Cancer / palliative care / analgesia Flashcards
State what is meant by ‘end of life’
When a person is likely to die within the next 12 months
Think of the surprise question ‘would you be surprised if ‘Y’ died within the next 12 months?
State the tool used to help identify people whose health is deteriorating and the 6 general indicators of decline
SPICT tool - “Supportive and Palliative Care Indicators Tool”
- Helps to identify people whose health is deteriorating
1) Significant weight loss or remaining underweight
2) Increased dependance on others for care
3) Reducing WHO performance status
4) Persistent symptoms despite optimal management
5) Patient themselves declines treatment or asks for palliative care
6) Multiple unplanned hospital admissions
State some features present in the dying stage (respiratory / oral / neurological) aka. that suggest a patient is dying
Respiratory / circulation:
- Respiratory secretions
- Shallow breathing
- Cheyne-Stokes respiratory pattern
- Use of accessory muscles of respiration
- Skin colour changes
- Temperature change at extremities
Oral:
- Difficulty swallowing
- Decreased / absent oral intake
Neurological:
- Decreasing level of consciousness
- Agitation / restlessness
- Decreased urine output / incontinence
State 5 indication to consider in anticipatory prescribing and the medications you could use
1) Pain
2) Breathlessness
3) Respiratory secretions
4) N&V
5) Restlessness / agitation
Medications:
1) Pain - Morphine 2-2.5mg SC PRN
2) Breathlessness - Morphine 2-2.5mg SC PRN
3) Respiratory secretions - Glycopyronium 200-400mcg SC PRN (MAX 4 HOURLY)
4) N&V - Levomepromazine 2-2.5mg SC PRN
5) Restlessness / agitation - Midazolam 2.5-5mg SC PRN
Outline the difference between best supportive care and palliative care
Best supportive care:
- Starts from diagnosis
- Helps the patient and their family to cope with their condition and treatment of it (through the process of diagnosis, continuing illness or death and into bereavement)
- Helps to maximise the benefits of treatment and to live as well as possible with the effects of the disease
Whereas palliative care only takes over from advanced disease, or death and into bereavement. Part of best supportive care, with active holistic care of patients with advanced progressive illness
- Optimising QOL through management of pain and other symptoms and provision of psychological, social and spiritual support is paramount
+ End of life care is a form of palliative care, when someone is close to the end of life
Outline the difference between nociceptive and neuropathic pain (including character) and how it is treated differently
Nociceptive = visceral or somatic from intrinsic damage to soft tissue / bone
- ‘Traditional pain’
- Dull / sharp
- Can radiate
Neuropathic = intrinsic damage to nerves
- Burning / shooting / stinging
- Paraesthesia
- Numbness
- Allodynia (sensitivity to normally non-painful stimuli e.g. feather)
List some drugs useful in neuropathic pain
Gabapentin / Pregabalin = anticonvulsants
Duloxetine = SSNRI
Amitriptyline = tricyclic antidepressant
Diazepam = benzodiazepine
Dexamethasone = steroid
Zoledronic acid (bisphosphonates for bone pain)
For the following drugs used in neuropathic pain, state their drug class
- Gabapentin / Pregabalin
- Duloxetine
- Amitriptyline
- Diazepam
- Dexamethasone
- Zoledronic acid
Gabapentin / Pregabalin = anticonvulsants
Duloxetine = SSNRI
Amitriptyline = tricyclic antidepressant
Diazepam = benzodiazepine
Dexamethasone = steroid
Zoledronic acid (bisphosphonates for bone pain)
What are adjuvants for pain relief and when should their use be considered
Adjuvants for pain relief are drugs whose primary purpose isn’t pain relief
Should be considered when pain only partially managed by opioids, or if opioids not effective
List analgesia in the WHO pain ladder (step 1, step 2, step 3)
Step 1 (non-opioid):
- Paracetamol
- NSAIDs e.g. Ibuprofen or Naproxen (Celecoxib if GI risk) + PPI
+ non-opioid analgesia e.g. adjuvants
Step 2 (weak opioid):
- Codeine / Dihydrocodeine
- Co-codamol
- Tramadol
Step 3 (strong opioid):
- Morphine / Diamorphine
- Oxycodone
- Fentanyl
- Buprenorphine
State 3 main side effects from opioids in patients with advanced cancer
- N&V
- Constipation
- Drowsiness / reduced QOL
Outline the conversion dose from Codeine to Morphine
Divide by 10
Codeine : Morphine = 10:1
E.g. 10mg of Codeine = 1mg of Morphine
Outline how to calculate new opioid pain relief pain for a patient struggling with pain
Add up total daily dose (include regular opioids and PRN opioids)
Regular background dose = total daily dose / 2 (bd)
PRN = total daily dose / 6
State the conversion from oral Morphine to
1. Subcut
2. IV
Oral : subcut = 2:1
Oral : IV = 3:1
State 2 drugs which should be prescribed alongside opioid drugs
- Antiemetics e.g. Metoclopramide or Laxido
- Laxatives
