ECEPC Flashcards
(236 cards)
1
Q
What is palliative care?
A
The active, total care of the patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of social, psychological and spiritual problems is paramount.
2
Q
What is the surprise question?
A
Would I be surprised if the person were to die in the next 6-12 months?
3
Q
What is terminal care?
A
Management of a person in the last few days, weeks or months of their life when it is clear that the person is in a progressive state of decline.
4
Q
Where is the majority of palliative care delivered?
A
In GP and community nursing services.
Generalist Palliative care vs specialist palliative care
5
Q
What is involved in supportive care?
A
Self-help and support
User involvement
Information giving
Psychological support
Symptom control
Rehabilitation
Complementary therapies
Spiritual support
End of life and bereavement care
Social Support
6
Q
Who is part of the palliative care MDT?
A
Palliative medicine consultant
Clinical nurse specialist
Social worker
Spiritual care worker
Allied health professional (physiotherapist, occupational therapist, speech and language)
PharmacistW
7
Q
What is the leading cause of death (WHO, 2019)
A
Ischaemic Heart Disease
Stroke
COPD
Lower Respiratory infection
Neonatal conditions
Trachea, bronchus, lung cancer
Alzheimer disease and other dementias
Diarrhoeal disease
DM
8
Q
What is a holistic assessment?
A
Listening and discussing the situation with the patient
Opportunity to outline their wishes and preferences for further care
Clinical assessment covering physical, social, emotional and spiritual issues
ACP discussions
9
Q
How many people will develop and die from cancer?
A
1 in 2 will develop cancer
1 in 4 will diet from cancer
4/10 most common causes of death are from cancer
10
Q
How many new cases of cancer in the UK in 2016-2018? And how many deaths?
A
375,000
167,000 deaths
11
Q
What are the most common cancers?
A
Breast
Prostate
Lung
Bowel
12
Q
Where does stomach and bowel cancer metastasis to?
A
Liver
13
Q
Where does breast, lung and prostate cancer metastasis to?
A
Bone
14
Q
Where does breast and kidney cancer spread to?
A
Lung
15
Q
When does lung and breast cancer also spread to?
A
Brain
16
Q
What are the types of MND?
A
ALS (Amyotrophic Lateral Sclerosis)
Progressive Bulbar Palsy (PBP)
Progressive Muscular Atrophy
Primary lateral sclerosis
17
Q
What are the symptoms and prognosis of ALS?
A
Tripping, dropping things
Progressive weakness and wasting in limbs
Muscle cramps and stiffness
Prognosis - 2-5 years
18
Q
What are the symptoms and prognosis of PBP?
A
Affects muscles of face, throat and tongue. Symptoms include slurring of speech or difficulty swallowing.
Prognosis - 6 months to 3 years
19
Q
What are the symptoms of progressive musclar atrophy?
A
Weakness or clumsiness of the hands
Prognosis - More than 5 years
20
Q
What are the symptoms of PLS?
A
Weakness in the lower limbs
Clumsiness in the hands or speech
Prognosis 10-20 years
21
Q
What are the key symptoms of patients with MND?
A
Insomnia
Stiff joints
Dysphagia and nutritional needs
Dysarthria and communications needs
Drooling
Depression and emotional needs
Breathlessness and respiratory failure
22
Q
How do you manage insomnia in MND?
A
Look for cause ? pain, fear of choking, depression
AVOID night sedatives re: resp depresssion
23
Q
How do you manage stiff joints in MND?
A
Active/passive exercises, massage and positioning
NSAIDS
Muscle spasms - baclofen, gabapentin
Muscle cramps - quinine sulphate
Skin pressure - manage with regular turning and pressure relieving mattress
24
Q
How do you manage dysphagia in MND?
A
Referral to SLT
25
How do you manage dysarthria in MND?
Light writers, iPads or tablets
Alphabet boards, yes/no boards
26
How do you manage drooling in MND?
Hyoscine Hydrobromide Patch (can cause confusion and sedation)
Can use glycopyrronium as has less CNS side effects
Referral to Botulinum toxin A to reduce secretions
27
How do you manage breathlessness and respiratory failure in MND?
Nocturnal hypoventilation - poor sleep, nightmares, early morning headaches, daytime tiredness
Can treat with NIPPV which can be extended
28
What are the types of multiple sclerosis?
Relapsing Remitting RRMS
Secondary Progressive
Primary Progressive
Progressive relapsing
29
What is the incidence of multiple sclerosis?
Most commonly in patients in the 20s and 30s
3x more common in women
100,000 people have MS in the UK
Most common is relapsing remitting
30
What are the presenting symptoms of MS?
Changes in vision (painful eye movements), optic neuritis
Ascending motor/sensory dysfunction in limbs or face
Loss of balance, vertigo, clumsiness, gait changes
Pain and Spasticity
fatigue
Tingling, numbness
Sexual dysfunction
Loss of continence
31
What are the main symptoms of MS that are managed?
Pain
Ataxia/Tremor
Bowel and bladder disturbances
Spasticity
Emotional and cognitive disturbances (fatigue)
32
How do you manage pain in MS?
Can be neuropathic, nocioceptive, musculoskeletal and total
Neuropathic pain: Gabapentin, pregabalin, amitriptyline
Musculoskeletal pain: Back pain - NSAIDs or paracetamol
Physiotherapy - Active and Passive excercises, wheelchair, mobility aids, massage, acupuncture
33
What is Lhermitte's sign
Intermittent burning or electric shocks on neck flexion.
Can use a cervical collar to help
34
What is Trigeminal neuralgia treated with?
Carbamazepine
Gabapentin
35
What is the management of ataxia and tremor in MS?
