Yr4 Palliative Care - Study Points Flashcards
1
Q
Analyse 10 of the common responses and emotions of people living with life-limiting illnesses and their families.
- What might influence these responses?
A
People living with life-limiting illnesses and their families experience a wide range of responses and emotions, which can evolve throughout the illness trajectory. These responses are complex and influenced by various factors, including the individual’s personality, coping strategies, social support, cultural background, and the nature of the illness itself.
2
Q
Identify 10 sources of spiritual, social and psychological support for people with life- limiting illnesses and their families
A
Examples of Australian Services
1. Redkite - kids of cancer
2. Cancer council WA
3. Palliative Care Australia Helpline
4. My Aged Care
3
Q
Recognise how one’s own experiences, values and beliefs about death and dying affect their personal and professional responses and interactions with people with life- limiting illness and their families.
- 8 points?
A
In summary, one’s own experiences, values, and beliefs about death and dying significantly influence their personal and professional responses and interactions with people with life-limiting illnesses and their families. Awareness of these factors, along with ongoing reflection, education, and support, can help healthcare providers navigate the complexities of end-of-life care with empathy, compassion, and cultural humility.
4
Q
Demonstrate by way of reflective writing, the emotional, spiritual and educational impact of the palliative medicine rotation.
- Framework for exam essay Q?
A
- Introduction
- Emotionally
- Spiritually
- Educationally
- Conclusion
5
Q
Conceive personal strategies to develop the necessary emotional resilience to cope effectively with the stresses of caring for the dying in all areas of the medical profession.
- 10 strategies?
A
Developing emotional resilience to cope effectively with the stresses of caring for the dying in the medical profession is crucial for maintaining well-being and providing high-quality care.
6
Q
Define: Bereavement, Grief, & Mourning.
- 7 Components of Normal Grief?
- 7 Components of Abnormal Grief & Bereavement?
A
Bereavement: the loss of a close relation or friend to death
Grief: the internal experience of sadness in response to bereavement and other meaningful losses (e.g., loss of functional abilities)
Mourning: the outward expression of grief as influenced by factors such as religious beliefs, social norms, and cultural traditions
7
Q
List 13 Characteristics of Normal Grief.
- How does it differ from MDD?
A
- Often occurs in waves
- Duration varies significantly (resolves within 6 to 12 months)
- Intense sorrow, yearning for the deceased, emotional distress
- Guilt connected to the care, loss, or prior relationship with the deceased
- Anxiety
- Insomnia
- Anorexia, weight loss
- Somatic symptoms (e.g., nonspecific chest pain, epigastric discomfort, headaches)
- Thoughts of preoccupation, about death, and memories of the deceased
- Illusions or hallucinations of the deceased (considered normal if the individual does not believe that they are real)
- No significant suicidal ideation
- No persistent or long-term functional impairment
- Preoccupation with thoughts and memories of the deceased and the circumstances surrounding their death
8
Q
List & Outline the stages of 2 Models of Normal Grief.
A
1 - Kubler-Ross Model
A model describing 5 stages of grief following a loss. Individuals may experience some or all of these stages and not always in the order presented below.
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
2 - The four phases of grief model
Proponents of this model believe that grief is a waxing and waning of the emotional process instead of fixed phases.
1. Shock or numbness
2. Yearning or searching
3. Disorganization or despair
4. Reorganization
9
Q
Persistent complex bereavement disorder
- Definition?
- Overview?
- Diagnostic Criteria: A, B, C, D, & E?
- Management?
A
10
Q
What is End of Life Counselling?
- 4 Goals?
- Describe how counseling for terminally ill patients is performed.
A
Definition: End-of-life counseling is an individualized, holistic, patient-centered approach that addresses the dying person’s practical, psychological, emotional, and spiritual care needs.
Goals
1. To involve the patient in end-of-life treatment decisions for improved care, comfort, and quality of life.
2. To provide comfort and psychosocial support for family and caregiver.
3. To determine the patient’s wishes regarding the involvement of others (e.g., family, caregivers) in care.
4. To inform all individuals involved in the patient’s care of the patient’s and family’s wishes regarding end-of-life treatment including palliative care.
11
Q
Describe how spiritual care and counseling can be provided to terminally ill patients.
- 3 Goals?
