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MD4001 WEEK 10 > Palliative care > Flashcards

Palliative care Flashcards

1
Q

Describe the national importance plans of palliative care in Scotland.

A

– Living and Dying well- 2008 - updates 2011 and 2012
– Scottish Government Quality strategy- 2020 vision
(Palliative and End of Life Care Strategic Framework for Action)

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2
Q

Describe the national importance plans of palliative care in England.

A

– End of life care strategy 2008
– Everyone Counts: Planning for Patients 2014/15 to 2018/19
(Actions for End of Life Care: 2014-16)

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3
Q

Describe the national importance plans of palliative care in Wales.

A

– Together for Health – End of Life Delivery Plan 2013

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4
Q

Describe palliative care.

A

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

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5
Q

How does the GMC define end of life?

A

‘Approaching the end of life’
– likely to die within the next 12 months

Those facing imminent death and those with:
– Advanced, progressive, incurable conditions
– General frailty (likely to die in 12 months)
– At risk of dying from sudden crisis of condition
– Life threatening conditions caused by sudden catastrophic events

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6
Q

What are the key themes for development in palliative care?

A
  • Early identification of patients who may need palliative care
  • Advance/anticipatory care planning (including decisions regarding cardiopulmonary resuscitation (DNACPR))
  • Care in last days/hours of life
  • Delivery of effective and timely care
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7
Q

What are the aims of palliative care?

A
  • Whole person approach
  • Focus on quality of life, including good symptom control
  • Care encompassing the person with the life- threatening illness and those that matter to them
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8
Q

What are the principles of good end of life care?

A
  • Open lines of communication
  • Anticipating care needs and encouraging discussion
  • Effective multidisciplinary team input
  • Symptom control – physical and psycho-spiritual
  • Preparing for death - patient and family
  • Providing support for relatives both before and after death
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9
Q

Describe generalist palliative care.

A

Integral part of the routine
care delivered by all health and social care professionals to those living with a progressive and incurable disease, whether at home, in a care home, or in hospital

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10
Q

Describe specialist palliative care.

A

Based on the same principles of palliative care, but can help people with more complex palliative care needs

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11
Q

Describe the multidisciplinary team.

A
  • Specialist nurses (macmillan, community, hospice, other)
  • Palliative care doctors
  • GP
  • Secondary care (non-palliative teams)
  • District nurses
  • Occupational therapists
  • Dieticians
  • Physiotherapists
  • Counsellors
  • Chaplain etc…
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12
Q

Describe the symptoms of end of life.

A 
Physical
– Pain
– Dyspnoea
– Nausea/vomiting
– Anorexia / weight loss 
– Constipation
– Fatigue
– Cough etc, etc...
Psycho-spiritual
Medical / surgical emergencies
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13
Q

Describe the characteristics of pain.

A
  • Can be multifactorial
  • Most patients have more than one pain
  • Background/ Breakthrough/Incident pain
  • Physical causes:
    – Cancer related (85%)
    – Treatment related
    – Associated factors-cancer and debility
    – Unrelated to cancer
  • Overlap of physical/ psycho-spiritual causes
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14
Q

Describe bone pain.

A

Worse on pressure or stressing bone / weight bearing

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15
Q

Describe nerve pain (neuropathic).

A

Burning/shooting/tingling/jagging/altered sensation

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16
Q

Describe liver pain.

A

Hepatomegaly/right upper quadrant tenderness

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17
Q

Describe raised intracranial pressure pain.

A

Headache (and/or nausea) worse with lying down, often present in the morning

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18
Q

Describe colic pain.

A

Intermittent cramping pain

19
Q

Describe the steps of WHO analgesic ladder for pain.

A

Step 1:
Non opioid: (eg. aspirin, paracetamol or NSAID)
+/- adjuvant

Step 2:
Weak opioid: (for mild to moderate pain e.g.. codeine) +/- non-opioid
+/- adjuvant
(Other Step 2: (weak opioid): Dihydrocodeine; Tramadol)

Step 3: for moderate to secrete pain (e.g. morphine) +/- non-opioid
+/- adjuvant
(Others Step 3: strong opioid): Diamorphine; Fentanyl; Oxycodone)

20
Q

How effective is the WHO pain ladder?