Early occupational therapy and pelvic and thoracic support
Equipment aids
36
What are the symptoms of bladder disturbances?
Hyperreflexia of bladder - associated with low volume capacity bladder and symptoms of urgency, frequency and incontinence.
37
What do you manage bladder disturbance in MS?
Oxybutynin or tolterodine
Incoplete bladder emptying - intermittent self catheterisation
Noctural incontinence - desmopressin nasal spay
38
How do you manage constipation in MS?
Balanced diet
Regular laxatives or suppositories/enema
39
What is spasticity in MS?
Increased muscle tone - can be painful and cause difficulty with daily functions and sleeping. Can be aggravated by constipation, urinary tract infections or pressure sores.
40
What is the first line management of spasticity in MS?
Baclofen 5mg TDS - any reduction in dose should be gradual as can cause hallucinations
Gabapentin 300mg nocte
Slower titration in the elderly
41
What is the second line management of spasticity in MS?
Dantrolene sodium (25mg) daily
Tizanidine - alternative to baclofen
Can cause sedation and dry mouth and liver function should be monitored
42
What is the third line management of spasticity in MS?
Benzodiazepines - e/g Diazepam 5mg
Could consider cannabis/cannabinoids - mostly unlicensed. Consider Sativex
43
How do you manage emotional and cognitive disturbances in MS?
Antidepressants
Patients can develop pathological laughing or crying - treatment with amitriptyline
44
How do you manage fatigue in MS?
Overwhelming tiredness not relieved by sleep
Fatigue can be exacerbated by muscle weakness
Precipitated by raised temperature e.g hot baths/hot weather
Need guidance from physical and occupational therapists - pacing/prioritising activities, regular rest
45
How many people aged 65 and over are affected by dementia?
One in 14
46
What are the types of dementia?
Alzheimer's
Vascular dementia
Dementia with Lewy Body
Frontotemporal dementia
47
What are the common symptoms of alzheimer's dementia?
Lapses of memory
Issues with word finding
Forgetting names of people, places, recent events
Mood swings as the disease progresses
Increasing withdrawal
Difficulty carrying out everyday activities
48
What are the symptoms of vascular dementia?
Slowness of thought, problems with planning or organising, making decisions
Difficulty with planning or understanding
Problems with concentration
Mood, personality or behavioural changes
Feeling disorientated and confused
49
What are the symptoms of dementia with lewy body?
Hallucinations
Muscle stiffness
Slower movement
Shaking and trembling of arms and legs
Shuffling while walking
Sleep problems
Loss of facial expression
50
What are the symptoms of frontotemporal dementia?
Poor judgement
Loss of empathy
Socially inappropriate behaviour
Lack of inhibition
repetitive complusive behaviour
Inability to concentrate or plan
Mood changes
Speech difficulties
Problems with balance or movement
51
What is the pharmacological management of dementia?
Acetylcholinesterase inhibitors - Donepezil, Rivastigmine, Galantamine
NDMA receptor - Memantine
52
What are the behavioural and psychological symptoms of dementia?
Delusions
Vivid Hallucinations
Illusion Anxiety
Disinhibited behaviour
Agitation
Apathy and depression
Aggression
Elation
53
What are the pharmacological management of behaviour and psychological symptoms of dementia?
Acetylcholinesterase inhibitors
Antidepressants
Antipsychotics
54
What medication must you avoid in Lewy Body Dementia
Levomepromazine
Haloperidol
Can have catastrophic reactions and must be avoided
55
How do you manage pain in confused patients?
Pain assessment tools
Vocalisation - groaning, crying, calling out
Facial expression - frowning, grimacing
Body language - rocking, guarding, massaging/patting a painful area, withdrawing
Behaviour/activity change - confusion, withdrawal, inability to stay still, refusing to eat
Physiological indications - blood pressure, flushing, perspiring, pulse change
56
Do PEG tubes have benefit on patient mortality?
No
Can be uncomfortable, sore, infected, dislodged, pulled out.
57
What measures can be used when caring for someone with dementia?
Colour - bright colours, paint toilet doors, (yellow and blue)
Sign posting - Labellign doors/toilets
reminiscence - Photos and books, objects like dolls, reminiscence areas like furniture, jar of sweets.
Reminiscence discussion groups - life, childhood, schooldays.
Music therapy - playing music
58
What is sundowning and how is it managed?
Patient with dementia experience sleep disturbances with being active at the end of the day.
Reduce caffeine, active days, maintaining a routine and creating a calm, quiet atmosphere.
59
What are the NHYA Classifications of Heart Failure?
I - Heart disease present but no dysnpnoea
II - comfortable at rest; dyspnoea on ordinary activities
III - Less than ordinary activity causes dyspnoea which is limiting
IV - Dyspnoea is present at rest.
60
What is the life expectancy from diagnosis for heart failure?
Less than 5 years
61
What are the symptoms of heart failure
Shortness of breath
Fatigue
Oedematous ankles and legs
Difficulty sleeping
Cough
62
What is the pharmacological treatment of heart failure?
ACE inhibitors
Beta blockers
Aldosterone antagonists
Digoxin
Diurecticsh
63
Which drugs can contribute to the symptoms of heart failure in palliative care?
NSAIDs - salt and water retention
Tricyclic antidepressants - Anticholingeric effects on heart
Cyclizine - Anticholingeric effects on heart
Steroids - water retention
64
What are the main symptoms of heart failure in palliative care?
Pain
Breathlessness
Anxiety and depression
Fatigue
Weight Gain
65
How do you manage pain in heart failure?