A
Goals of Spiritual Care/Counseling in Terminally Ill Patients
1. Reduction of psychosocial and spiritual distress.
2. Promotion of dignity and meaning at the end of life.
3. Improvement of overall quality of life through a supportive understanding of the patient’s spiritual and/or religious beliefs and values.
12
Q
How can End-of-life counseling be provided for families?
A
13
Q
How should family and friends of a deceased patient be addressed?
- 4 Helpful resources?
A
14
Q
Describe Counseling for individuals experiencing bereavement.
A
15
Q
How may a physician process the death of a patient?
A
16
Q
Discuss 10 strategies for facilitating collaborative decision-making on care goals with people with life-limiting illnesses and their families.
A
17
Q
Analyse the effect of care giving on the family networks of people with life-limiting illnesses.
- 8 Impacts?
A
Caring for a loved one with a life-limiting illness can have profound effects on family networks, impacting various aspects of their emotional, social, financial, and physical well-being.
18
Q
Describe 5 epidemiological and 6 clinical features along the illness trajectory of specific life-limiting illnesses - 1) advanced malignancy?
A
- Advanced malignancy refers to cancer that has spread from its site of origin to other parts of the body, typically resulting in a more aggressive and difficult-to-treat disease.
- The epidemiological and clinical features of advanced malignancy vary depending on factors such as the type and stage of cancer, treatment history, and individual patient characteristics
- Overall, advanced malignancy represents a complex and challenging illness trajectory characterized by progressive symptoms, functional decline, and significant palliative and supportive care needs.
- A multidisciplinary approach involving oncologists, palliative care specialists, nurses, social workers, and other healthcare professionals is essential to address the diverse needs of patients and families throughout the illness trajectory.
19
Q
Describe 5 epidemiological and 8 clinical features along the illness trajectory of specific life-limiting illnesses - 2) end stage cardiac disease?
A
- End-stage cardiac disease, also known as advanced heart failure, refers to a stage of heart disease in which the heart’s ability to pump blood efficiently is severely impaired, leading to significant symptoms and limitations in daily functioning.
-In summary, end-stage cardiac disease is a complex and challenging health condition characterized by progressive symptoms, functional decline, and significant palliative and supportive care needs. - Early recognition of symptoms, comprehensive management, and timely integration of palliative care are essential to optimize outcomes and enhance quality of life for patients and families affected by end-stage cardiac disease.
20
Q
Describe 5 epidemiological and 7 clinical features along the illness trajectory of specific life-limiting illnesses - 3) end stage respiratory disease?
- List 8 examples of life-limiting illnesses of the respiratory tract?
A
- End-stage respiratory disease, also known as advanced respiratory failure or end-stage lung disease, refers to a stage of chronic respiratory conditions characterized by severe and irreversible impairment of lung function, resulting in significant symptoms and limitations in daily functioning.
- Examples:
1. COPD
2. Idiopathic Pulmonary Fibrosis (IPF)
3. Cystic Fibrosis
4. Pulmonary Hypertension
5. Lung Cancer
6. Bronchiectasis
7. ILD
8. Alpha-1 Antitrypsin Deficiency
21
Q
Describe 5 epidemiological and 6 clinical features along the illness trajectory of specific life-limiting illnesses - 4) renal failure?
A
- Renal failure, also known as end-stage renal disease (ESRD) or chronic kidney disease (CKD) stage 5, refers to a condition in which the kidneys lose their ability to adequately filter waste products and regulate fluid and electrolyte balance, leading to significant impairments in kidney function.
22
Q
Describe 5 epidemiological and 6 clinical features along the illness trajectory of specific life-limiting illnesses - 5) progressive neurological disease?
- List 8 examples of life-limiting progressive neurological diseases?
A
- Progressive neurological diseases encompass a range of conditions characterized by the gradual degeneration and dysfunction of the nervous system, leading to progressive disability, impairment of motor and cognitive function, and significant challenges in daily functioning.
- Examples:
1. Alzheimer’s Disease
2. Parkinson’s Disease
3. Amyotrophic Lateral Sclerosis (ALS)
4. Huntington’s Disease
5. Multiple Sclerosis
6. Motor Neuron Diseases: Primary lateral sclerosis (PLS) and Progressive muscular atrophy (PMA)
7. Spinocerebellar Ataxias
8. Frontotemporal Dementia
23
Q
List some of the Nonpharmacological therapies available to Palliative Care Patients.
