WEEK 2: Palliative Care

Question 1

What is palliative care?

Answer 1

Palliative care is an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems

Question 2

Outline principles of palliative care.

Answer 2

Affirms life and regards dying as a normal process

Neither hastens nor postpones death

Provides relief from pain and other distressing symptoms.

Integrates the psychological and spiritual aspects of care.

Offers a support system to help patients live as actively as possible until death.

Offers a support system to help the family cope during the patients’ illness and in their own bereavement.

Question 3

State the 4 Components of Palliative Care.

Answer 3

Relief of symptoms
Psychosocial support
End-of-life care.
Caring for caregivers

Question 4

Outline the 4 main respiratory conditions in palliative care.

Answer 4

COPD: Chronic Obstructive Pulmonary Disease (COPD) is a progressive and chronic respiratory condition characterized by persistent airflow limitation in the lungs. The term encompasses two main conditions:

Chronic Bronchitis: In chronic bronchitis, there is inflammation and excessive mucus production in the bronchial tubes (large airways). This can lead to a persistent cough and difficulty breathing.

Emphysema: Emphysema involves damage to the air sacs (alveoli) in the lungs, reducing their elasticity and causing them to collapse. This results in difficulty exhaling air and decreased lung function.

BRONCHIECTASIS: Bronchiectasis is a chronic respiratory condition characterized by the abnormal dilation and widening of the bronchi (the large airways) in the lungs. This chronic dilation of the bronchi is often a result of repeated lung infections, inflammation, or other damage to the airways.

CYSTIC FIBROSIS: It is caused by mutations in the CFTR (cystic fibrosis transmembrane conductance regulator) gene, leading to the production of thick and sticky mucus.

HIV ASSOCIATED TB

Question 5

Describe the prevalence of COPD.

Answer 5

COPD is the third most common cause of death worldwide.
5YR mortality 40-70%

Nearly 100 000 men and over 65 000 women die from chronic obstructive pulmonary disease (COPD) in Europe each year.

Question 6

Discuss the symptoms of COPD.

Answer 6

Trajectory slow; Inexorable decline
- with prolonged periods of:
Disabling dyspnea
Reduced exercise tolerance

Recurrent hospital admissions

Premature death

End stage symptoms can often be worse than those of patients with advanced lung cancer.

Survival rates worse than those with many common cancers

Question 7

Discuss COPD and Palliative care.

Answer 7

Prevalence increasing worldwide
Disease trajectory and poor QOL: need for PC
Symptom burden greater than lung Cancer
Dyspnea more common
Poor support at EOL

Question 8

Outline Common symptoms in respiratory diseases.

Answer 8

Dyspnea
Cachexia
Fatigue
Hemoptysis
Cough
Physical pain
Psychosocial discomfort

Question 9

Describe how quality of life is impaired.

Answer 9

Poor
loss of dignity
social isolation
psychological problems
increasing dependency on caregivers

Question 10

Outline the Desired outcomes with Palliative care intervention.

Answer 10

Enable early detection of disease exacerbations.

Provide timely intervention for early symptom management.

Decrease patient /caregiver anxiety.

Reduce unscheduled visits to A/E

Prevent hospitalizations

Enables advanced care planning to avoid suffering at EOL.

Question 11

Discuss Barriers to provision of Palliative Care.

Answer 11

Highly unpredictable disease trajectories of non-malignant diseases.

Failure to appreciate that these disorders are life threatening.

Question 12

A Multidisciplinary Team (MDT) approach is crucial.

How can effective teamwork be facilitated?

Answer 12

Fundamental to the practice of palliative care.

Clear understanding and appreciation of team members’ roles and responsibilities facilitates effective team working.

Effective communication also facilitates effective teamwork.

Question 13

Outline team members in palliative care.

Answer 13

Palliative care specialist
Medical officers
Specialist palliative care nurses
Social worker
Community nurses
Psychologist
Pharmacist /OT/PHYSIO/SALT
Religious leader /Pastor

Question 14

How can cachexia and fatigue be managed?