Pain ladder - consider liver capsule distension
66
How do you manage breathlessness in heart failure?
review underlying cause?
Non-pharmacological interventions - handheld fan, relaxation and breathing techniques, exercise and stress reduction programmme
Early involvement of occupation and physical therapies
Low dose opioids
67
How do you treatment anxiety and depression in HF?
treat with medications
Complementary therapies - massage, hynoptherapies
SSRIs are preferable to tricyclics
68
What are the stages of renal failure?
Stage 1 = >90 eGFR
Stage 2 = 60-90 - Mildly reduced
Stage 3 = 30-59 - Moderately reduced
Stage 4 = 15-29 - Severely reduced kidney function
Stage 5 = <15 - End stage
69
What are the symptoms of renal failure?
Pain
Fatigue
Pruritus
Anorexia
Sleep disturbances
Anxiety and depression
Nausea
Restless legs
Dyspnoea
70
How does renal failure increase drug side effects?
- Decreased plasma protein binding due to loss of protein, as well as altered binding ability as a result of uraemia
- Build of up active drug metabolites due to decreased excretion
- Change in hydration affects distribution of drug in body
- Reduction of oral absorption of drugs because of vomiting, diarrhoea, GI oedema
- Increase permeability of the BBB due to uraemia exaggerating unwanted CNS effects
71
What is important to remember in patients getting haemodialysis with medications?
NSAIDS can be considered as a issue of preserving renal function is no longer a concern.
Analgesia will be cleared quicker, leaving patient in pain
72
What are the symptoms as a result of dialysis?
Hypotension, nausea, cramps, fatigue
73
How do you treat Gastric Statis in renal failure?
Prokinetics - metoclopramide
74
What opioids are important to avoid at end stage kidney disease?
Those excreted by the kidney - Codeine, Hydrocodone, morphine, diamorphine, oxycodone
75
How is uraemic itch managed in end stage renal disease?
Skin care with emollients +/- antihistamines
Aluminium hydroxide (phosphate binder) or low dose gabapentin
76
How can you manage restless leg and muscle cramps as a result of uraemia in renal disease?
Correct biochemical abnormalities - anaemia and low ferritin levels
Prophylactic quinine sulphate for cramps
77
What three aspect must be present if someone is to be described as having intellectual disabilities?
Impaired intelligence
Reduced ability to live independently
Start in childhood, with a lasting effect on development
78
What are the reasons for palliative care being under accessed by people with LD?
Communication difficulties
Assumption - HCP assuming people with LD will not cope with distressing information
Referral - incorrect assessment of symptoms, or attributed to LD.
79
What are the key points when communicating with someone with LD?
Avoid Jargon
Chunk and check
Information delivered by someone they trust
Avoid use of metaphors
80
What can be the causes of cancer related pain?
Bone invasion
Nerve compression
Soft tissue infiltration
Visceral stretch or infiltration
Muscle spasm
Raised Intracranial pressure
81
What can be the causes of pain as a result of treatment?
Surgery - post operative wounds, peritoneal adhesions
Radiotherapy - burns/fibrosis
Chemotherapy - neuropathy
Phantom Limb Pain
82
What are the associated factors for pain?
Constipation
Pressure sores
Bladder spasms
Stiff joints
Post-herpetic neuralgia
Immobility
Body image
83
How can you classify pain?
Nociceptive pain - somatic and visceral pain
Neuropathic pain
84
What is somatic pain?
Pain relating to tissue damage like bone or muscle and usually localised and aches/throbbing
85
What is visceral pain?
Lesions in or compression of a hollow viscus or solid organ (bowel/liver capsule)
86
What is peripheral neuropathic pain?
Pain caused by damage to PNS, associated with area of altered sensation.
In Complex Regional Pain syndrome (associated with limb injury), changes in skin temp, colour and swelling also present.
87
What is Sympathetic maintained neuropathic pain?
Pain as a result of damage to sympathetic nerves and characterised by burning and sensory disorder related to vascular as opposed to neural distribution.
88
How can you treat sympathetic maintained neuropathic pain?
Sympathetic plexus block
89
What is central neuropathic pain?
Damage to spinal cord or brain. Patients may still have peripheral pain, and cerebral vascular aneurysm or spinal cord compression are the most common causes
90
What are the symptoms of neuropathic pain?
Burning
tingling
Pins and needles
Numbness or alteration to stimuli
Allodynia (Pain caused by stimulus that does not normally evoke pain e.g feather
Hyperalgesia - changes in temperature and colour may also be noted
91
What is the definition of background pain?
Persistent pain of long duration managed with regular analgesia
92
What is breakthrough pain?
Transient exacerbation of pain in a person otherwise stable with controlled background pain. Usually moderate to severe and of short duration
93
What is spontaneous pain?
Pain without an external trigger and prior to when the next dose of analgesia is due. If needing this more than twice a day consider increasing background pain.h
94
What is incidental pain?
Pain associated with an identifiable incident e.g
1. Procedural (dressing change)
2. induced by a voluntary act such as walking
3. Involuntary act such as coughing
95
What is end of dose pain failure?
This is the term used to describe pain that occurs in the period just before the next dose of analgesia is due and responds to the background long acting medication being increased
96
How do you do a pain assessment?
Structured approach focussing on the patients past history and current status
Assessment should include physicial, psychological, social and spiritual
97
What questions can you ask for assessing pain?
Ask focused open questions e.g ' How is the pain after eating'
Perception of pain - What do you think is making your pain worse?
Psychosocial factors influencing pain - How is the pain affected when you are out with others?
Shared language - Dull ache?
98
What are some examples of pain assessment tools?