- 3 Spiritual and social services?
- 4 Physical interventions?
- Mental health interventions?
A
24
Q
List some of the Nonopioid pharmacotherapy available to Palliative Care Patients.
- 1st line agents?
- Neuropathic pain?
- Metastatic bone pain?
A
Nonopioid pharmacotherapy
- First-line agents: acetaminophen and NSAIDs
- Neuropathic pain: Consider adding gabapentinoids and antidepressants.
- Metastatic bone pain: Consider adding bisphosphonates and denosumab. Consult radiation oncology for external beam radiotherapy.
25
**Assess the common symptoms and health problems associated with life-limiting illnesses - 1) Pain.**
- Description?
- Associated conditions?
- Assessment and Management?
26
**Assess the common symptoms and health problems associated with life-limiting illnesses - 2) Delirium.**
- Description?
- Associated conditions/Aetiologies in palliative care?
- Assessment and Management?
27
**Assess the common symptoms and health problems associated with life-limiting illnesses - 3) Nausea & Vomiting.**
- Description?
- Associated conditions?
- Assessment and Management?
28
**Assess the common symptoms and health problems associated with life-limiting illnesses - 4) Constipation**
- Description?
- Associated conditions?
- Assessment and Management?
29
**Assess the common symptoms and health problems associated with life-limiting illnesses - 5) Dyspnoea**
- Description?
- Associated conditions?
- Assessment and Management?
30
**Assess the common symptoms and health problems associated with life-limiting illnesses - 6) Anxiety**
- Description?
- Associated conditions?
- Assessment and Management?
31
**What is 'Hospice/EOL' care?**
- 4 Principles?
- Who is eligible?
- Facilities/Services?
**Hospice/EOL** = Type of palliative care specifically given to patients at the end of life.
**Principles**
1. Preserve the dignity of patients during the final stages of life.
2. Provide maximum comfort to the patient.
3. Ensure pain relief (including administration of opioids, anxiolytics, or sedatives). Not all treatment should be withdrawn. Antibiotics, for example, can still be given if the patient develops an infection.
4. Prioritize positive effects over potential negative effects (e.g., pain relief over the risk of respiratory depression), according to the ethical principle of double effect.
**Who is eligible for hospice care?**
1. Estimated life expectancy < 6 months
2. Patients are usually on Medicare, Medicaid, or private insurance plans.
3. The patient (and family) has made the decision to stop curative or life-preserving treatment in order to maximize quality of life.
32
**Deprescribing medications in Palliative Care**
- 2 General considerations?
- 3 Considerations for deprescribing?
- 6 Drugs considered for deprescribing?
33
Analyse and explain 8 principles of management, including pre-emptive prescribing, for the amelioration of physical symptoms, psychological problems and spiritual concerns in the terminal phase.
**4. Symptom Management:**
**Physical Symptoms**:
1. **Pain**: Use a stepwise approach to pain management, starting with non-opioid analgesics and escalating to opioids as needed. Consider adjuvant medications for neuropathic pain or breakthrough pain.
2. **Dyspnoea**: Provide oxygen therapy as needed and use bronchodilators, opioids, or benzodiazepines for symptom relief. Consider non-pharmacological interventions such as positioning or fan therapy.
3. **Nausea and Vomiting**: Prescribe antiemetics such as metoclopramide or haloperidol for symptom control, adjusting dose and route as needed.
**Psychological Problems:**
1. **Anxiety and Depression**: Use anxiolytics (e.g., lorazepam) or antidepressants (e.g., selective serotonin reuptake inhibitors) for symptom relief. Offer supportive counseling, psychotherapy, or spiritual care as needed.
2. **Delirium**: Identify and address underlying causes such as infections, medications, or metabolic disturbances. Use low-dose antipsychotics (e.g., haloperidol) for agitation or hallucinations.
**Spiritual Concerns:**
- Provide spiritual care and support, respecting the patient's beliefs, values, and cultural practices.
- Offer opportunities for prayer, meditation, or pastoral care. Facilitate discussions about existential concerns or end-of-life wishes.
34
Identify 5 interventions that will optimise physical function for people with life-limiting illnesses and their families.
