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Health 32 > End of Life care > Flashcards

End of Life care Flashcards

1
Q

Pharmacology of analgesics and
pain therapeutics

Define pain

A

unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage

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2
Q

what is meant by socrates?

A

Site, Onset, Characteristics, Radiates, Associated symptoms, Time course, Exacerbating or relieving factors, Severity

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3
Q

give 3 non questionnaire pain assessment tools?

A

give 3 non questionnaire pain assessment tools?

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4
Q

name 2 pain questionnaires that can be used for pain assessments?

A

mcgill
lanss

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5
Q

describe the different characteristics of acute pain?

A

diagnosable cause, protective function, defined cause of onset, expectation of time limit, equal more or less severe to chronic pain

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6
Q

describe the pain characteristics of chronic pain?

A

no protective function, adaptation of ANS, physical and psychological effects, can lead to hyperalgesia, allodynia and spontaneous pains

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7
Q

chronic pain can lead to what 3 things?

A

hyperalgesia, allodynia and spontaneous pains

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8
Q

what is meant by Hyperalgesia?

A

increased painful response to painful stimuli

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9
Q

what is meant by allodynia?

A

pain evoked by non painful stimuli

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10
Q

what is meant by spontaneous pains?

A

has no precipitating stimulus

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11
Q

what type of pain is the following;

localised, ache throbbing

soft tissue, bone, visceral, neuropathic or incidental?

A

soft tissue

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12
Q

what type of pain is poorly localised, throbbing, diffuse, referred and cramping

soft tissue, visceral, bone, neuropathic and incident

A

visceral

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13
Q

what type of pain is localised aching/ tenderness

soft tissue, visceral, bone, neuropathic and incident

A

bone

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14
Q

what are the characteristics of neuropathic pain?

A

difficult to describe, stabbing, burning, sensory loss

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15
Q

what are the key features of incident pain?

A

episodic, on movement, weight bearing, dressing change

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16
Q

what response does soft tissue + visceral pain have to analgesia?

A

> 80% control with opioid + non opioid

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17
Q

what response does bone pain have to analgesia?

A

NSAID + RT

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18
Q

what response does neuropathic pain have to analgesia?

A

poor

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19
Q

what analgesia could help relieve incident pain?

A

physio, nitrous oxide, spinal analgesia, short acting steroids

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20
Q

step one of the who analgesic ladder?

A

non opioids with or without adjuvant

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21
Q

what stage of the pain ladder would nsaids and paracetamol fall under?

A

1

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22
Q

step 2 of the pain ladder ?

A

opioid for mild to moderate pain with or without adjuvant

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23
Q

what drugs would you expect to see as part of step 2 of analgesic ladder?

A

codeine, dihydrocodiene, tramadol

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24
Q

step 3 of the analgesic ladder is opioids for moderate to severe pain with or without adjuvants. List some of the drugs that you might expect to see here?

A

morphine, diamorphine, fentanyl, oxycodone, hydromorphone, methadone

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25
Q

What is the difference between acute and chronic pain and how might this affect the way that we use the WHO analgesic pain ladder?

A

Acute pain is short-term and usually caused by tissue damage.
Chronic pain lasts longer than 3 months and is often associated with a chronic condition.
Chronic pain may require higher steps on the WHO ladder.

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26
Q

What are the different ways to manage pain?

A
  1. Treat the cause.
  2. Treat the symptom with analgesics and adjuvants
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27
Q

5 ways to treat cause of pain?

A

surgery
antibiotics
antivirals
anti-inflammatories
radiotherapy

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28
Q

two ways to treat symptoms of pain?

A

analgesics
adjuvants

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29
Q

4 things to consider TOTAL pain

A

physical, social, psychological, spiritual

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30
Q

What is the appropriate use of analgesics for acute pain?

A

Use analgesics on a short-term basis while healing occurs. Use drugs peri-operatively for post-surgical pain. Use appropriate route of administration (IV, oral).

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31
Q

whats PCA?

A

Patient Controlled Analgesia

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32
Q

moa of paracetamol?

A

not fully understood but acts predominatly by inhibiting prostaglandin synthesis in the cns and peripheral action by blocking pain impulse generation

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33
Q

side effects of paracetmol?

