support for relatives and close
friends
• Recognition and relief of spiritual / existential suffering - work with chaplain
• Sensitive communications between professional carers,
patients, relatives, and colleagues
• Inter-professional / multi-disciplinary team caring where
possible
• Helping patients achieve their wishes at the end of life

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4
Q

what are the benefits of palliative care

A

• Improved quality of life
• Reduced depression
• Improved pain and symptom control
• Increased patient and family satisfaction
• Reduced utilisation of aggressive interventions at the end
of life (CPR, ITU, dialysis, tracheostomy…)
• Increased survival in patients with advanced Non Small
Cell Lung Cancer

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5
Q

study with non-SCLC and palliative care

A

randomised pts to best onch treatment with or without palliative
pal – better pain, symptom control management, qol, less depression used less aggressive treatment at end of life, better survival rate, pts and families more satisfied

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6
Q

what is end of life care

A

care in final weeks

–months; some definitions include final year of life

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7
Q

what is terminal care

A

hours to days

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8
Q

distinction between end of life care and palliative care

A

You don’t have to be dying to receive palliative care
• Patients are often fearful of being referred to
palliative care as they think this means they are
about to die

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9
Q

what is care of the last days of life

A

NICE

dying in the last 2-3 days of life

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10
Q

what is the relationship between palliative, end of life and terminal care

A

palliative care encompasses all of it

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11
Q

what is involved in terminal care

A

psychosocail support of pt and family
symptom managemnet
spiritual care

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12
Q

what is involved in end of life care

A 
ongoing medical treatment as appropriate 
hospice care/home supports 
condition is non-curative 
wks/mo to live 
symptom management 
spiritual care
psychosocial support
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13
Q

what is involved in palliative care

A 
introduction to palliatve approach 
living with life limiting illness with any progress
symptom management 
maximising QOL
palliative chemo/radio
palliative surgery 
maximising community supports
psychosocial support
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14
Q

who gives general palliative care

A

– GPs / district nurses, junior

doctors / ward nurses / CSW

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15
Q

why do people need specialist palliative care

A

when their symptoms are harder to control

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16
Q

who gives specialist palliative care

A

Community specialist palliative care teams (community
specialist palliative care nurses= ‘Macmillan nurses’)
• Hospice inpatient units
• Hospital specialist palliative care teams , specialist palliative
care consultants, specialty registrars, junior doctors (F1 to
F3), clinical nurse specialists

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17
Q

role of community specialist nurse

A

 Contact with pots ion home- phone contact, visit no more than once a week, unless get more complicated) no hands on care – district nurse do hands on nurse care

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18
Q

summarise hospice palliative care

A

in patient units
 50% discharge, 50% die – not just a place where people go to die
 Hospice – short stay unit – max 2wk
look after pt for EOL care and symptom control – admitted for symptom control then go home when better

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19
Q

how many people die in England /yr

A

500000

20
Q

age of deaths

A

2/3 >75yrs

21
Q

what are the causes of majority of deaths

A 
follow period of chronic illness:
• Cardiovascular disease
• Cancer
• Chronic respiratory disease
• Stroke
• Neurological disease
• Dementia
22
Q

time progression of cancer

A

pt will continue func on good level and then there is a point where they deteriorate which continues at a rapid rate – fairly predictable

23
Q

time progression of organ failure eg COPD

A

func decline at gradual – punctuated by dips which are infective exacerbation of COPD for example – AB recover, not up to baseline – keep gradually decline – have to determine which dip not going to jump back to baseline

24
Q

time progression of fraility eg dementia

A

fluctuate along and then get better again – more gradual decline over time

25
Q

when is palliative care involved on a patient’s journey

A

can encounter palliative care
throughout
• Palliative care not just for imminently dying
patients
• Palliative care for cancer patients who will be cured
• Palliative care for cancer patients with progressive
disease
• Palliative care for dying patients

26
Q

how can palliative care help during cancer treatment

A 
symptom control
• Pain
• Nausea and vomiting
• Constipation
• Breathlessness
• Treatment of side effects from chemo e.g.
peripheral neuropathy, vomiting/ nausea
Pain control post radical radiotherapy causing
severe oesophagitis and dysphagia
Palliation of sub acute/
bowel obstruction while
having chemotherapy
27
Q

physical symptoms in cancer

A 
fatigue 
pain 
breathlessness
anorexia
cough
constipation 
depression 
nausea
insomnia 
anxiety
28
Q

palliative care in advanced metastatic disease

A 
• Treatment of nausea and
vomiting secondary to
hypercalcaemia
• Palliation of headaches and
nausea secondary to brain
metastases
29
Q

how do you know that someone is dying

A 
All reversible causes have been treated and, despite
this, the patient is not getting any better
Progressively bed bound
• Increasingly drowsy
• Decreasing communication
• Decreasing oral intake
• Progressive loss of swallow 
progressively unable to talk
30
Q

is it always appropriate to treat reversible things

A

things – if going to die in next day – not going to treta pleural effuision with chest drain because painful – what are you going to achieve by treating this. Sometimes tricky for ward teams to determine the ceiling of care