35
Identify 5 interventions that will optimise psychological function for people with life-limiting illnesses and their families.
36
Identify 5 interventions that will optimise social function for people with life-limiting illnesses and their families.
37
**Focus Questions – Palliative Care Case**
A 74-year old woman is admitted to the general medical ward where you are working with jaundice. She was diagnosed with a large caecal carcinoma 2 years ago and underwent hemi- colectomy and adjuvant chemotherapy. In the last three months she has exhibited abdominal pain, 12kg weight loss and reduced mobility. Your registrar arranged abdominal computed tomography which demonstrates multiple hepatic metastases.
1) When is ‘palliative care’ or ‘treatment with palliative intent’ appropriate? (7 points)
"Palliative care" or "treatment with palliative intent" is appropriate in various circumstances across the illness trajectory, depending on the patient's needs, preferences, and goals of care.
Overall, palliative care or treatment with palliative intent is appropriate when the primary goals of care shift from prolonging life to optimizing quality of life, relieving suffering, and addressing the holistic needs of patients and their families throughout the illness trajectory. It is an approach that focuses on comfort, dignity, and support, regardless of the stage or severity of the disease.
38
**Focus Questions – Palliative Care Case**
A 74-year old woman is admitted to the general medical ward where you are working with jaundice. She was diagnosed with a large caecal carcinoma 2 years ago and underwent hemi- colectomy and adjuvant chemotherapy. In the last three months she has exhibited abdominal pain, 12kg weight loss and reduced mobility. Your registrar arranged abdominal computed tomography which demonstrates multiple hepatic metastases.
2) When do the palliative care goals replace the intention to continue active (potentially life- prolonging) therapies? (5 points)
39
3) How would you manage the patient optimally on your ward with the aim of facilitating ‘a good death’?
- 6 points?
**1) Symptom Management:**
1. **Pain**: Assess and manage pain effectively using a combination of pharmacological and non-pharmacological interventions. Prescribe appropriate analgesics, including opioids, and titrate doses based on pain severity and patient response. Consider adjuvant medications for neuropathic pain. Non-pharmacological interventions such as positioning, heat therapy, and relaxation techniques can also help alleviate pain.
2. **Jaundice**: Manage symptoms related to jaundice, such as pruritus, fatigue, and nausea, with medications and supportive measures. Ursodeoxycholic acid may be prescribed to reduce bile acid levels and alleviate pruritus. Provide skin care to prevent breakdown and discomfort.
3. **Fatigue**: Address fatigue through energy conservation techniques, scheduling rest periods, and providing support with activities of daily living. Encourage gentle exercise as tolerated to maintain mobility and function.
4. **Nausea and Vomiting**: Prescribe antiemetics as needed to control nausea and vomiting, considering the underlying cause and patient preferences. Offer small, frequent meals and encourage oral hydration to prevent dehydration.
40
What 8 specific complications or risks can be anticipated in this patient based on the pathophysiology of her disease and its progression?
Given the patient's history of caecal carcinoma with hepatic metastases, several specific complications or risks can be anticipated based on the pathophysiology of her disease and its progression:
1) **Jaundice and Biliary Obstruction**: The presence of multiple hepatic metastases can lead to biliary obstruction, resulting in jaundice, pruritus, and elevated bilirubin levels. This can contribute to discomfort and may require interventions such as biliary stenting or drainage to alleviate symptoms.
2) **Liver Dysfunction**: Hepatic metastases can impair liver function, leading to hepatic insufficiency, coagulopathy, and hypoalbuminemia. This may manifest as fatigue, ascites, easy bruising, and altered mental status.
3) **Portal Hypertension and Ascites**: Hepatic metastases can cause portal hypertension, leading to complications such as ascites, variceal bleeding, and hepatic encephalopathy. Ascites can contribute to abdominal discomfort, respiratory compromise, and increased risk of infection.
4) **Pain and Discomfort**: Abdominal pain, which the patient has been experiencing, is common in patients with hepatic metastases due to tumor infiltration, stretching of the liver capsule, or compression of surrounding structures. Pain management may be challenging and require multimodal approaches, including pharmacological and non-pharmacological interventions.
41
How reliable is eGFR in the palliative care (malignancy) population?
How might you calculate a more accurate GFR? (4)
**Creatinine Clearance (Cockcroft-Gault Equation)**
- Can be used to estimate kidney function for CKD staging.