A

allergic reaction, rash, swelling, flushing, low blood pressure

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34
Q

drug interactions of paracetamol?

A

other products with paracetamol, alcohol, valproate, vincristine and warfarin

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35
Q

NSAIDs moa?

A

inhibit enzyme cyclooxygenase (COX)- required to convert arachidonic acid into thromboxanes, prostaglandins, and prostacyclins

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36
Q

side effects of NSAIDs?

A

GI
headache
indigestion
stomach ulcer

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36
Q

drug interactions of NSAIDs?

A

When combined with blood-thinning medicines (such as warfarin) NSAIDs increase the risk of bleeding.

NSAIDs -> kidney failure when combined with ACEi and diuretics

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37
Q

Prostaglandin synthesis – complete the diagram from your notes
(add in missing arrows and products of arachidonic acid
metabolism)

A

Membrane phospholipids (Phospholipase A2)
Arachidonic acid
COX1 or COX2
Prostaglandins
Thromboxane
Prostacyclins
5-LOX
Leukotriene B4
Cysteinyl leukotrienes

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38
Q

COX exists in 2 isoforms, which one is responsible for the following

maintain gastric mucosal integrity
platelet aggregation
renal blood flow

A

COX1

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39
Q

which COX isoform induced in activated inflammatory cells, mediates pain and inflammation

A

COX2

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40
Q

how are NSAIDs simply classified?

A

by ability to inhibit cox1 or 2
- variation in potency

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41
Q

name the 4 classes of NSAIDs

A

preferential COX1
non selective COX inhibitors
preferential COX2 inhibitor
selective COX2 inhibitor

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42
Q

name 2 preferential cox 1 inhibitors?

A

indometacin and keterolac

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43
Q

aspirin, ibuprofen, naproxen and nabumetone are all examples of what type of cox inhibitors?

A

non selective cox inhibitors

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44
Q

name 2 preferential cox 2 inhibitors?

A

diclofenac and meloxicam

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45
Q

name 2 selective cox 2 inhibitors?

A

celecoxib and etoricoxib

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46
Q

what to remember when initiating NSAIDs?

A

use lowest effective dose
shortest duration

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47
Q

what 4 things to look at for individual when initiating NSAIDs?

A

any…
contraindications
drug ints
Med Hx
monitoring needed for oral NSAIDs?

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48
Q

diclofenac and high dose ibuprofen should be avoided in what condition?

A

HF

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49
Q

if required which 2 nsaids are the most appropriate to be used for the lowest effective dose for the shortest duration?

A

ibuprofen or naproxen

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50
Q

max ibuprofen daily dose?

A

1200mg

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51
Q

max naproxen daily dose?

A

1000mg

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52
Q

why should nsaids be avoided in patients with antihypertensive drugs if their egfr is below 30ml/min/1.73m2?

A

risk of AKI

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53
Q

true or false, only one nsaid should be prescribed at any one time and concomitant use with low dose aspirin should be avoided?

A

true

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54
Q

High risk patients: prescribe COX-2 inhibitor with what, to lower risk of GI SEs?

A

PPI

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55
Q

moderate risk px, to avoid GI SE, use NSAID +

A

PPI

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56
Q

low risk use non selective NSAID to lower GI SE risk T/F? no PPI

A

true

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57
Q

why might ibuprofen be used in preference to naproxen in terms of duration?

A

ibuprofen is short acting

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58
Q

why is buprenorphine different to other opioids?

A

its a PARTIAL mu receptor agonist. (not full)

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59
Q

codiene is a pro drug of morphine and has low oral ba, acts as an anti tussive and can cause constipation.

Demethylation is blocked by cyp2d6 inhibitors, name 2 drugs where this would be the case?

A

fluoxetine
paroxetine

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60
Q

tramadol has opioid and non opioid actions and is metabolised to m1 in the liver by cyp2d6 which is 2-4 x more potent than tramadol. What does it inhibit the reuptake of?

A

nordarenaline and serotonin

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61
Q

T/F: tramadol has much lower affinity for opioid receptors than morphine?

A

true

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62
Q

tramadol analgesic effect is reduced by what?

A

ondansetron

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63
Q

does carbamazepine reduce or increase the effect of tramadol?

