Yr4 Palliative Care - Lectures Flashcards

Question

What might duloxetine cause/exacerbate? - Risk of dexamethasone? - Naproxen? - Give 2 examples of when side effects may be used beneficially?

Answer 1

**A knowledge of ALL side effects is valuable** - The propensity for duloxetine to cause or exacerbate hyponatraemia could be a relative contra-indication! - The risk of dexamethasone induced proximal myopathy might be a relative contraindication where mobility was already compromised. - Naproxen may cause gastric intolerance

Answer 2

**Multi-modal analgesia vs. polypharmacy** Polypharmacy is common in the palliative care patient population because - Patients are often elderly - Multiple co-morbidities - Multiple symptoms requiring palliation The contemporary approach to effective analgesia encourages co administration of multiple drugs providing analgesia by differing mechanisms…

Answer 3

**1. Use the oral route when possible** - Ease of administration - Minimises risk - Easily transferable to a home setting - Rescue PRN dose for opioids = approx 1/10th of their daily background dose - If PRN >3xday —> increased background opioid dose OR consider non-opioid responsive causes

Answer 4

- BTP = breakthrough pain

Answer 5

**Opioids for breakthrough pain relief** - IR opioid dosing interval in response to sub-therapeutic plasma levels is determined by Tmax (time to peak plasma level.) - Breakthrough dosing intervals are dependant on the ROUTE of ADMINISTRATION rather than the particular opioid chosen. - For non-opioid and adjuvant analgesics the dosing interval is related to the ½-life of the drug. - When using opioids to relieve breakthrough pain, the intent is to rapidly raise the opioid plasma levels to exceed the present (temporary) analgesic threshold. - Because a rapid response is desired use only immediate-release opioids on a prn basis. - If you can be certain that plasma opioid levels have already peaked without the desired analgesic effect, it is reasonable to repeat the IR opioid dose.

Answer 6

- Sub-maximal dosages of two, three or more drugs may result in improved analgesic efficacy and fewer adverse effects than maximal dosages of a single drug. - Non-opioid analgesics should be continued when opioids are introduced IF THEY HAVE BEEN OF BENEFIT, and may be helpful even for patients on moderate doses of opioid

Answer 7

**Using multi-modal analgesia in practice** - Classify the type of pain: Nociceptive (Somatic/Visceral) vs. Neuropathic - Understanding the different mechanisms of pain can help guide the choice of analgesic agent - Make use of the wide range of oral or transdermal sustained-release opioids now available along with appropriate non-opioids - When patients are entering the terminal phase use imagination and all available forms of administration (parenteral infusions, sublingual, transdermal, rectal) to continue using multi-modal therapy where possible if of proven benefit

Answer 8

You don't! Remember that if you are ever asked to convert to or substitute methadone for an opioid, insist on the need to seek advice from an expert and experienced Pain Specialist or Pall Care Specialist.

Answer 9

- Apply patch at same time of last dose of SR oxycontin as it will take up to 24hrs to ready steady state - Need to check her renal function —> if she’s in renal failure she may be accuulating oxycontin which is causing her disorientation/drowsiness ALSO is this her usual dose - Could use a subcut infusion of morphine - steps: 1. 40mg oxyctonin convert to 60mg of oral morphine (x1.5) then convert oral morphine to subcut morphine by diving by 3 = 20mg of subcut morphine over 24hrs - Always covert to morphine and oral then to whatever you need

Answer 10

**Ongoing management** An appropriate regimen might include: 1. IV paracetamol 2. Rectal indomethacin 3. Equivalent analgesic dose of an opioid 4. Confidence that depressed level of consciousness is due to the disease process, rather than overdose of opioid

Answer 11

1. No proven benefit 2. Causes confusion 3. Increases risk of errors 4. More difficult to calculate appropriate background and prn doses 5. Sometimes necessary due to lack of availability of suitable preparations e.g. fentanyl, methadone 6. In some situations, changing to another opioid (opioid rotation) can be helpful

Answer 12

- Rapidly escalating opioid requirements usually mean we have missed something! - Morphine requirements exceeding 250mg orally per day (or equivalent for other opioids) should prompt a review - Be alert to dose-limiting side effects.

Answer 13

**Historically, a dichotomous division of goals of care** - Focus on curing illness Little attention to relief of suffering, care of dying - Hospice / palliative care arose in response to a need.

