Cancer and palliative care Flashcards
(44 cards)
Management of weakness, fatigue and drowsiness in palliative care
- treat the reversible causes: drugs, emotional, biomedical abnormalities, anaemia, infection, poor nutrition, prolonged bed rest, raised ICP
- advice on lifestyle modification
- if Sx persists, dexamethasone 4mg/d OR antidepresssant +
psychological support for patients & carers
+ referral to physio, review aids & appliances, home layout/ home care.
A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia, and her diet mainly consists of pureed food. She has no advance directives, and her daughter says that when her mother was independent, she mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 are within the reference range. Her serum albumin concentration is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Short term rehabilitation
B. Prescribe oxycodone
C. Home hospice care
D. Insert feeding tube
E. Inpatient palliative care
This patient has already had advanced dementia (as indicated by her speech problems, total functional dependence, food regurgitation, and incontinence) for at least 1 year. Given that the average life expectancy after the onset of severe dementia is < 18 months, the patient’s estimated life expectancy is likely < 6 months
Answer: C
This patient is malnourished, has advanced Alzheimer dementia, and is almost completely dependent on all activities of daily living. Onset and progression of feeding difficulties is a hallmark of advanced dementia and indicates a poor prognosis. Considering that her life expectancy is likely under 6 months, she qualifies for hospice care. While this patient lacks decision-making capacity at this time, she expressed that she would not want resuscitation or life-saving procedures in the past, which constitutes another indication for hospice care for this patient.
For anaemic pallitiave patient, if Hb <____g/dL, and symptomatic, consider transfusion.
If Hb <10 g/dL and symptomatic Treat any reversible cause (e.g. iron deficiency, GI bleeding 2° to NSAIDs). Consider transfusion
If transfused Record whether any benefit is derived (as if not, further transfusions are futile) and the duration of benefit (if <3 wk—repeat transfusions are impractical). Monitor for return of symptoms; repeat FBC and arrange repeat transfusion as needed
Hypercalcaemia occurs with which malignancies?
10% malignant tumours—> particularly myeloma (>30%) and breast cancer (40%).
Management of hypercalcaemia
Depending on the general state of the patient, make a decision whether to treat the hypercalcaemia or not.
If a decision is made not to treat, provide symptom control and do not check the serum calcium again.
Hypercalcaemia can be fatal. if Ca2+ >3.5mmol/L or severe Sx, admit for lowering of Ca2+ with forced diuresis + IV biphopshonate
see p.336
For diagnosis of cause of hypercalcaemia:
if albumin level normal/ low,
phosphate high/ normal,
Alk phos high
It could suggest _____
bone metastases
sarcoidosis
thyrotoxicosis
For diagnosis of cause of hypercalcaemia:
if albumin level normal/ low,
phosphate high/ normal,
Alk phos normal
It could suggest _____
myeloma
excess Vit D
Milk alkali syndrome
A 65-year-old man is admitted to the hospital because of a 1-month history of fatigue, intermittent fever, and weakness. Results from a peripheral blood smear taken during his evaluation are indicative of possible acute myeloid leukemia. Bone marrow aspiration and subsequent cytogenetic studies confirm the diagnosis. The physician sets aside an appointed time-slot and arranges a meeting in a quiet office to inform the patient about the diagnosis and discuss his options. He has been encouraged to bring someone along to the appointment if he wanted. He comes to the office at the appointed time with his daughter. He appears relaxed, with a full range of affect. Which of the following is the most appropriate opening statement in this situation?
A. “I may need to refer you to a blood cancer specialist because of your diagnosis. You may need chemotherapy or radiotherapy, which we are not equipped for.”
B. “Your lab reports show that you have an acute myeloid leukemia”
C. “What is your understanding of the reasons we did bone marrow aspiration and cytogenetic studies?”
D. “Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?”
E. “You must be curious and maybe even anxious about the results of your tests.”
C.
When delivering bad news, physicians should follow the SPIKES protocol.
- creating an appropriate SETTING;
- addressing the patient’s PERCEPTION of his/her situation;
- seeking the patient’s INVITATION;
- giving KNOWLEDGE to the patient regarding diagnosis and prognosis;
- addressing the patient’s EMOTIONS;
- providing a management STRATEGY and SUMMARY of what had been discussed so far.
Mangement for Deep gnawing pain that is Worse on moving/weight bearing in palliative care
This is bone pain
Try NSAIDs and/or strong opioids
Consider referral for palliative radiotherapy, strontium treatment (prostate cancer), or IV bisphosphonates (decrease pain in myeloma, breast, and prostate cancer)
Refer to orthopaedics if any lytic metastases at risk of
fracture, for consideration of pinning
For sharp ache pain in the abdominal area that is worse on bending or breathing, what’s the management?