A

reduce

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64
Q

what effect might tramadol have on warfarin?

A

may prolong INR

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65
Q

3 drug interactions with tramadol?

A

ondansetron
carbamazepine
warafrin

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66
Q

buprenorphine is a partial mu agonist, what makes it suitable for transdermal delivery?

A

highly lipid soluble

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67
Q

what makes buprenorphine fairly safe in renal impairment?

A

large vd and high ppb

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68
Q

bu patches are available for what 3 different lengths of time?

A

72h, 4 day, 7 day

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69
Q

what is the equivalent dose of bu patch in mcg to 30-60mg oral morphine over 24 hrs?

A

35mcg

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70
Q

is dose reduction of bu required in cases of renal insufficiency, yes or no?

A

no

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71
Q

morphine t1/2?

A

2-4 hrs,
longer in renal impairment

peak: 1-2 hrs

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72
Q

morphine metabolism and excretion?

A

in liver by CYP3A4 -> M3G and M6G, then excreted in urine.

M6G = longer t1/2, accumulate

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73
Q

morphine formulations available?

A

IR
MR

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74
Q

Morphine can cause several side effects, including

A

nausea, vomiting, constipation, dizziness, sedation, and respiratory depression

managed with dose adjustments or supportive care.

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75
Q

what is the most serious potential side effect of morphine and requires prompt intervention, such as the administration of naloxone.

A

Respiratory depression
..
Patients should also be monitored for signs of opioid-induced hyperalgesia, which can occur with prolonged use of opioid

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76
Q

what strength of morphine would be appropriate 4 hrly for frail or elderly patients?

A

5mg

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77
Q

what modifications can be made to dose of morphine in the case of reduced renal function?

A

reduce dose or increase dosing interval

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78
Q

true or false, if a patient is using MR morphine they should also be provided with IR morphine liquid or tablets?

A

true

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79
Q

rescue doses can be opioids that can be prescribed for regular medication with the exception of maybe fentanyl or methadone.
The dose should be what fraction of the 24 hr dose of basal analgesia?

A

1/6

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80
Q

oral rescue doses should be given max every x-y mins?

A

60-90

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81
Q

parenteral doses of rescue therapy should be given max every x-y mins?

A

15-30

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82
Q

what can breakthrough pain, spontaneous pain, incident pain and end of dose failure all be classed as?

A

episodic pain

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83
Q

what is meant by spontaneous/ idiopathic pain?

A

unpredicatble

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84
Q

true or false, incident pain is not predictable?

A

false

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85
Q

what is the term given to the type of pain that occurs before the next dose of opioid is due or exacerbations against a background on controlled pain?

A

breakthrough

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86
Q

Why might you consider second line
opioids?

A
  • Unable to swallow ? - formulation
  • Adverse effects ?
  • Renal failure? – choose non-renally excreted opioid
  • Genetic differences?
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87
Q

fentanyl is a very lipophilic molecule with a high vd, what is its plasma half life?

A

3h

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88
Q

what is the inactive metabolite that fentanyl is converted to in the liver?

A

norfentanyl

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89
Q

transdermal fentanyl patches have the following characteristics

plasma half life 17 h

onset of action 8-12 h

metabolised by cyp3a4

are interactions more likely with the transmucosal or transdermal form?

A

transmucosal

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90
Q

do you expect to see individual variability in transdermal fentanyl patch abs?

A

yes

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91
Q

what makes transdermal fentanyl a good option for use in the case of renal failure?

A

no dose adjustment needed and not removed by haemodialysis

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92
Q

what effect might heat have on abs from transdermal fentanyl patches?

A

increases absorption

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93
Q

-> FPM in liverwith Transmucosal fentanyl , sublingual and buccal formulations, how much absorbed through mucosa and hm swallowed (GI system)?

A

25% mucosa
75% swallowed

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94
Q

alfentanil is a lipophilic opioid mu receptor antagonist with rapid onset and shorter duration of action. Is dose reduction required in the case of renal failure, yes or no?

A

no

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95
Q

potency of alfentanil is X that of fentanyl

A

1/4

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96
Q

T/F alfentanil is 10-20x morepotent than IV morphine?