Answer 14

**Multiple goals of care** - Multiple goals often apply simultaneously - Goals are often contradictory - Certain goals may take priority over others - You need to understand what the patient’s priorities and preferences are every step of the way **Goals may change** - Some take precedence over others - The shift in focus of care: may be gradual, may be rapid, is an expected part of the continuum of medical care. - Review with any change in: 1. Health status 2. Advancing illness 3. Setting of care 4. Treatment preferences

Answer 15

1. Create the right setting 2. Determine what the patient and family know 3. Explore what they are expecting/ hoping for 4. Suggest realistic goals 5. Respond empathically 6. Make a plan and follow-through 7. Review and revise periodically, as appropriate

Answer 16

“Capacity” implies the ability to understand and make own decision. Patient must: 1. Retain and understand the information 2. Use the information rationally 3. Appreciate the consequences 4. Come to a reasonable decision for him or herself 5. Communicate the decision Any doctor can determine capacity * Capacity varies by decision * Other cognitive abilities do not need to be intact

Answer 17

When a patient lacks capacity - Proxy decision-maker (EPG = Enduring Power Guardianship) **Sources of information:** 1. Written advance health directive or advance care plan 2. Patient’s verbal statements 3. Patient’s general values and beliefs 4. How patient lived his / her life 5. Best interests determinations

Answer 18

**Is death approaching?** EARLY 1. Bed bound 2. Loss of interest and/or ability to eat and drink 3. Cognitive changes 4. Increasing time spent sleeping and/or the onset of delirium MID 1. Further decline in mental status 2. Slow to rouse to stimulation 3. Only brief periods of wakefulness 4. Death rattle = Pooled oral secretions that are not cleared due to loss of swallowing reflex LATE 1. Coma 2. Fever - Usually from aspiration pneumonia 3. Altered respiratory pattern - Periods of apnea, hyperpnoea or irregular breathing 4. Mottled extremities

Answer 19

- Are they in pain? - agitated, grimacing, tachycardic, localising - Starving? - normal trajectory, food & fluids only for comfort/pleasure at this point

Answer 20

1. Dyspnoea (Community and Inpatient) 2. Nausea and Vomiting 3. Pain 4. Respiratory Tract Secretions 5. Terminal Restlessness/Agitation

Answer 21

**Investigations** 1. Corrected serum Ca - normal 2. Haemoglobin– normal 3. WCC - normal 4. CRP 14 5. Urea 64 mmol/L 6. Creatinine 282 umol / L **Management** 1. Exclude and correct electrolyte imbalance 2. Urinary catheter 3. Ultrasound or CT imaging 4. Urgent stenting of ureters if survival estimate is in the order of months to years 5. Consider acute management of pain

Answer 22

**Clinical diagnosis of chronic opioid toxicity - Management** **3 options:** 1. Reduce opioid dose 2. Use a different route of opioid administration 3. Opioid rotation: transition to methadone

Answer 23

- This sounds like neuropathic pain = TRUE - He’s definitely been drinking too much beer = FALSE - no evidence for this although alcohol can cause a proximal myopathy - The neurological signs are typical for cord compression = TRUE although they are not exactly typical - The neurological examination is reassuring = FALSE

Answer 24

= Cord Compression - Needs MRI to confirm sites & Dexamethasone 16mg daily

Answer 25

**You diagnose SVCO** - He is given 16mg dexamethasone - An SVC stent is inserted radiologically with relief of symptoms - He is discharged home and recommences chemotherapy as planned - This man will probably die within the next 6 months = FALSE = Median survival ~8 month

Answer 26

- The nurses should stop dressing the wound = FALSE - but maybe minimise changes - This man must be admitted to hospital = FALSE, not if he wants to be at home. - Nothing can be done if the bleeding gets worse = FALSE - It is important to discuss future care at this stage = TRUE - Need to discuss pt's wishes should bleeding become a more prominent feature of his disease/ what to do if catastrophic bleed.

Answer 27

- You better watch what you do, she’s got friends who are lawyers = Always TRUE - It is unlikely that she has a significant infection = FALSE - Lack of temperature is unreliable/false reassurance because if you are 1/52 post chemo = neutropenic = may not mount a temperature. - The brain mets/radiotherapy have probably made her dizzy = FALSE - could be but more likely to be 2nd to septic shock. - She definitely needs admission to hospital = TRUE - She needs urgent IV BS Abx with pseudomonas cover. **Management…** - Bloods in hospital show that she is neutropenic. She remains apyrexial but is hypotensive and tachycardic. - She is commenced on oxygen, IV fluids and broad spectrum antibiotics and makes a good recovery. - She returns to ED again 15 days after her 4th cycle of chemotherapy. Her husband reports that she has been becoming increasingly vague and forgetful over the past week and she vomited this morning.

Answer 28

- Hypercalcaemia is rare in breast cancer = FALSE - quite common - Once treated, the hypercalcaemia is unlikely to recur = FALSE - Need to actively monitor/follow up - Prognosis is likely to be less than 3 months = TRUE for symptomatic hypercalcaemia - It is important that she sorts her will, EPA, EPG as soon as possible if the confusion resolves = TRUE - poor prognosis

Answer 29

**Key elements of palliative care** 1. Symptom relief, particularly sufficient analgesia 2. Assistance in the organization of adequate, needs-based care 3. Support regarding social services 4. Psychological support of patients and their families **Members of a palliative care team** 1. Physicians (including palliative care specialists) 2. Nurses 3. Social workers 4. Psychologists 5. Chaplains 6. Pharmacists Palliative medicine is not synonymous with end-of-life care. It is often used to improve a patient's quality of life even as life-prolonging therapy continues.

