Wk 17: Palliative care Flashcards
What are the signs that a patient is dying?
- Bed bound + profound weakness
- Red consciousness
- Sips of fluid
- Unable/difficulty taking oral meds
- Deteriorating day by day
What are the rules when reviewing regular medication?
- Non-essential drugs: discontinued
- Essential oral drugs (analgesics, antiemetics, anticonvulsants + steroids: SC or CSCI
- PRN: prescribed for anticipated symptoms SC
When should PRN sc meds be prescribed?
- Pain
- Agitation/restlessness
- Respiratory tract secretions
- Nausea/vom
- Breathlessness
What do you give if the patient is not on regular analgesia and are currently pain free?
Morphine injection 2.5mg-5mg prn upto hourly sc
What do you give if the patient is not on regular analgesia and are currently in pain?
Morphine injection 2.5mg stat sc
Effective: morphine injection 10mg sc over 24 hrs CSCI + prn morphine
How do you use the syringe driver?
- Mix w/ water or 0.9% sodium chloride
- Irritation to skin = add dexamethasone
How would you give longer acting drugs?
STAT sc (haloperidol + levomepromazine)
When would you use oxycodone?
- Mod-severe pain
- If morphine not tolerated
- Caution pain w/ renal impairment
What do you do when you convert from PO to SC?
Half 24hr dose
When would you use alfentanil?
- Severe renal impairment
- V short half life tf only use in CSCI
Define allodynia
Pain due to stimulus which wouldn’t usually provoke pain (eg. light touch)
Define hyperalgesia
Increased response to stimulus which is normally painful
What are the side effects of normal therapeutic level opioids?
- Constipation
- Nausea
- Urinary retention
- Itch/rash
- Dry mouth
What are the side effects of high therapeutic level opioids?
- Hallucinations
- Abnormal skin sensitivity
- Sedation
- Respiratory depression
What is the neuropathic pain ladder?
- Steroid
- Antidepressant
- Anticonvulsant
- NMDA antagonist
- Spinal analgesia
What are the reasons why patients experience nausea + vomiting?
- Opioids
- Hypercalcaemia (bone metastases)
- Liver failure
- Raised intracranial pressure
- Brain metastases
If a patient was already on a regular anti-emetic, how could you optimize their therapy?
Sc or CSCI
Which anti-emetic can’t be given by injection?
Domperidone tf convert to metoclopromide
What do you give if the nausea + vomiting is metabolic, infective or drug induced?
Haloperidol - 0.5-1.5mg sc hourly prn (max 3mg)
What do you give if the nausea + vomiting is for bowel distension/obstruction, vestibular problems or raised intracranial pressure?
Cyclizine - 50mg sc hourly (max 150mg)
What do you give if the nausea + vomiting is for bowel distension/obstruction, vestibular problems or raised intracranial pressure but the patient has severe HF or renal failure?
- Haloperidol or levomepromazine
- No cyclizine - tachycardia
What do you do for nausea + vomiting at the end of life (gastric stasis - large vol vomit, hiccups + belching)?
- Check over feeding: PEG red or stop + stop IV/SC fluids
- Oral metoclopramide: switch to sc or discontinue
What must you not give if vomiting due to bowel obstruction?
Metoclopramide bc prokinetic
What do you give if a patient isn’t responding to antiemetic?
Levomepromazine (sedating) - 5mg/6.26 sc prn hourly (max 25mg)
What is terminal agitation?
Agitation that occurs in last few days of life
What are the causes of agitation?
- Meds
- Pain
- Nausea
- Emotional distress
What do you give for terminal agitation?
Midazolam - 2.5-5mg sc PRN hourly
Responds: CSCI 10mg sc/24hrs
What do you give if the patients agitation doesn’t settle after giving highest dose of midazolam?
Levomepromazine - 6.25mg/12.5mg sc prn
Responds: CSCI or stat dose
What do you give if a patient has respiratory tract secretions?
- Reposition
- Hyoscine hydrobromide - 100mcg prn hrly, CSCI 1200mcg/24hrs
- Sedative
What do you give if a patient has respiratory tract secretions + renal failure?
Hyoscine butylbromide (non-sedating)
- 20mg sc PRN (120mg max)
- CSCI: 60mg/24hrs
What other reasons other than respiratory tract secretion, would you give hyoscine butylbromide?
Bowel colic/bladder spasm
If a patient has secretions despite hyoscine HB/BB, what would you prescribe?
Glycopyrronium - 200mcg sc prn hourly
CSCI: 600/1200mcg/24hrs
What do you prescribe a patient with breathlessness?
Opioid - 2.5mg-5mg sc upto hourly prn
What do you prescribe a patient with breathlessness who is already on opioids?
Midazolam - 2.5mg-5mg sc upto hourly prn
- 2/more doses needed, add to syringe driver