A

true

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97
Q

oxycodone has high oral ba and partly metabolised to oxymorphone by cyp2d6 with an onset of 4-6h.

What happens to its t half life in the case of

  1. liver failure
  2. renal failure
A

doubles, increases

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98
Q

methadone is an agonist at which 2 receptors?

A

mu and delta

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99
Q

methadone is a nmda receptor channel blocker and works to block what hormone pre synaptically?

A

serotonin

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100
Q

is methadone removed by haemodialysis?

A

no

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101
Q

methadone may be used in patients that cannot tolerate other opioids and for neuropathic pain, why must it only be started by a specialist?

A

inter individual variation means half life can be 5-130 hrs

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102
Q

what class of drugs can be used as an adjuvant analgesic for anti inflammatory action?

A

NSAIDs

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103
Q

what adjuvant analgesic class of drugs can be used for nerve compression pain?

A

corticosteroids

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104
Q

name an antidepressant that can be used as an adjuvant analgesic for neuropathic pain?

A

amitriptyline

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105
Q

name 3 antiepileptic drugs that can be used as adjuvant analgesics for neuropathic pain?

A

gabapentin, carbamazepine, pregabalin

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106
Q

name 2 agents that can be used for an nmda receptor blockade to help treat neuropathic pain?

A

ketamine and methadone

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107
Q

name an antispasmodic that can be used as an adjuvant analgesic for GI pain?

A

hyoscine

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108
Q

name one muscle relaxant that can be used as an adjuvant analgesic?

A

diazepam

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109
Q

Ethics, law and Palliative Care

what is ethics?

A

study of what we may classify as a good or a
bad action and provides a framework for us to
weigh that action

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110
Q

difference between
morals
ethics
laws

A

Morals- personal principles, subjective

Ethics- societal codes of conduct, study or morality, objective

Laws- eg Mental capacity act, doctrine of double effect, Data protection act, (failed) Assisted Dying Bill

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111
Q

4 basic principles of healthcare ethics?

A

consequentialist
1. beneficience (do good)
2. non maleficience (do no harm)

Deontological
3. respect for autonomy
4. distributive justice

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112
Q

Beneficence vs non maleficence
* Desirable and adverse effects
* Benefits and burdens
example

A

Fred has carcinoma lung with cerebral metastasis
causing headache. Surgery, radiotherapy and
chemotherapy are not treatment options for him.
Steroids may help symptom control of headache by
reducing peri-tumour oedema and therefore
intracranial pressure

… weigh up beneficence and Maleficence

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113
Q

Beneficence vs non maleficence
EG
* Tight diabetic control with TDS biphasic insulin and
strict diet
Weigh up this treatment regimen for
1. Mina, 30 year old PE teacher
2. Altaf, 70 year old with severe COPD who has
very poor appetite and expected prognosis of
weeks

answers on page 2

A
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114
Q

what does STOPP tool stand for?

A

Screening Tool of Older People’s potentially
inappropriate Prescriptions

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115
Q

come back to scenarios from ethics law and palliative care lec

A
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116
Q

What about when patients do not
have autonomy?
* Cannot make decisions for themselves
* Do not have “Capacity”

A

MCA- Mental Capacity Act
* ACP-Advance care planning
* LPA- Lasting Power of Attorney
* IMCA- independent mental
capacity advocate
* ADRT-advance decision to
refuse treatment

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117
Q

what does MCA provide?

A

to make decisions for themselves.
Determines
* Who makes those decisions
* How those decisions should be made

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118
Q

5 key principles of MCA?

A
  1. Must assume a person has capacity, unless can establish
    incapacity
  2. Individuals should be supported where possible to make own
    decisions – capacity may vary, at different times, for different
    reasons
  3. Right to make eccentric/unwise decisions
  4. If lack of capacity established, someone must decide in ‘best
    interests’ of the patient
  5. Rights and freedoms must be restricted as little as possible
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119
Q

The two stage test for capacity
1st stage
Does the person have an impairment or disturbance of the
mind or brain?
what to do if no/yes?

A
  • If ‘no’, then it must be concluded that the person has capacity.
  • If ‘yes’, then proceed to 2nd stage of the test.
120
Q

impairment/ disturbance, what conditions come under this?