NRS - Numerical rating scale - on a scale of 0-10
Visual Tool - Pain thermometer
SOCRATES - exploring pain
99
How do you assess pain in people with cognitive impairment?
Significant behaviours
- Vocalisation
- facial expression
- Changes in body language
- Physiological change
- Physical change
- Disease related symptoms
Behaviour assessment tools e.g DS-DAT, DiSDAT, Dolopus-2, Abbey Pain Scale
100
What are some examples of behavioural assessment tools in people with advanced dementia?
DS-DAT (discomofrt scale for dementia of the Alzheimer's type)
DisDAT (Disability Distress Assessment Scale)
Dolopus-2 (behavioural pain tool in the elderly
Abbey Pain Scale (adopted by care homes for people with dementia)
101
What is the Rules of Thumb - Six Steps guide?
Systematic approach to understanding causes of agitation/restlessness.
102
What is the WHO pain ladder?
Step 1 - Mild to moderate pain - Non opioid + adjuvant (Paracetamol and NSAID)
Step 2 - Moderate pain - pain persisting or increasing - Weak opioid + non opioid + adjuvant
- Co-codamol, dihydrocodeine or low dose tramadol.
Step 3 - Moderate to severe pain - strong opioid and non opioid + adjuvant
- 1st - Morphine oral, sc diamoprhine/morphine
- 2nd oxycodone sc/oralo
103
How would you initiate a strong opioid for severe pain?
Consider morphine - start with 5-10 of IR morphine regular 4 hour intervals with PRN doses (may need lower doses of opioid sensitive, elderly or frail patients).
- If pain not controlled, consider increasing dose by 30% increments if no signs of opioid toxicity
- Once pain is controlled, converse to a modified release preparation.
104
What is the conversion factor from codeine to morphine?
10
105
A patient is taking two cocodamol 30/500 four times a day - how much is that equivalent in morphine
30 x2 =60
60 x 4 =240
240/10 = 24mg of morphine
106
What type of morphine is prescribed as PRN?
Immediate release
107
How do you calculate the PRN dose?
1/6 of the 24hr opioid requirements
108
What examples are there of fentanyl preparations
Oral trasmucosal (Actiq), buccal or sublingual (Effentora, Abstral), or intranasal (Instanyl) preparations
109
What is important to remember when opioid switching?
Start low, go slow and ensure adequate breakthrough
Calculate equivalent analgesic dose of the new opioid and reduce this by 1/3 to start with, ensuring that adequate PRN medication is available
110
How do you convert from oral morphine to alfentanil in CSCI?
Divide by 30
111
How do you convert from oral to subcutaneous morphine?
Divide by 2
112
How do you convert from morphine to diamorphine?
Divide by 3
113
A patient is no longer able to swallow MST 120mg BD, how do you convert this to diamorphine CSCI?
120x2 =240mg
240/3 = 80mg diamorphine CSCI
114
When would you use alfentanil?
Renal failure as it doe snot accumulate with poor renal excretion
115
When should a transdermal patch be used?
For stable pain
Only if there are particular difficulties or compliance issues with oral medications
116
What are the common opioid side effects?
Drowsiness/Sedation
Constipation
Nausea/vomiting
Dry mouth
117
How do you manage drowsiness/sedation as a result of morphine?
Mild sedation may occur for the first 48hrs hours, and risk of driving/operating machinery.
118
What are the driving rules of opioids?
Avoid driving for 5 days after commencing or increasing opioids
Avoid driving within 4 hours of an extra breakthrough dose
Avoid driving until they feel 100% safe to do so
Start with short, quiet trips on familiar roads with a companion
No legal requirement but insurance companies generally advise to inform DVLA.
119
How to manage opioid related constipation?
Patients should be prescribed a laxatives - a stimulant and a softner
Can consider Naloxegol or Naldemedine (peripherally -acting Mu opioid antagonist
Methylnaltrexone Relistor
Targinact is oxycodone with naloxone
120
How do you manage opioid related nausea and vomiting?
1/3 patient get affected with this. All patients should be prescribed an antiemetic for first 5 days.
Metoclopramide orally 10mg TDS - first line because of central effects and impact on opioid induced gastric statis)
Haloperidol 0.5mg-1.5mg nocte
121
How do you manage opioid related dry mouth?
Good oral hygiene
Sugar free chewing gum to simulate saliva Saliva substitutes
122
When is opioid toxicity most likely to occur?
Rapid upwards titration
Renal failure leading to accumulation of active metabolites
Conversion from one opioid or change in route
Development of an acute infection
Commencement of adjuvant medication such as pregabalin
Topical opioid absorption can be increased in conditions causing pyrexia
123
What are the symptoms of opioid toxicity?
Drowsiness
Myoclonic jerks
Pinpoint pupils
Confusion
Hallucinations
Vivid dreams
Cognitive impairment
respiratory depression
124
What is the first step of opioid toxicity?
1. Bloods - Renal and hepatic function to be checked re: hypercalcaemia/infectionh
125
How do you manage mild opioid toxicity?
Reduce dose of opioid
Consider rehydration and treat underlying cause
If agitation/confusion give haloperidol
126
How do you manage moderate opioid toxicity?
If RR >8, oxygen sats normal and patient not cyanosed and easily rousable - omit the next dose or regular opioid immediately and wait and see.
Reassess opioid needs starting with low dose short acting medication
127
How do you manage severe opioid toxicity?
If RR <8, oxygen sats abnormal or cyanosed needs urgent treatment. Consider reversal of respiratory depression using naloxone. Reverse respiratory depression without compromising pain control or precipitating generalised opioid withdrawal.
128
How do you naloxone?