Answer 30

Address reversible underlying causes of symptoms as long as the investigations and treatment required are consistent with the patient's care plan and wishes.

Answer 31

**Modified WHO Analgesic Ladder** This illustration shows a stepwise, bidirectional algorithmic approach to the management of acute and chronic pain. Acute pain is initially treated with the strongest analgesic for that intensity of pain and then stepped down. Chronic pain is treated from the bottom up. The original WHO analgesic ladder was unidirectional (escalating) and included only the first 3 steps; other authors have since modified the ladder, by adding the fourth step including interventional procedures (e.g., nerve blocks) for unrelenting pain.

Answer 32

1. **Nociceptive pain**: caused by damage or potential damage to tissue (excluding neural tissue). 2. **Neuropathic pain**: caused by damage to a somatosensory nerve 3. **Nociplastic pain**: caused by altered nociception despite there being no underlying tissue damage 4. **Mixed pain**: the simultaneous or concurrent presence of nociceptive, neuropathic, and/or nociplastic pain in one area of the body. 5. **Emotional pain**: a term used to describe both mental suffering and the impact of emotions on the experience of pain. 6. **Total pain**: the combination of physical, social, spiritual, and psychological/emotional pain components.

Answer 33

**Methadone** - Conversion factors have not been provided for methadone. - Methadone conversions are complicated. - Prescribing should be restricted to medical specialists with experience of methadone prescribing for pain management.

Answer 34

1. There are many opioids and many formulations available (e.g. tablets, patches, injections) 2. Each opioid medication binds to opioid receptors differently 3. Therefore, a different amount of each opioid is needed to have the same analgesic effect

Answer 35

**Equianalgesic doses of oral opioids** The guide is colour coded as a visual prompt: - GREEN shaded opioids are those STRONGER than morphine mg for mg - PURPLE shaded opioids are those WEAKER than morphine mg for mg

Answer 36

Good palliative care involves anticipatory sourcing of medications and pre-emptive prescribing.

Answer 37

1. Dyspnoea (Community and Inpatient) 2. Nausea and Vomiting 3. Pain 4. Respiratory Tract Secretions 5. Terminal Restlessness/Agitation.

Answer 38

The Search for Meaning 1. * What has mattered most to you in your life? 2. What are your goals? 3. Has there been any sense of continuity, a theme or Mission that describes what your life has been about? 4. What is your contribution to your family/your friendship group/society in general? 5. What is important to you in the future?

Answer 39

**Demoralization Syndrome** - Persistent sense of meaninglessness & loss of purpose in life [>2 weeks] - Sense of being stuck, trapped - Helplessness - Hopelessness - Often isolated or alienated - May develop into a desire to die - May be co-morbid with depression = loss of pleasure or interest in activities for long periods of time.

Answer 40

**Spiritual Distress** - Disease as a punishment (e.g. infidelity giving cervical cancer) - Abandonment by God (e.g. disease progression) - Loss of meaning/demoralisation (e.g. loss of faith) - Fatalism, God’s will - Fear of God’s rage (e.g. spiritual doubt)

Answer 41

**What is spiritual care?** - Relates to meaning and purpose - Delivered in response to feelings - Value the person - Seek to get to know & understand them - Explore the meaning of their illness, their relationships, their life - Explore the need for reconciliation - Celebrate the majesty and mystery of life - through nature, meditation, stillness, religious symbols & rituals

Answer 42

Interprofessional (multidisciplinary) teams play a crucial role in the management of patients with life-limiting illnesses and their families across various care contexts. These teams consist of professionals from different disciplines, such as doctors, nurses, social workers, psychologists, chaplains, pharmacists, and therapists, who collaborate to provide comprehensive care tailored to the unique needs of each patient and their family. Here's how their role varies in different care contexts:

Answer 43

Effective communication involves actively listening, providing clear and accurate information, being sensitive to individual needs and preferences, and fostering collaborative relationships with patients, families, and colleagues. By prioritizing communication and teamwork, healthcare professionals can ensure that patients with life-limiting illnesses receive compassionate, person-centered care that addresses their physical, emotional, and spiritual needs.

Answer 44

By approaching palliative care with cultural respect, sensitivity, and humility, healthcare professionals can foster trust, build meaningful relationships, and provide care that is tailored to the unique cultural and spiritual needs of Aboriginal and Torres Strait Islander patients and their families.

Answer 45

- Eliciting patients' hopes and values is essential for facilitating person-centered advance care planning, which aims to align medical care with the patient's goals, preferences, and values. - By using these strategies to elicit patients' hopes and values, healthcare professionals can facilitate meaningful advance care planning conversations that empower patients to make informed decisions about their future care that align with their values and priorities.