A

Conditions associated with some mental illness
* Dementia
* Significant learning disabilities
* Long-term effects of brain damage
* Physical or medical conditions that cause confusion,
drowsiness or loss of consciousness
* Delirium
* Concussion following a head injury, and
* Symptoms of alcohol or drug use

121
Q

2nd stage…
(come back to page 6)

A
122
Q

Care of a dying person workshop

what is palliative care?

A

affirms dying as normal natural part of life

supports patients to live as well as possible till the end of life

provides support for family and carers to live as well as possible

123
Q

true or false, palliative care is not about giving up?

A

true

124
Q

what does dying look like?

A

reduced appetite

reduced energy

reduced conciousness

loss of reliable swallow

breathing changes

circulation changes

cold and pale

125
Q

4 priorities for care of the dying person

A
  1. recognise and communicate early
  2. sensitive communication
  3. theyre involved in treatment and care decisions
  4. explore and respect family needs
    ..5. individual plan of care
126
Q

what is advance care planning (ACP)?

A

voluntary discussion between individual and carers

identifies wishes and values, concerns and preferences for care

will take place in anticipation for future deterioration

127
Q

true or false ACP is a way to communicate wishes if capacity is lost?

A

true
capacity = autonomy

128
Q

how can an ACP enhance hope?

A

information leads to less fear and more control

helps maintain relationships

preserves normality

reduce sense of burden

encouraging sense of control

allows people to prepare

improve satisfaction with eol care

129
Q

loss of swallow at the eol means that patients might need medicines delivered by what other route?

A

SC

130
Q

Symptom control for the
dying phase
additional symptoms that may require just in case meds include…

A

Pain
Breathlessness
Nausea
“Death Rattle”
Anxiety
Delirium/Agitation
Dry mouth

131
Q

list 4 just incase medicines that may be given via syringe driver at the eol?

A

hyoscine butylbromide,
midazolam,
morphine
levomepromazine

132
Q

what is the purpose of levomepromazine?

A

nausea and vomiting

133
Q

what is the purpose of midazolam?

A

agitation and restlessness

134
Q

what is the purpose of hyoscine butylbromide?

A

respiratory secretions

135
Q

what is the purpose of morphine?

A

pain and respiratory distress

136
Q

who is allowed to administer just in case medicines for patients if they wish?

A

district nurse

137
Q

what might be the side effects of anticipatory medicines?

A

drowsiness, nausea and dry mouth

138
Q

only a x or x can give anticipatory medicines?

A

doctor or nurse

139
Q

where should just in case/ anticipatory medicines be taken when they are no longer needed by the patient for safe disposal?

A

local community pharmacy

140
Q

what are the benefits of anticipatory medicines?

A

can manage symptoms whenever they occur

drugs can be hard to get hold of at night or on weekends otherwise

141
Q

would the following be appropriate on a medication chart at the end of life?

iv fluids, tight diabetic regimen, oral medications such as statins and antihypertensives and prophylatic lmwh?

A

no

142
Q

anorexia is almost universal as eol approaches and is due to absence of hunger. artifical or forced feeding does not prolong life once dying. In what ways can it risk reducing the quality of life?

A

aspiration and nausea

143
Q

hydration is also a problem at eol as there is a reduction in thirst and fluid homeostasis is dimished, if fluids are forced what are the potential risks?

A

oedema and respiratory secretions

144
Q

how often should patients hydration be reviewed?

A

daily

145
Q

what can be done for dry mouth?

A

ice chips

gum

soft toothbrush

stop unecessary medicines

monitor for candida

saliva replacements

146
Q

name 2 salivia replacements?

A

glandosane spray and biotene gel

147
Q

continous subcutanous infusions (csci) can be given via syringe drivers. They are battery powered and can be used at home, care home or hospital. what are the benefits?

A

can use up to 3 drugs in combination

more comfortable

less infection risk than iv

148
Q

one resource to consult for syringe drivers is the syringe driver book (Dickman), name a website where you can go to view compatability tables?

A

palliativedrugs.com

149
Q

what issues might pharmacists be involved with in eol care?

A

identify dangerous or erroneous prescriptions

information giving

timely access to meds

safe disposal

communicating with distressed people

150
Q

tips for communicating with people that are distressed?