For Burning/shooting pain associated with altered sensation, what’s the management?
for rectal pain, what’s the management?
for muscle pain, what’s the management?
for bladder pain or spasm, what’s the management?
For pain of short duration e.g. from dressing changes, what’s the management?
try a breakthrough dose of oral duration morphine 20min prior to the procedure
A 78-year-old man with stage IV non-small cell lung cancer is admitted to the hospital for palliative care because of a 2-day history of severe bone pain and insomnia. He has not received opioid medications in the past. Treatment with intravenous morphine via a patient-controlled pump is initiated. Twelve hours later, the patient says, “The pain is still unbearable, please do something or help me sleep forever. I can’t do this anymore.” His temperature is 37.0°C (98.6°F), pulse is 106/min, respirations are 21/min, and blood pressure is 142/72 mm Hg. Examination shows shallow breathing. The patient-controlled analgesia system is checked and found to be functioning properly. Which of the following is the most appropriate next step in management?
A. Increase morphine dosage as needed for pain control
B. Change morphine to a nonopioid analgesic and add zolpidem for insomnia
C. Remove the patient-controlled pump immediately to prevent intentional morphine overdose
D. Continue morphine therapy at the same dosage to avoid respiratory depression
E. Request psychiatric evaluation to assess for suicidal ideation
The shallow but rapid breathing, insomnia, and features of sympathetic activation (e.g., tachycardia, hypertension) are most likely due to pain. For terminally ill patients, pain relief is prioritized over the potential adverse effects of pain medication (i.e., the principle of double effect).
Answer: A
This patient’s severe, persistent pain indicates that he is currently not receiving an adequate dosage of morphine. Under close monitoring, a titrated increase in opioid dosage (typically by 25–50% every 24 hours until the desired pain relief is achieved) minimizes the risks of severe side effects (e.g., respiratory depression). For individuals on patient-controlled analgesia, this dosage titration can be achieved by decreasing the duration of the lockout period, increasing the single bolus limit, and/or increasing the daily dose limit of the opioid. In addition, a continuous low-dose infusion of opioids or nonopioid analgesics can be used as an adjuvant for pain relief.
A 78-year-old man receiving home hospice care for advanced metastatic prostate cancer is examined at home at the request of his wife. He was diagnosed with prostate cancer 10 months ago, and the cancer has metastasized to his lower spine, pelvis, right femur, liver, and lungs despite hormonal ablation therapy. The patient declines chemotherapy. His wife reports difficulty managing her husband’s pain and that he is restless. He has avoided solid food for the past 2 weeks and has lost weight. He often coughs after drinking water. Current medications include extended-release morphine, acetaminophen, oxycodone as needed, and lactulose. The patient appears to be in moderate distress. Temperature is 37.9°C (100.2°F), pulse is 102/min, respirations are 24/min, and blood pressure is 121/85 mm Hg. Physical examination shows decreased skin turgor and dry mucous membranes. Cardiopulmonary examination shows no abnormalities. There is severe tenderness to palpation of the lower back, and the patient is unable to sit up on his own due to pain. Which of the following is the most appropriate next step in management?
A. Schedule external beam radiation therapy
B. Prescribe a transdermal fentanyl patch
C. Prescribe diazepam for the evenings
D. Prescribe codeine for the evenings
E. Have the patient crush his morphine pills and take them with soft foods
Answer: B
This patient is in distress due to insufficiently controlled pain, and he has dysphagia. Accordingly, his oral medications should be reduced as much as possible, and a non-oral form of analgesia is the most appropriate next step in management. Fentanyl is a synthetic full opioid agonist with a higher potency than morphine. The transdermal formulation of fentanyl is indicated in the treatment of chronic pain, providing steady analgesia because it diffuses continuously into the blood.
TIP:
This terminally ill patient has insufficient pain control, as evidenced by his restlessness, tachycardia, and tachypnea.
To become eligible for hospice care, a patient must have an estimated life expectancy of < ____ and decide to forgo therapies that have life-prolonging intent.
6 months
A 78-year-old woman receiving home hospice care for end-stage metastatic colon cancer is examined at her daughter’s request because of a 2-week history of progressive breathlessness. She reports that her mother has been bedridden for the past 3 months and started sleeping in an upright position in the last few days. Two months ago, a percutaneous endoscopic gastrostomy (PEG) tube was placed because the patient was unable to feed herself. For the past day, she refuses to drink water or to be fed through the PEG tube. Medications include morphine, magnesium hydroxide, metoclopramide, and dexamethasone. The patient appears cachectic. Pulse is 85/min, respiratory rate is 11/min, and blood pressure is 110/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. The skin overlying the PEG catheter appears well perfused with no tenderness to palpation and no purulent discharge. Lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management for this patient’s breathlessness?