31
Q

what needs to be done when you recognise that a patient is dying

A

a senior decision/recognition that they are
dying and that the focus of care should be comfort
and symptom control
urgently to discuss with the patient and
family about what is going on - especially if pt can’t communicate
stop all unnecessary/painful interventions
e.g. blood tests, iv cannulation, blood pressure
monitoring
• Check that the patient has a DNACPR form and
clear ceilings of care documented

32
Q

survey - what is important to patients in their final days

A 
. Be kept clean. 
named decision maker
nurse that they feel comfortable with 
know what to expect about physical condition 
have someone that will listen 
maintain dignity 
trust physician 
have financial affairs in order
be free of pain 
maintain sense of humour
33
Q

what do you do when family ask if it will be tonight

A

o Should know if they should spend the night or go home
o Really hard to get it right about prognosis
o Don’t know but want to give them an idea
o Plan for the worst and hope that better – better to do things too soon than too late
o Things can change really quickly
o People can stabalise/get worse
o Prepare for short frame or longer one
o If told def die in 12hrs and then still there in 4days = hard to cope with
o need to be reminded to look after themselves

34
Q

what is important in the final days

A

The patient and their symptoms
• Do they have spiritual needs that can be met now?
• The family
• Communication with the family
• Do they understand what is going on and the
urgency?
• Compassion

35
Q

common symptoms in last hours/days of life

A

pain
agitation
noisy breathing - upper airway secretions
nausea - not that common an issue, will affect how give med, need to think about but not common

36
Q

considerations of medicine at end of life

A

Many people die peacefully needing no medical
intervention
• Many cancer patients will have had pain, and be on
regular oral analgesia,
• When unable to swallow –need analgesia via a different
route
• Similarly if they have been vomiting,
• need to continue antiemetic via different route
• Otherwise, nausea not a particularly common symptom

37
Q

pain management

A

o Drugs parenterally – subcut – don’t want cannular more painful SC less painful than IM
o Therefore need opioids – if opioid naïve and normal renal func – give morphine sulphate 2,5mg sc prn – then titrate up
o If impaired renal fun – avoid morphine – oxycodone 1mg

38
Q

distress/agitation at end

A

o Common in dying
o Terminal agitation – people agitated but not necessarily dying – used in hospicies a lot – just before dye become agitated and distressed
o Need to exclude easily reversible – pain/urinary retention
o Marked in young pots/previously psych distress
o Existential thing – scared
Sometimes very marked in young patients or those
with previous psychological distress
• Helped by some drugs

39
Q

management of distress/agitation

A

• Midazolam 2.5mg sc prn (short acting
benzodiazepine)
• May need bigger doses e.g. 5mg sc prn
• May need syringe driver if need >2 doses (continuous subcutaneous
infusion csci)
• 2
nd line drug is levomepromazine
• Higher dose than for vomiting i.e. levomepromazine
12.5mg sc
• Ask for help from the Specialist Palliative Care Team

40
Q

describe noisy upper airway secretions

A

‘Death rattle’
• Usually in unconscious patient - chest clear, all comes from upper airways
• Distressing for families - o Explaining to family helps and saying that they don’t think opt is aware
chest clear and all comes from upper airway – reposition pt, avoid suctioning, may be gently if something in mouth

41
Q

management of noisy upper airway secretions

A 
Repositioning
• Avoid suctioning
• Glycopyrronium 0.2mg sc
• Hyoscine hydrobromide/hyoscine butylbromide
• Can use syringe driver
42
Q

treatment for N and v

A
  • Haloperidol 0.5mg sc prn
  • Levomepromazine 3.125mg-6.25mg sc prn
  • Both can be used in a syringe driver
  • Eg Haloperidol 2- 5mg sc / 24 hours
  • Levomepromazine 6.25mg-25mg sc / 24 hours
43
Q

what are anticipatory drugs

A

o Written up for pts who think dying
o So that pts who are dying might get the symptoms and we know the drugs available
o Should be prescribed at point recognised dying
o On as required chart in case something crops up – in case something develops in the coming hours
o When going home – prescribed in advance, put in house a few weeks in advance if pt doesn’t want to return to hospital and ceilings fo care recognise
o Days to hours in hospital

44
Q

what are THE anticipatory drugs

A

• Morphine 2.5mg sc prn (pain)
• Midazolam 2.5mg sc prn (agitation)
• Glycopyrronium 200 mcg sc prn (respiratory
secretions)
• Haloperidol 0.5 mg sc prn (nausea/vomiting)

45
Q

challenges of looking after someone dying of cancer

A

Really hard for doctors to see our patients die
• We need to support them and their families
• Often our compassion is the best support
• Very hard to go into the room where the patient has just
died and their family is there grieving
• Families really appreciate it when doctors do that and it may
well be one of the things they remember
• Although you may not influence the eventual outcome,
what you say/do makes a real difference
• Easy for families to feel abandoned
• Doctors (and nurses) too need support

DPD (38 decks)

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