Dilute 0.4mg in 10mg NaCl
Use IV cannula or butterfly
Give 20microgram-100mcg IV every 2 minutes until RR is satisfactory.
Further boluses may be necessary
if no IV access - use 100 micrograms-200micrograms SC/IM every 2-3 minutes
Montor RR, Oxygen Sats and Conscious level every 15 mins for 2 hours.
129
What co-analgesic is an antidepressant?
Neuropathic pain - amitriptyline, duloxetine
130
What co-analgesic is an anticonvulsant?
Gabapentin, pregabalin, carbamazepine
131
What co-analgesic is an antispasmodic?
bowel colic - hyoscine butylbromide
132
How can antibiotics be used for pain?
Pain from infection
133
How can anxiolytics be used for pain?
Pain aggravated by anxiety - e.g lorazepam
134
How can bisphosphonates be used for pain relief ?
Pain relief in bone pain - pamidronate
135
What medications can be co-analgesics for nerve pain?
Capsaicin cream, lidocaine medicated plaster.
136
What pain can steroids be used for?
Nerve pain
Visceral pain
137
What are other examples of pain relief?
Nerve blocks and regional analgesics
Fractured neck of femur (lumbar plexus)
Pancreatic pain (coeliac plexus block).
138
What is the management of malignant bone pain?
Palliative radiotherapy
NSAIDs
Bisphosphonates
DenosumabWh
139
What is the management of colic pain?
Hyoscine Butylbromide - subcut
140
What is the management of liver capsule pain?
Pain caused by stretching of the peritoneum on the liver surface can often be eased with corticosteroids (dex 4-6mg)
141
What is the management of muscle pain?
Skeletal muscle relaxants - diazepam 2mg TDS or baclofen
142
What is the concept of total pain?
Focus on all aspects of the patient - not just physical symptoms
1. Physical - Drugs + affects other aspects of life
2. Spiritual - Guilt/remorse, fear of what happens after death, sense of connectedness
3. Social - Distress over family/carers, loss of role, participation issues
4. Emotional - adjustment disorder, anxiety, depression, frustration, helplessness
143
What sort of complementary therapies can help alongside treatment?
Acupuncture
Massage
Aromatherapy
Hypnosis
Reflexology
Exercise
Talking therapies
Psychosocial supprot
144
What is a TENS machine?
TENS - trancutaneous electrical nerve stimulation - effective method of pain relief that is non-invasive. Sensory nerves are excited by TENS and either the pain gate mechanisms or opioid system is stimulated.
Placed on the appropriate level of the back approximate to the nerve root, on either side of the pain point.W
145
When can you not use a TENS machine?
Patients with pacemaker, recent haemorrhage, anterior aspect of neck or carotid sinus or where there is an underlying tumour
146
What are the main AHPs involved in palliative rehabilitation?
Art therapists - art media as its primary mode of expression and communication
Dieticians - assess and advise on nutrition and hydration plans
Lymphodema Therapists - Manage lymphoedema secondary to cancer + non-cancer
Occupational therapists - Assess people's ability to care for themselves
Physiotherapists - functional independence
Speech and language therapists - Empower patient + family to manage swallowing and communication
147
What are the measures to assess performance status as per the OACC project?
Phase of illness
Australia-modified Karnofsky Performance status (AKPS)
Integrated Palliative Outcome Scale (IPOS)
Views on Care
Barthel Index
Carer Measures
148
What is a stable phase of illness?
Patient's problems and symptoms are adequately controlled by the established plan of care and further intervention to maintain symptom control and quality of life have been planned and family carer situation is relatively stable.
This phase ends when needs of the patient/family increase, requiring changes to existing plan of care
149
What is a unstable phase of illness
An urgent change in the plan of care or emergency treatment is required because the patient experiences a new problem that was not anticipated in the existing plan and/or the patient experiences a rapid increase in the severity of the current problem and/or family circumstances suddenly change.
Phase ends the new plan is in place, and has been reviewed and no further changes to care plan required. Also if death is likely within daysW
150
What is a deteriorating phase of illness?
The care plan is addressing anticipated needs but requires periodic review because the patient experiences a gradual worsening of existing problems, and/or the patient experiences a new but anticipated problem and/or the family carer experience gradual worsening distress that impacts on patient care.
Phase ends when condition plateaus (patient stable) or an urgent change in care plan (unstable) or death likely in days (dying)
151
What is a dying phase of illness?
Death is likely within days
Phase ends if patient dies or no longer dying (stable or deteriorating)
152
What are the 3 general causes of breathlessness?
Cancer related
treatment related
Other causes
153
What are the cancer related causes of breathlessness?
Cancer related
- Primary or secondary tumours
- Superior vena cava obstruction
- Ascites
- Fatigue/weakness
- Phrenic nerve palsy
- Pleural/pericardial effusionW
154
What are the treatment related causes of breathlessness?
Radio/chemo induced fibrosis
Surgery - lobectomy/pneumonectomy
Radiotherapy/chemotherapy - pneumonitis, fibrosis
Fluid retaining or bronchospasm inducing medication
Tracheostomy complication, if the tube is blocked by secretions
155
What are some additional causes of breathlessness?
Anaemia
Heart failure
PE
COPD
Pneumothoracx
Traceostomy complication
Psychological
156
What are the symptoms associated with breathlessness?
Cough
Fever
Wheeze
Haemoptysis
Stridor
Pain - chest wall or pleuritic
157
What are the potentially reversible causes of breathlessness?