A. Administer supplemental oxygen
B. Increase morphine dosage
C. Add midazolam
D. Administer furosemide
E. Administer naloxone
TIP: Terminally ill patients with end-stage cancer commonly experience breathlessness during their last weeks of life
Answer: B
Systemic opioids (e.g., morphine) are indicated in patients with severe terminal dyspnea that is not relieved by nonpharmacological interventions (e.g., a fan, body posture aids, breathing techniques). Opioids relieve dyspnea through various mechanisms, including altering central perception of dyspnea, reducing anxiety, and decreasing the respiratory drive. The opioid dose should be slowly titrated until the optimal risk-benefit ratio between efficacy and adverse effects (e.g., constipation, nausea, pruritus, bronchospasm, drowsiness) has been reached. Patients and caregivers should be informed about the benefits and safe use of opioid therapy, as well as treatment of adverse effects (e.g., stimulant laxatives for constipation).
A is incorrect: Supplemental oxygen is recommended for symptom relief in palliative care patients with dyspnea and hypoxemia (oxygen saturation <95%). In nonhypoxemic patients, supplemental oxygen should not be used as there is no benefit over room air. Instead, airflow interventions (e.g., a hand-held fan) can be offered to the patient as supportive therapy.
C is incorrect: Benzodiazepines (e.g., midazolam) are a second-line pharmacological treatment option in palliative care patients with dyspnea-related anxiety and/or persistent dyspnea. Treating anxiety may reduce the severity of dyspnea. However, this patient shows no signs of anxiety and has not yet received nonpharmacological or first-line pharmacological therapies. Furthermore, monotherapy with benzodiazepines is not routinely recommended for terminally ill patients with dyspnea. Benzodiazepines are also used for palliative sedation, which may be initiated to relieve severe distress at the end of life in patients with refractory symptoms (e.g., breathlessness, pain), terminal agitation, or perceived discomfort. However, sedation should only be used after all other attempts to control or relieve symptoms have failed. The decision to start palliative sedation should be made under the guidance of a palliative care physician and/or a medical ethicist. Because the treatment induces unconsciousness and may hasten death, the plan should be discussed with the patient, caregivers, and/or family, who must give informed consent before sedation begins.
D: Diuretics, e.g., furosemide, are indicated to treat dyspnea in patients with pleural effusion due to congestive heart failure or pulmonary edema. However, this patient has no signs of an underlying condition and her dyspnea is likely caused by end-stage colon cancer.
E: Naloxone is indicated in patients with opioid-induced respiratory depression. Clinical features of opioid intoxication include a decreased respiratory rate, altered mental status, bilateral miosis, myoclonic jerks, and decreased bowel sounds. Although this patient is taking morphine and has a low respiratory rate, she does not present with any other features of opioid intoxication. Her dyspnea is likely caused by end-stage colon cancer, for which naloxone is not indicated.
What are the signs of opioid toxicity?
Altered mental status, euphoria
CNS depression (intensifies in combination with other CNS-depressing substances, such as alcohol, benzodiazepines)
Bilateral miosis (pinpoint pupils)
Respiratory depression (↓ respiratory rate and ↓ tidal volume), hemorrhagic lung eodema
Myoclonic jerks , seizures
↓ Gag reflex
↓ Bowel sounds
↓ Heart rate and ↓ blood pressure, hypothermia
Rhabdomyolysis
NOTE: Constipation is a very common adverse effect of opioid therapy. Unlike opioid associated nausea and vomiting this adverse effect does not improve with opioid tolerance. Unless there is a contra-indication, it is best practice to co-prescribe a laxative with a regular opioid.
For drug/toxin/metabolic induced nausea & vomiting, choice of antiemetic:
Haloperidol (1.5–5mg nocte)
Levomepromazine (5mg stat or 6.25mg nocte)
If persistent nausea due to opioids, consider changing opioid
For nausea & vomiting due to chemotherapy or radiotherapy , choice of antiemetic:
- Granisetron (1mg bd) or ondansetron (8mg bd PO or 16mg od PR ) –> chemo- or radiotherapy-induced vomiting
- haloperidol 1.5–5mg nocte—radiotherapy-induced vomiting
- Dexamethasone 4–8mg daily PO/sc—often given as part of
a chemotherapy regimen - Metoclopramide 20mg tds
For nausea & vomiting due to increased ICP, choice of antiemetic:
Dexamethasone 4–16mg/d
Cyclizine 50mg bd/tds (or 150mg/d via syringe driver)
For nausea & vomiting due to anxiety, fear or pain, choice of antiemetic:
- Benzodiazepines, e.g. diazepam 2–10mg/d or midazolam sc
- Cyclizine 50mg bd/tds
- Levomepromazine 6–25mg/d
