W9 Palliative and EOL Care Flashcards
1
Q
Palliative care can be applied where there is no…?
A
no expectation of recovery or cure
* Advances in diagnosis means that patients with palliative conditions can be identified
decades before their death
* The place of care can vary based on the patient’s needs and preference, and may be the patient’s home, nursing or
care home, hospice, or hospital.
* For patients who wish to remain at home with their families, support can be provided by community nurses, social care
staff, volunteers and hospices, together with the patient’s GP and palliative care team.
* Not just oncology – other life limiting conditions where there is no cure - heart failure,
respiratory, motor neuron disease (MND)
* Bereavement care is a core element of palliative care.
2
Q
What is palliative care?
A
- It is the active holistic care of an individual with a life-limiting or life-threatening condition provided by a multidisciplinary team.
- It may be provided for months or years.
- Aim is to improve QOL for patients with incurable disease
- Treat symptoms
- Address social, psychological and spiritual issues
- Patient doesn’t have to be in a hospice or about to die
- Palliative care won’t hasten or postpone death
3
Q
What is end of life/ terminal care?
A
- ‘End-of-life-care’ refers to the care of individuals in their last 12 months of life
- ‘Terminal care’ refers to the care of those in their last few weeks or days of life.
- End of life care aims to help you live as comfortably as possible in the time you have left
- Managing physical symptoms
- Emotional support
- Talking about what to expect as you move
towards the end of your life - Discussing needs or wishes
- Giving practical support
4
Q
Non-drug treatment
Examples?
A
- Used for symptom management.
- For example, pain or breathlessness
can be managed by using positioning,
relaxation, controlled breathing, and
anxiety management techniques
5
Q
Drug treatment (for info)
A
- Medicines used in palliative care are often unlicensed or used off-label (outside of the recommendations of their marketing authorisation, such as an unapproved route, indication, or dose).
- MDT collaborations to ensure continuity of supply when transferring between care locations.
- For parenteral drug administration, appropriate diluents and flushes may also need to be prescribed.
- When prescribing for elderly or frail patients, and for patients who are malnourished, cachectic and/or
oedematous: renal function tests may underestimate the actual degree of renal impairment.
6
Q
Deprescribing in Palliative Care
Why is this important?
A
- The use of multiple medicines concurrently for chronic conditions
and symptom management is common in palliative care. - Deprescribing of medicines should be considered where appropriate.
- Safe withdrawal of medicines that are no longer appropriate, beneficial or wanted, to improve QoL and reduce the burden of
unnecessary treatments. - Medication reviews within all specialties should be undertaken
regularly to reduce potential harm. - Any prescribed medicines that are not providing symptomatic benefit, are causing harm, or are deemed no longer necessary
should be stopped.
7
Q
Anticipatory prescribing and last days of life
examples of medications and their indications?
A
- Assess which medicines may be needed to manage symptoms likely to occur in the patient’s last days of life
(such as morphine for pain and breathlessness; midazolam for agitation; levomepromazine or haloperidol for nausea and vomiting and delirium; or
hyoscine butylbromide for respiratory secretions). - Prescribing of anticipatory drugs: specification of indication, route, dose, frequency, and maximum dosage.
- Individuals may also benefit from a dose range to allow flexibility for administration by community teams,
especially out of hours. - The hydration status of the patient should also be assessed in their last days of life, and the need for clinically-assisted hydration reviewed.
8
Q
Routes of Administration
which is preferred?
when may this not be possible?
A
- Where possible, the oral route is the preferred method of drug administration.
- For patients with swallowing difficulties, consider reducing the number of drugs and frequency of administration.
- A speech and language therapist (SALT) assessment can inform the feasibility of using alternative oral formulations,
e.g. dispersible or soluble tablets, or oral liquids. - The oral administration of drugs may not always be possible, e.g. when there is persistent N&V, dysphagia, bowel
obstruction, poor absorption of oral drugs, or patient preference, therefore alternative routes of administration
(e.g. buccal or sublingual, intranasal, rectal, transdermal, subcutaneous, and enteral feeding tube). - If drugs are required to be given via an enteral feeding tube, consider suitable formulations.
9
Q
Parenteral Administration
What is the preferred route?
A
- For patients who are unable to take or tolerate oral medicines, subcutaneous or intravenous administration should be considered, although the subcutaneous route is the preferred choice.
- The use of continuous subcutaneous infusions (CSCIs) is common within palliative care particularly for patients with
swallowing difficulty. - CSCIs reduce the need for bolus injections, provide comfort from stable drug plasma concentrations, and allow control of multiple symptoms with a combination of drugs.
- CSCIs are usually administered via a portable continuous infusion device (such as a syringe driver or pump), thus
supporting patient independence and mobility. - The use of intramuscular injections is not recommended.
10
Q
Continuous Subcutaneous Administration
A
- CSCIs over 24 hours are considered satisfactory in terms of
sterility, practicality, and stability. - The dilution of CSCIs minimises the risk of injection-site
reactions and drug incompatibility, and reduces the impact
of priming the infusion line. - 20 mL syringes are generally recommended as the minimum
size for use with a syringe driver or pump. - WFI is the standard diluent.
- Large volumes of WFI are hypotonic, which can cause
infusion site pain or skin reactions
11
Q
Continuous Subcutaneous Administration ll
A
- NaCl 0.9% is isotonic and is preferred for diluting irritant
drugs or if inflammatory skin reactions occur at the
injection site, but incompatibility can be a problem with
some drugs. - Some parenteral drug formulations (e.g. chlorpromazine,
diazepam) are too irritant to be given by CSCI and
alternatives should be used. - It is common practice for two or three different drugs to be
mixed in a CSCI (unlicensed product), although the
greater the number of drugs mixed, the greater the
potential for compatibility issues. - Physical and/or chemical changes can occur when
mixing drugs that may lead to reduced efficacy
12
Q
Compatibility with diamorphine in syringe driver s/c:
A
- Cyclizine: may precipitate >10mg/ml or in NaCl 0.9% or higher concn of diamorphine; or after 24 hours;
- Dexametasone: can be difficult to prepare;
- Haloperidol: >2mg/ml likely to precipitate after 24 hours;
- Hyoscine butylbromide, Hyoscine hydrobromide & Levomepromazine: safe with diamorphine;
- Metoclopramide: may become discoloured – discard
- Midazolam: monitor for correct rate, colouration or discolouration
13
Q
6 common drugs for 4 common symptoms?
A
- Diamorphine/Morphine – pain
- Cyclizine – N&V
- Hyoscine Hydrobromide/Glycopyrronium - secretions ‘death rattle’
- Midazolam - Anxiety, agitation
14
Q
Common Symptoms in Palliative Care?
A
- Pain
- Nausea & vomiting
- Constipation
- Hypercalcaemia
- Dyspnoea
- Confusion
- Cerebral oedema
- Spinal Cord Compression
- Anxiety
15
Q
WHO Analgesic ladder
A
- Non opioid +/- Adjuvant
- Add Weak Opioids for mild to moderate pain +/- Non-opioid and Adjuvant
- Add Strong Opioids for moderate to severe pain +/- Non-opioid and Adjuvant