Infection or aspiration pneumonia - antibiotics
Pneumothorax - chest drain
Pulmonary embolus - anticoagulation
Exacerbation of COPD - steroids/bronchodilators
Pain - analgesia
Pleural/pericardial effusion - consider aspiration
HF - diuretics
Superior vena cava obstruction - steroids, stenting, radiotherapy
Symptomatic anaemia - blood transfusion
Lymphangitis carcinomatosis - steroid/anticancer treatment
158
What is the pharmacological management of breathlessness?
Limited evidence that opioids may reduce sensation of breathlessness in cancer and non-cancer patients
- Morphine 5mg MR
Titrate slowly
Doses above 30mg unlikely to produce benefit
Bronchodilators - Salbutamol/ipratropium, saline nebs
Corticosteroids - dexamethasone can reduce peri-tumour oedema
- Dexamethasone 4-8mg orally for a one week trial - if not benefit in 3-5 days stop.
Monitor BMs
Anxiolytics - Lorazepam, diazepam, midazolam (in terminal phase)
Oxygen - patients with SpO2 consistently <90% or patients who report significant relief of breathlessness from oxygen.
In general there is no role for monitoring oxygen in comfort-focused care in the last few days of life.
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What is the non-pharmacological management of breathlessness?
Physiotherapy interventions - relaxed breathing techniques
Support with management of secretions - assist drainage, lying on side
Very occasionally suction
NIV can be used in those with MND
General positioning
Occupational therapy interventions - with adaptive equipment, perching stools.
Calming Hand - recognition (hold thumb), sigh out, inhale, exhale, stretch your hand out.
Hand held fans
Open windows to ensure room is ventilated
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What are the signs of end stage breathlessness?
Persistent dyspnoea despite max therapy
Additional support for activities of daily living
Increased frequency of unplanned hospital admissions
Minimal and reduced improvements following consecutive admissions
Expressions of fear and anxiety
Increased fatigue
Concerns expressed by patient/family about death and dying
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What are some examples of skin problems at the end of life?
Pruritus
Lymphoedema
Wound Care
Pressure areas
Sweating
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What are the causes of itch in palliative care?
Carcinoma in situ - anal/vulval
Haematological cancers - CLL, lymphoma, multiple myeloma
Paraneoplastic syndrome, breast, colon, lung, stomach carcinomas
Metastatic infiltration of the skin
Cholestasis
Psychogenic - anxiety
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What are the systemic causes of itch?
Biliary and hepatic disease - PBC
Chronic renal failure - Uraemia
Drugs - Opioids, citalopram, fluconazole
Endocrine - Diabetes, thyroid
Haematopoetic - lymphoma, multiple myeloma
Infectious disease - HIV
Malignancy - Breast, Stomach, Lung, Carcinoid
Neurological - Stroke, psychogenic cause
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What would be involved in a patient history of itch?
Severity of itch
Frequency and duration
Generalised or local
Rash associated
Skin broken, bleeding, seepage of serous fluid
Exacerbating factors and sources of relief
Drug and previous medical history
Social history - does anyone else have the same symptoms?
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What is the general management of itch in palliative care
Minimise skin inflammation and ensure comfort
- Skin moisturisers
- Corticosteroid creams - for localised area of inflamed skin, short term use only
- Avoid Scratching - keep nails short, wear cotton gloves at night
- Tepid baths or showers - aqueous cream or emulsifying ointment
- Pat skin dry rather than rubbing
- Avoid alcohol and spicy food
- Hynotherapy and behavioural treatment
- Topical anti-pruritic preparations such as calamine
166
How do you manage renal failure/uraemic itch?
Aluminium hydroxide TDS
Opioid antagonist
Ondansetron (5-HT3 antagonist)
Anti-epileptics - Gabapentin
167
How do you manage opioid induced pruritus?
Known side effect of morphine, particularly when given through spinal injection centrally
Ondansetron is useful
Opioid switch/rotation
168
How are malignant wounds (fungating tumours) caused?
As a result of infiltration of the skin by local invasion by a primary tumour (breast cancer more commonly) or by distant metastases.
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What entails the assessment of a malignant wound?
Ask patient prioritise and concerns and how they perceive the impact on themselves and others
How it affects their ADLs
Anything that makes it better or worse
Inform family to ensure they are aware of Management of bleeding if that is the caseW
170
How do you manage pain from a malignant wound?
Is the pain superficial or deep
Is it aching, stabbing or stinging itch
Pre-medication prior to dressing can be effective
Entonox can be used during the actual dressing change
Diamorphine or morphine mixed with hydrogel to a 0.1w/w solution can help relieve pain.
Care plan for frequency of dressing is important.
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How do you manage exudate from a malignant wound?
Alginate and hydro fibre dressing and foam can be effective in controlling wounds with high exudate levels
Topical metronidazole for anaerobic bacterial wounds
Can use thin hydrocolloid sheet surrounding area
Cavilon, Netelast, padding, cling film
Involve TVN
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How do you manage odour from a malignant wound?
Dressings - charcoal, silver dressing
Topical or oral metronidazole
Diffusers, vaporisers and deodorisers can be used with aromatherapy oils
173
How do you manage bleeding from a malignant wound?
Sometimes Radiotherapy
Dressings to reduce bleeding - Non-adherent, those with haemostatic properties - alginates (Kaltostat)
Oral Tranexamic acid or topical
Gauze soaked in adrenaline
Sucralfate liquid
Dressings to minimise disruption to wound when changed
- Non-stick
- Aquacel and alginate dressing
- Sorbasan that liquefies on the wound and then can be washed off
- Dressing removed gently with saline washes
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What is the assessment tool for a pressure ulcer?
Waterlow, others include Braden, Norton.
175
What is the aSSKINg Framework for pressure ulcers?