- Can be used to adjust or discontinue medications based on kidney function.
42
How might you alter your opioid prescribing in response to the patient’s kidney function?
Switch to non-renally excreted: fentanyl & methadone
43
What are the risk factors for complicated grief? (10)
Complicated grief, also known as prolonged grief disorder or persistent complex bereavement disorder, is a condition characterized by intense and prolonged grief reactions that significantly impair daily functioning and well-being.
**Risk factors**
1. Female
2. Older age
3. An unexpected or violent death, such as death from a car accident, or the murder or suicide of a loved one.
4. Death of a child
5. Close or dependent relationship to the deceased person
6. Social isolation or loss of a support system or friendships
7. Past history of depression, separation anxiety or post-traumatic stress disorder (PTSD)
8. Traumatic childhood experiences, such as abuse or neglect
9. Other major life stressors, such as major financial hardships
44
What 7 interventions can you implement to assist a family in their grief response?
45
List 5 potential factors that may exacerbate the grief response?
46
Which patients should receive a palliative care approach?
47
How can patients
at risk of deteriorating and dying be identified?
What is the SPICT?
48
How might you introduce a patient to a palliative approach to care?
- What factors may influence the timing of the introduction of a palliative approach?
49
What are the benefits of an early introduction of a palliative approach to care?
50
Describe 4 Common illness trajectories in people approaching death with examples?
Patients with cancer and other life-limiting illnesses may become seriously ill on a number of occasions only to have their life prolonged for a significant but unpredictable period; this uncertainty can be stressful for the patient and their family. The use of drug therapy and other modern technologies to prolong life can introduce the phenomenon of prolonged dying, rather than a sustained period of life with quality. Discussion about which interventions are acceptable to a patient should be considered in advance care planning, while the patient is well enough to participate in discussions and before decision-making becomes urgent.
51
**Who provides palliative care?**
- Medical care?
- Nursing care?
**Nursing care**
- The nursing needs of palliative care patients range from basic hands-on care to complex and specialist problem solving. Any nurse may be required to provide palliative care on occasion.
- Specialist palliative care nurses and nurse practitioners are vital to the successful care of patients with complex problems, and in some settings may be the key healthcare providers.
- Doctors often rely on a nurse's clinical assessment of a palliative care patient for much of their decision-making, particularly when the patient is in the community or in a rural or remote area where daily review by doctors is not practical.
52
**Who provides palliative care?**
- Allied health care?
- Psychosocial, spiritual and other support?
- Families, carers, volunteers and community groups?
**Allied health care**
Allied health care providers bring a range of skills that are vital to help patients to achieve the best possible function and quality of life as their disease progresses. They can be particularly effective in helping a patient to remain in the community, or facilitating discharge from hospital to home. Allied health workers who may be involved in palliative care include occupational therapists, physiotherapists, pharmacists, speech pathologists and dietitians.
53
Where is palliative care provided?
- Places of care?
54
What are the 5 phases of palliative care?
The course of life-limiting illness has been defined in five phases that provide a common language to enhance communication between healthcare providers looking after palliative care patients. The Palliative Care Outcomes Collaborative (PCOC) uses these phases (and other standardised clinical assessment tools) to measure and benchmark patient outcomes in palliative care; many specialist palliative care services across Australia participate in the Collaborative. The five phases are described below (summarised and adapted from the PCOC clinical manual; for the full definitions see the PCOC clinical manual).
55
Outline the 5 phases of palliative care.
56
**What is Advanced Care Planning?**
- What information may be included in an advance care plan?
57
What is a Substitute decision-maker?
58
What are the 4 key ethical principles in healthcare?
Most ethical issues in palliative care relate to how decisions are made and the extent of medical investigation and treatment, including withholding or withdrawing treatment. Ethical dilemmas arise because of concerns or differing views about what kind of care is best for a patient, especially when the patient is unable to communicate their wishes or make decisions themselves. This can cause conflict between healthcare providers, patients and families.
59
List 8 healthcare provider factors and 8 work environment factors that can increase the risk of stress and burnout in a healthcare provider.
60
**Define Burnout.**
- 5 Physical and emotional effects?
- 8 Attitudes and behaviours?