Answer 14

Cachexia – Early nutritional support

Fatigue: 4/5 pts in lung ca – psychosocial support, exercise. Sleep hygiene, meds – e.g. anti-depressants.

Question 15

Pain is the most common reason people seek health care.

In cancer, the prevalence of pain in advanced disease is 70-90%.

In HIV disease, pain prevalence is about 50%.

Other illnesses may have significant pain but no clear data.

What is pain?

Discuss what is meant by pain is subjective?

Answer 15

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Pain is a subjective experience.

The experience varies from person to person and from time to time.
Pain is whatever the experiencing person says it is, existing wherever he says it does.

Question 16

Palliative care has adopted total pain concept.

Discuss the concept.

Outline the 4 components of the total pain concept.

Answer 16

The Total Pain Concept recognizes that pain and suffering extend beyond just physical aspects.

The model emphasizes the interconnectedness of various dimensions of pain, incorporating physical, psychological, social, and spiritual components.

Physical 
Social 
Spiritual 
Psychological

Question 17

Outline Barriers to Pain Management.

Answer 17

Inadequate education in pain management.

Fears and myths about pain and opioid analgesics

Inadequate follow-up processes

Question 18

Discuss the WHO Analgesic Ladder: adults.

Answer 18

Step 1: Mild Pain
For mild pain, non-opioid analgesics are recommended.

Step 2: Moderate Pain

If pain persists or increases, the next step involves adding a weak opioid with or without the non-opioid analgesic and adjuvants.

Step 3: Moderate to Severe Pain
For moderate to severe pain, stronger opioids are recommended with or without the non-opioid analgesic and adjuvants.

Question 19

Give examples of the following:
1. Non-opioids

Answer 19

1. Non-opioids: Ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin
2. Weak opioids: Codeine, tramadol, or low-dose morphine
3. Strong opioids: Morphine, fentanyl, oxycodone, hydromorphone, buprenorphine
4. Adjuvants: Antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid

Combining an opioid and non-opioid is effective, but do not combine drugs of the same class.
Time doses based on drug half-life (“dose by the clock”); do not wait for pain to recur

Question 20

What principles guide the administration of pain medication?

Answer 20

Administration of Pain Meds:
*By the mouth
*By the clock
*By the ladder
*For the individual
Attention to detail

Question 21

State Adverse Effects of Opioids.

*Common
*Less frequent
*Rare

Answer 21

Common Less Frequent Rare
· constipation · urinary retention · allergy
· nausea · pruritus · respiratory
· sedation · depression
· Dry mouth · confusion

Question 22

Define adjuvant medication.

Answer 22

Medicines that are not primarily used for analgesia.

Enhance the analgesic activity of the NSAIDs or opioids.

Have independent analgesic activity for certain pain types (such as neuropathic pain)

May counteract the side effects of NSAIDs or opioids.

Question 23

Discuss the management of dyspnea.

Answer 23

Management focuses on cause.

Relief of obstructions or pleural effusions

Supplemental oxygen.

Cold air/ fan to face /positioning.

Reassurance and relaxation techniques

Morphine

Question 24

Describe the management of hemoptysis.

Answer 24

Common in lung ca
TB
Distressing – anxiety

Position – lie on affected side to reduce blood flow
Meds: anticoagulants
Coagulation
Radiotherapy
Provide dark towels.

Question 25

Discuss the management of cough.

Answer 25

Common dry / productive: debilitating

Remove irritants / pollutants.

Check for Iatrogenic causes eg. ACEI

Bronchodilators

Codeine / morphine

Secretions – hyoscine
antibiotics

Question 26

Discuss psychological support in palliative care.

Answer 26

Distress at time of diagnosis
Depression: need close surveillance
Advance care planning
Coordination of services – decrease anxiety
Spiritual support

Question 27

It is the ethical duty of health care professionals to alleviate pain and suffering, whether physical, psychosocial or spiritual, irrespective of whether the disease or condition can be cured