Assessment: Risk
Surface: Make sure patients have right support
Skin inspection: early inspection means early detection
Keep patient moving
Incontinence/increased moisture
Nutrition/hydration
GIVE: information
176
How do you avoid pressure ulcer development? What interventions could you do?
Profiling/low air loss bed
Memory foam mattress
Nutrient rich diet
keep skin dry - free of urine and sweat
Avoid friction - use sliding sheets when lifting
177
How often does NICE recommend you move a patient?
Every 6 hours with 2-4 hours repositioning for vulnerable patients.
178
What are the underlying causes of sweating in the palliative care?
Disease related: Lymphoma, disseminated cancer (liver mets)
Medication related: SSRIs, Hormone therapies (tamoxifen)
Endocrine: Oestrogen deficiency, androgren deficiency, hypo and hyperthyroidism
Hypoglycaemia
Alcohol withdrawal
Autoimmune neuropathy
179
What is the non-pharmacological management of sweating?
Assess, treat underlying cause and review medications
Maintain fluid intake and optimise hydration
Consider environment - cool, well ventilated room, cotton lightweight bedding
Encourage lightweight clothing
Tepid spongingW
180
What are the pharmacological management of sweating associated with tumours?
Tumour associated sweating -
- NSAIDs or Dexamethasone 1-2mg
Antimuscarins (amitriptyline, oxybutinin)
181
What are the pharmacological managements of sweating with pyrexia?
Paracetamol 1g 4-6 hourly
NSAIDS
182
What is the definition of lymphoedema?
Accumulation of fluid in body tissues causes swelling as a result of inadequate lymphatic drainage.H
183
How does lymphoedema occur?
Secondary lymphoedema as a result of damage or obstruction to the lymphatic system. Can be as a consequence of oncological surgery/radiotherapy and malignant infiltration of lymphatic system
184
What are the core parts of lymphoedema management?
Skin care
Lymphatic massage
Compression bandaging and garments
Exercise and elevationW
185
When should prophylactic antibiotics be prescribed for patients with lymphoedema?
With patients who have more than 2 episodes of cellulitis in one year
186
Why are palliative care patients more susceptible to oral problems?
Fluid and nutritional intake may be reduced
Patients are often taking medications that dry up secretions
Associated interventions such as chemo
Low level of reporting - not perceived as serious
Inability of patient to attend to own oral hygiene needs
187
What is the assessment of the oral symptoms of a patent?
Identify and record any changes - chewing, talking, swallow, pain
Previous dental history
Bleeding and inflamed gums
Visual check for signs and symptoms
Fit and function of dentures and plates
188
What are the causes of a dry mouth?
Medications (anti-muscarinics, antidepressants, opioids, diuretics)
Thrush
Dehydration
Anxiety
Mouth breathing non-humidified oxygen therapy
189
What is the non-pharmacological management of dry mouth?
Treat underlying cause
- Sips of cold water or sucking ice chips. Pineapple can stimulate saliva
- Sugar free chewing gums or sucking sugar-free sweets
- Petroleum jelly to lips or water-based gels
- Use of a toothbursh and mild flavoured non-foaming toothpaste
190
What could cause a sore mouth or stomatitis?
Infection (HSV)
Ulceration
Poor mouth care
Mucositis post radiotherapy/chemotherapy
Vitamin C deficiency
Iron deficiency
Tumour infiltration
191
What is the pharmacological management of sore mouth?
Local anaesthetic agents such as choline gel (Bonjela, Difflam)
Saline or soluble aspirin gargle or mouth wash
Benzydamine Hydrochloride mouth wash
Alcohol free chlorhexidine mouth rinse
Gelclair or Mugard barrier mouth gels
192
What is the management of oral thrush?
Good mouth care
Nystatin suspension
Fluconazole
193
What is the management of dry mouth?
Saliva stimulation
- Pilocarpine 5mg orally to stimulate salivary gland
- Pilocarpine 4% eye drops dropped onto tongue
Salivary Orthana
Bethanechol
Water based oral gels
194
What are some causes of nausea and vomiting?
Constipation
Intestinal obstruction
Gastric Statis
Raised intracranial pressure
Anxiety and Fear
Metabolic Causes e.g Renal failure, HyperCa
Pain
treatment related post chemo
Infection
Drug induced (opioids, abx, digoxin, iron)
Oral thrush
195
What is the primary assessment of N+V?
Frequency, triggers and exacerbating factors
Vomiting - frequency, volume, colour, smell and timing
Related symptoms - dyspepsia, tachycardia, constipation, diarrhoea, headache, cough
196
What antiemetics are suitable for drug or toxin induced N+V?
Haloperidol
Levomepromazine
197
What antiemetics are suitable for radiotherapy induced N+V?
Haloperidol
Ondansetron
Granisetron
198
What antiemetic are suitable for chemotherapy induced N+V?
Ondansetron
Granisetron
Dexamethasone
Metoclopramide
Aprepitant
199
What antiemetics are suitable for metabolic N+V?
Haloperidol
Levomepromazine
200
What antiemetics are suitable for raised intracranial pressure N+V?
Cyclizine
Dexamethasone
201
What antiemetics are suitable for complete bowel obstruction N+V?
Cyclizine
Hyoscine Butylbromide
Octreotide
Ondansetron
202
What antiemetics are suitable for delayed gastric emptying N+V?
Metoclopramide
Domperidone
203
What antiemetics are suitable for gastric irritation N+V?
Treat Gastritis - PPI
Stop Gastric irritants - NSAIDs
Cyclizine
204
What are the non-pharmacological management of N+V?