‘Burnout’ is a term used to describe the progressive loss of idealism and commitment to work, leading to reduced energy and purpose, role dissatisfaction and the development of negative attitudes to patients, colleagues and oneself. It can overlap with anxiety and depression. Healthcare providers developing burnout may exhibit the features outlined in Figure 10.9. Having a reduced sense of accomplishment and loss of self-esteem can predispose healthcare providers to developing depressive illness.
61
List some of the self-care measures to help prevent stress and burnout in healthcare providers?
62
List 8 characteristics of Normal grief?
**Characteristics of Normal Grief**
1. Separation distress - preoccupation with thoughts or images of the deceased, especially yearning for the deceased
2. Intense sadness, tearfulness
3. Loss of usual levels of activity and capacity to undertake normal tasks
4. Withdrawal from others
5. Physical symptoms, including fatigue and loss of appetite
6. Sleep disturbance
7. Fleeting images and hallucinations involving the deceased
8. Anxiety about the future.
63
What are the 8 characteristics of Complicated grief?
64
**What are the Risk factors for complicated grief?**
- 4 personal factors?
- When is it more likely?
**Risk factors for complicated grief** - Personal factors that are associated with an increased risk of complicated grief, and potentially the need for clinical intervention, include:
1. Limited social support (including practical and emotional support for grief)
2. Previous difficulties coping with loss, or past traumatic loss
3. Multiple losses over time
4. A history of psychiatric illness, alcohol and other drug problems, or significant physical illness.
65
List some of the resources available for bereaved people?
- Resources for children, and families whose child has died?
1. Australian Centre for Grief and Bereavement—Grief information sheets for adults and children.
2. Calvary Health Care—Bereavement support across cultures.
3. CareSearch—Bereavement, loss and grief.
4. National Association for Loss and Grief—Brochures about grief.
5. Palliative Care Australia—Information about grief and links to telephone counselling.
6. Solace Australia—Group support programs for people whose partner has died.
66
**Emergency care presentations in palliative care - Acute severe pain**
- 5 principles?
- 5 options for dosing?
1) morphine 2.5 to 5 mg intravenously, repeated at 5-minute intervals as required.
2) morphine 2.5 to 5 mg subcutaneously, repeated at 10-minute intervals as required.
3) fentanyl 25 to 50 micrograms intravenously, repeated at 5-minute intervals as required.
4) fentanyl 25 to 50 micrograms subcutaneously, repeated at 10-minute intervals as required.
5) fentanyl 25 to 50 micrograms intranasally, as a single divided dose, repeated at 5-minute intervals as required.
67
Calculate an as-required breakthrough dose of IV morphine for a patient taking oral modified-release oxycodone 60mg BD.
68
Calculate an as-required breakthrough dose of IV fentanyl for a patient taking oral modified-release hydromorph 32mg Once Daily.
69
Calculate an as-required breakthrough dose of subcutaneous morphine for a patient using a transdermal fentanyl 25mg/hour patch.
70
**Emergency care presentations in palliative care - Acute severe dyspnoea**
- Which meds?
Relief of distress is paramount and pharmacological treatment with an opioid with or without a benzodiazepine can be effective. Carefully adjusting the dose of opioid to the level of dyspnoea can minimise the risk of causing respiratory depression.
Continue to review response and adjust the opioid and benzodiazepine doses until the dyspnoea is controlled; however, if dyspnoea is not controlled by the third dose, consider seeking specialist advice. Seek specialist support early if the likelihood of response to an opioid and benzodiazepine is in doubt.
71
**Emergency care presentations in palliative care - Acute Airway Obstruction**
- Which meds?
72
**Emergency care presentations in palliative care - Superior Vena Cava Obstruction**
- Which meds?
73
**Emergency care presentations in palliative care - Acute agitation and Altered mental state**
- Which meds?
74
**Emergency care presentations in palliative care - Spinal Cord Compression**
- Clinical symptoms?
- Which meds? Doses?
- When to cease?
If no benefit is seen within 5 days, cease the dexamethasone.
75
**Emergency care presentations in palliative care - Severe haemorrhage**
- Clinical symptoms?
- Which meds? Doses?
- When to cease?
76
**Emergency care presentations in palliative care - Seizures**
- Which meds? Doses?