A

70–90% effective

21
Q

What is the preferred route for the pain ladder?

A

The oral route is preferred for all steps of the pain ladder

22
Q

Describe the times analgesics should be given in the pain ladder.

A

Cancer pain is continuous - analgesics should be given at regular intervals, not on demand

23
Q

Describe adjuvants.

A

To help calm fears and anxiety, adjuvant drugs may be added at any step of the ladder”

24
Q

What is the 1st line strong opioid?

A

Morphine

25
Q

What are the indications for opioids?

A

– Moderate-severe pain/ dyspnoea

26
Q

What are the actions of opioids?

A

– Opioid receptor agonist (μ-receptors)

– Centrally acting

27
Q

What are the cautions of opioids?

A

– Longlist in BNF; including renal impairment and elderly; Avoid in acute respiratory depression
– ‘…in the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to use of opioid analgesics’

28
Q

What are the side-effects of opioids?

A

– Most common
N&V, constipation, dry mouth, biliary spasm
Watch for signs of opioid toxicity…

29
Q

Describe administration of opioids.

A

– Enterally- oral/ rectal
– Parenterally- im / sc injections
– Delivery via syringe driver over 24 hours

30
Q

Describe the signs of opioid toxicity.

A 
– Shadows edge of visual field – Increasing drowsiness
– Vivid dreams / hallucinations 
– Muscle twitching / myoclonus 
– Confusion
– Pin point pupils
– Rarely, respiratory depression
31
Q

Describe modified release morphine.

A
  • Background pain relief
  • Either twice daily preparations at 12 hourly intervals
  • OR once daily preparation at 24 hourly intervals
32
Q

Describe immediate release morphine.

A
  • Breakthrough pain
  • As required
  • Eg. Oramorph liquid/ Sevredol tabs
33
Q

How can constipation from morphine be treated?

A

ALMOST ALWAYS GIVEN

  • Stimulant and softening laxative
  • Senna/ Bisacodyl + Docusate
  • Magrogol eg.laxido/movicol
  • OR Co-Danthramer alone
34
Q

How can nausea from morphine be treated?

A
  • Antiemetic
  • Metoclopramide
  • Haloperidol (consider QT interval)
35
Q

Describe the principles to bio by for moving onto STEP 3.

A
  • Stop any Step 2 weak opioids
  • Titrate immediate release strong opioid
  • Convert to modified release form
  • Monitor response and side effects
36
Q

Describe the adjunct medications used for liver capsule pain/raised intracranial pressure.

A
  • Steroids (eg. Dexamethasone)

remember to consider gastroprotection

37
Q

Describe the adjunct medications used for neuropathic pain.

A
  • Amitriptyline/ Gabapentin / Carbamazepine
38
Q

Describe the adjunct medications used for bowel/bladder spasm.

A
  • Buscopan (Hyoscine Butylbromide)
39
Q

Describe the adjunct medications used for bony pain/soft tissue infiltration.

A
  • NSAIDs/ Radiotherapy for bony metastases
40
Q

Describe Diamorphine.

A
  • Semi-synthetic morphine derivative
  • More soluble than morphine -> smaller volumes needed
  • Can be used for parenteral administration (injection/syringe driver)
41
Q

Describe Oxycodone (Oxynorm/Oxycontin).

A
  • Second line opioid

- Less hallucinations, itch, drowsiness, confusion

42
Q

Describe the Fentanyl patch.

A
  • Second line opioid
  • Lasts 72 hours
  • Only use in stable pain
  • Useful if oral and subcutaneous routes not available
  • Useful if persistent side-effects with morphine/ diamorphine
43
Q

Describe syringe drivers.

A
  • Delivery over 24 hours - usually subcutaneous
  • Useful when oral route inappropriate
  • Often useful for rapid symptom control
  • Multiple mediations can be added

MD4001 WEEK 10 (12 decks)

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