Calm reassuring environment away from sight or smell of food
Small snacks and light meals regularly
Positioning in bed or chair
Mouth care
Avoid precipitating factors - tension, anxiety
Hypnotherapy
Control of malodorous- fungating wound, colostomy
Consider aromatherapy diffusers
205
What is the definition of cachexia?
Involuntary weight loss (more than 5-10% of pre-morbid weight 6 months with loss of skeletal muscle mass)
206
What is cancer cachexia?
Complex syndrome
- Ongoing loss of skeletal muscle mass
- Loss of muscle mass cannot be fully reversed by conventional nutritional support
- Progression functional impairment
207
What is the management of anorexia and cachexia?
Early involvement of dietician to enhance caloric intake
Encourage exercise to reduce loss of muscle mass
Small portions of attractive melas
Conducive environment at meal times
Appetite enhancers like alcohol
Treat pain and constipation
Focus on what they enjoy
Support family
208
What is the pharmacological management of anorexia?
Prokinetics - Metoclopramide
Corticosteroids - initially enhance appetite, stop if no effect after a week.
Progesterone - may enhance appetite
Consider megeastrol acetate - risk of thrombosis
209
What are the causes of constipation?
Pressure - Tumour/ascites
Tumour infiltraion
Immobility
Decreased food intake
Low residue
Inpatient admission (change in environment)/lack of privacy or using commode
Fluid depletion - poor fluid intake, fluid loss
Frailty - Inability to teach toilet, get position for defaecation, inability to raise intra-abdominal pressure
Metabolic disturbance - hypercalcaemia/hypothyroid
Pain - anal/rectal conditions - anal fissure
Neurological disease - PD, MD, MND, lumbar, sacral, cauda equina nerve damage
Medication induced constipation
- Opioid induced, also tricyclic antidepressants, cyclizine, levodopa, iron, diuretics
210
What are the clinical features of constipation?
Abdominal pain
Overflow diarrhoea
Urinary retention or frequency
Embarrassment
Confusion or restlessness
211
What are some examples of stimulant laxatives?
Senna
BIsacodyl tabs/supps
212
What is the MOA of stimulant laxatives?
Need bacterial transformation in large bowel to be active. Have little small intestinal effect.
Can cause cramps, avoid in patients with intestinal obstruction
213
What are some examples of osmotic laxatives?
Lactulose
Macrogol
Phosphate enema
Magnesium salts
214
What is the MOA of osmotic laxatives?
Not absorbed from the gut, increase water in the lumen. Causes increase in volume and cause peristalsis and expulsion of faeces.
Can cause abdominal distension + abdominal cramps + lactulose can cause flatulence.
215
What are some examples of faecal softners?
Docusate
Poloxamer
Glycerol supps
216
What is the MOA of faecal softners?
Reduces surface tension and improves water penetration of stool.
217
What are some examples of opioid antagonist laxatives?
Methylnaltrexone
Naloxegol
Naldemedine
218
How do you manage faecal impaction/overflow treatment?
Check history, do a PR, may confirm on abdo XR.
- Bisacodyl suppositories (must be in contact with rectal mucosa)
- Microlax enema to soften stool
- Consider opioid antagonist
- Phosphate enema
- Abdo massage
- Encourage diet - fluid
- Movicol 8 sachets a dayha
219
What is the definition of diarrhoea?
Frequent loose stool, more than 3 unformed stools in 24hrs.
220
What is a common cause of diarrhoea in palliative care?
Imbalance of laxative therapies
Drugs - NSAIDs, iron, C diff from abx
Faecal impaction - overflow
Radiotherapy
Malabsorption
Gastrectomy
Illeal resection
Colectomy
Colonic/rectal tumour
Endocrine tumour
Diets high in fibre, hot and spicy food
IBD, UC, hyperthyroidism, infection
221
What does a pale fat smelly stool suggest?
Malabsorption with pancreatic or ileal disease
222
What does sudden onset diarhroea after constipation suggest?
Faecal impaction
223
What does alternating diarrhoea and constipation suggest?
Poorly regulated laxative therapy
224
What does profuse watery stool suggest?
Colonic diarrhoea
225
What does diarrhoea without warning, 2 to 3 times in 24hr suggest?
Anal incontinence
226
What are the non-pharmacological management of diarrhoea?
Encourage oral intake
Discourage diary products, fatty foods, caffeine
Perianal hygiene - barrier creams
Consider short course of 1% hydrocortisone to help
227
What is the pharmacological management of fat malabsorption?
Pancreatin/CREON
228
What is the pharmacological management of radiation diarrhoea?
Ondansetron, cholestryramine
229
What is the pharmacological management of pseudomembranous colitis?
Metronidazole or Vancomycin
230
What is the management of profuse secretoy diarrhoea?
Octreotide sc
231
What is the first line management of diarrhoea?
Loperamide - does not affect CNS (only used when infection is ruled out).
Can also consider codeine
232
What symptoms suggest a high level of an intestinal obstruction?
Frequent vomits of unchanged stomach contacts
Often bilious colouring
N+V shortly after eating no warning
233
What are the symptoms suggesting a low level of intestinal obstruction
Semi digested or faeculant vomit
Increase background of vomiting
Less correlation with food
234
What medication can be used in bowel obstruction?
Metoclopramide (contraindicated in complete bowel obstruction)
Hyoscine butylbromide
235
How do you manage obstruction in advanced malignant disease?
Decrease oedema - Dexamethasone
Stimulate gut motility - metoclopramide
Manage N+V - Cyclizine, Haloperidol, Levomepromazine
Manage colic - Hyoscine butylbromide
Manage constipation
Consider octreotide
Can consider NG tube but rare
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