Although emergency care staff may be experienced in managing seizures, carers in a home or nonacute care setting are unlikely to have that experience. For a palliative care patient, if seizures are considered likely to occur, it is important that:
- any required medication is available
- the carer is educated in first aid principles for management of a seizure.
- For acute management of seizures, a carer or emergency care provider may need to give a benzodiazepine if the seizure activity is not self-limiting.
- Parenteral routes are preferred because sublingual or intranasal medication may be difficult to administer if the seizure is generalised. Use:
77
List 10 specific symptoms seen in palliative care patients.
78
**Symptom assessment in palliative care**
- History?
- Examination?
- What other questions would you ask?
79
List 6 clinical assessment tools that can be used in palliative care?
80
**List the routes of drug administration in palliative care.**
- When might change be required?
- Options for patients with swallowing difficulties?
81
What are the Key steps for deprescribing in palliative care?
82
**Deprescribing specific medications in palliative care**
- Diabetes?
83
**Deprescribing specific medications in palliative care**
- Elevated blood pressure?
- Other cardiovascular conditions?
- Dyslipidaemia?
**Dyslipidaemia**
The effects of lipid-modifying drugs are measured over a number of months, while the cardiovascular benefits are measured over years. In patients who are expected to live for months, lipid-modifying drugs can generally be stopped safely.
84
**Deprescribing specific medications in palliative care**
- Anticoagulants?
85
**Deprescribing specific medications in palliative care**
- Anti-platelet drugs?
- Thyroid replacement therapy?
86
**Deprescribing specific medications in palliative care**
- Corticosteroids?
- Psychiatric drugs?
- Progressive neurological diseases?
87
**Deprescribing specific medications in palliative care**
- Epilepsy?
- Long-term antiviral therapy?
88
List some of the uses of Steroids in palliative care.
- Corticosteroids are commonly used to manage several symptoms associated with malignant disease.
- These include nausea, vomiting, depression, fatigue, anorexia and cachexia.
- There are many uses for corticosteroids in cancer patients including bone pain, spinal cord compression, brain metastases or primary tumor, and bowel obstruction.
89
List 6 mechanisms of action of anti-emetics and examples of each.
- Neurotransmitters involved?
- Histamine via H1 receptors
- Serotonin via 5HT3 receptors
- Acetylcholine via M receptors
- Dopamine via D2 receptors
90
Explain the pathophysiology of emesis.
91
8 Classifications of Anti-Emetic drugs with examples?
92
**Metoclopramide**
- MOA?
- Use as an anti-emetic?
- Use an a prokinetic?
- Adverse effects?
- 6 Uses?
Uses - Potent antiemetic controls/ reduces vomiting due to:
1. Uraemia
2. Radiation
3. Viral gastro-enteritis, hepatic-biliary disease
4. Anticancer drugs
5. Migraine
6. Post-operatively
93
Why would you avoid using Ondansetron as an anti-emetic in palliative care?
It is very constipating.
94
What are 6 classes of laxatives and examples of each?
**Types of laxatives** - There are four main groups of laxatives that work in different ways.
1. **Bulk-forming laxatives** (also known as fibre supplements). For example, ispaghula (psyllium) husk, methylcellulose and sterculia. Unprocessed bran is a cheap fibre supplement.
2. **Osmotic laxatives**. For example, lactulose, macrogols, (also called polyethylene glycol, or PEG), phosphate enemas and sodium citrate enemas.
3. **Stimulant laxatives**. For example, bisacodyl, docusate sodium, glycerol, senna and sodium picosulfate.
4. **Faecal softeners**. For example, arachis (peanut) oil enemas, and liquid paraffin.
95
What is Movicol?
What is Bisacodyl?
**Osmotic laxatives**
- MOA: Osmotic laxatives draw water from the rest of the body into your bowel to soften poo and make it easier to pass.
- They take 2 or 3 days to work.
- They include: lactulose (also called by the brand names Duphalac and Lactugal) & macrogol (also called by the brand names Movicol, Laxido, CosmoCol, Molaxole and Molative)
polyethylene glycol
**Stimulant laxatives**
- MOA: These stimulate the muscles that line your gut, helping them to move poo along to your back passage.
- They take 6 to 12 hours to work.
- They include: bisacodyl (also called by the brand name Dulcolax) & senna (also called by the brand name Senokot) & sodium picosulfate
96
