Week 4- Palliative care + medication Flashcards
what is palliative care?
relieving pain without dealing with the cause of the condition
what are the principles of palliative care?
how do they identify people who would benefit from end of life care? what tools?
Gold Standard Framework Proactive identification guidance (PIG) (primary care)
AMBER bundle (secondary care)
Supportive and Palliative Care Indicators Tool
what groups of people need EoL care?
-advanced incurable conditions
-generally frail and
-existing conditions where they can have sudden acute crisis
-life threatening conditions due to sudden catastrophic accidents
what happens when someone has been identified to need EoL care?
-Identification of carers and people important to them
-Holistic needs assessment
-provision of information
-advanced care planning
-regular review of needs
-multidisciplinary care
what are some examples of conditions where people may benefit from palliative care?
Cardiovascular e.g. heart failure
Cancer
Renal failure
Hepatic failure
Neurological conditions e.g. MS, PD, stroke
COPD
CF
Dementia
….and many more
what is the role of the pharmacists for EoL care?
Drug choice
Doses
Legal aspects – off label use
Interactions
Side effects
Regular medications – to continue or deprescribe – ethics, consent
Pharmaceutical issues
-Compatibilities of drugs
-Diluents
-Rates of administration
-Syringe drivers
Feeds and fluids
what are some symptom relief in palliative care other than pain?
Nausea and vomiting
Excessive secretions
Dry mouth
Dyspnoea
Pruritis
Muscle spasm
Sedation
Headache
Capillary bleeding
Cough
Diarrhoea
Constipation
Convulsions
Insomnia
Anxiety
Hiccups
Oral candidiasis
Fungating malodourous tumours
what is the most common symptom for palliative care?
-pain
-need to identify the severity and cause of pain which will direct the pain
what is the most common analgesia in palliative care? what needs to be considered for it?
-opioids
Need to consider
Previous opioid therapy
Renal function
Hepatic function
Route of administration
What is the dosing of the PRN dose prescribed along with long acting opioids?
1/10-1/6 daily dose every 4 hours
what are some side effects of opioids?
-Constipation
Regular laxatives most effective
-Nausea & Vomiting
Initiation or dose increase
Ensure adequate antiemetic therapy is available
Switch opioids if if it doesn’t stop
Drowsiness
reduce dose or switch if not stoped
what are the routes of administration for opioids?
PO
Transdermal
Subcutaneous
-PRN
-Continuous subcutaneous infusion – AKA syringe driver
Dose conversions may differ depending on route
what is some advice for patients/carers for opioids?
Storage- safe, not in warm place
Keeping track of the dates patches applied
Disposal- return to pharmacy
PRN dose records
Hospital admissions – PODS
Order in good time
supplies no longer required
why do patients needing EoL care experience nausea and vomiting?
-could be due to the disease itself
-or medication they are taking
-nausea can be worse than vomiting
-serve itself can impair absorption
what is the mechanism for nausea and vomiting?
-in vomiting the parasympathetic system acts on muscarinic receptors in the smooth muscles of the gut with acetylcholine as the main neurotransmitter.
-in the sympathetic system it acts on adrenergic receptor and as noradrenalin as the neurotransmitter.
how do antihistamines work as a antiemetic?
Antihistamines e.g. cyclizine
-blocking H1 receptor- CTZ and vomiting centre
-sedation which can help with nausea
how do anticholinergics work as a antiemetic?
anticholinergics (antimuscarinic) e.g. hyoscine
-inhibit cholinergic transmission centrally (M1 receptors)
-antispasmodic action in gut
how do antidopaminergic work as a antiemetic?
antidopaminergic e.g. haloperidol
-block D2 receptors in CTZ
-antihistamine and anticholinergic action
how do metoclopramide and domperidone work as a antiemetic?
-block D2 receptors in CTZ
-prokinetic effect on GI tract
how do levomeproazine work as a antiemetic?
block D2, Ach, H1 & 5HT2 receptors . Nb weak action at each site
how do Selective 5HT3 receptors antagonist work as a antiemetic?
Selective 5HT3 receptors antagonist e.g. ondansetron
-block 5HT3 receptors peripherally on vagal nerve endings and also centrally in vomiting centre.
what are some interactions for antiemetics?
Antiemetic interactions
Metoclopramide and haloperidol – extrapyramidal side effects
Levomepromazine potential for EPSE – mix with care
QT interval prolongation – ondansetron, haloperidol, metoclopramide, levomepromazine
Cyclizine blocks prokinetic effect of metoclopramide
Opioids antagonise prokinetic effects
how do you manage anorexia that some patients experience during EoL?
-enticing foods
-manage cause e.g. nausea or constipation
-corticosteroid
how do you manage dyspnoea that some patients experience during EoL?
Low dose opioid
-may diminish chemoreceptor response to hypercapnoea and hypoxia
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