A

listen

acknowledge distress

explore whether they have support

respect they may know what they need

try not to:
- change the subject
- offer premature reassurance
- feel like you have to fix it
- take on more than you can manage

151
Q

Pain control and syringe drivers workshop

the equivalent dose of morphine is what fraction of a dose of codeine approx?

A

1/10

152
Q

what are the potential worries that patients might have regarding morphine?

A
  • Addiction/ dependence
  • Social stigma
  • AEs
  • Morphine = imminent death
  • Pain will become resistant to analgesia so ‘nothing left when pain is severe’
153
Q

what are the potential worries that healthcare professionals might have about morphine?

A

not confident about conversion

addiction

dependence

respiratory depression

excessive sedation

expediating death

diversion of supply for illegal use

154
Q

lactulose may not be appropriate for elderly patients with constipation and cancer because it is a osmotic laxative, can you suggest more appropriate alternatives?

A
  • stimulant laxatives like senna or bisocodyl
  • sodium docusate
  • Or combination of stimulant and osmotic laxative

or stool softeners like movicol if water intake is adequate

155
Q

what might be a potential issue of having morphine and buccal fentanyl tablets?

A

morphine drys mouth secretions and fentanyl needs moist membranes for abs

156
Q

What formulations of fentanyl are available for transmucosal administration

A

sublingual
buccal
nasal spray

  • all need moist membranes
157
Q

how might you advise patients to take fentanyl lozenges- buccal?

A

place lozenge in mouth against cheek

move around mouth using applicator

each lozenge sucked for 15 mins

water can be used to moisten buccal mucosa in patients with dry mouths

158
Q

how might you advise patients to take fentanyl buccal films?

A

moisten mouth

place film on inner lining of the cheek

hold for 5 secs until it dissolves

if more than one film required place on other side

avoid food until film has dissolved

avoid liquids 5 mins after application

159
Q

list some different factors that affect drug release from patches?

A

skin condition
how well its stuck
heat

160
Q

true or false, morphine has low bioavailability and variable hence all patients are different?

A

true

161
Q

how would you advise the change over from oral mr morphine to transdermal fentanyl ie when to take the last tablet and when to administer the first patch?

A

apply patch same time as last 12hrly dose

162
Q

what would monitor patients for in hospital that have been started on fentanyl patches?

A

whether pain is controlled

side effects like respiratory depression and sedation

163
Q

how would you counsel a patient on the admn of a patch fentanyl?

A

avoid external heat application

fold in half before disposing

check patch duration

apply to dry , non irritated, non irradiated non hariy skin on upper arm or torso

avoid same body part when changing

avoid using same area for several days

164
Q

what would amitriptyline 10mg be used for instead of an antipyschotic?

A

neuropathic pain

165
Q

why might someone with metastatic cancer be given a corticosteroid such as dexamethasone?

A

reduce inflammation around tumour site

166
Q

what might diclofenac be changed to, which is more suitable to be placed inside a syringe driver?

A

eteorolac

167
Q

what would be the breakthrough dose of morphine if a patient is taking 180mg daily as background analgesia?

A

30mg

168
Q

What alternative options are available for administration of opioids and what doses would be appropriate?

A
  • PEG tubes for swallowing difficulties
  • If too weak to take oral med, syringe drivers (continuous SC infusion)
  • IV infusion
    Other routes of analgesia: (spinal admin of opioids, local anaesthetics, ketamine, clonidine, nerve block/ nerve destruction)
169
Q

what are the benefits of syringe drivers to deliver medicines?

A

dont have to swallow

good drug availability

less infection risk as no venous access

well tolerated

easier to administer

170
Q

true or false the dose of sc is half that of oral morphine, for example an oral dose of 180mg would be an equivalent sc dose of 90mg?

A

true

171
Q

name a suitable diluent for subcut morphine?

A

WFI

172
Q

if a patient has renal deterioration and toxicity is starting to occur from morphine, what metabolite is likely accumulating?

A

M6G

173
Q

When to start a syringe driver?

A
  • Persistent nausea and vomiting
  • Difficult swallowing
  • Poor alimentary absorption
  • Intestinal obstruction
  • Unconscious or profoundly weak
  • Drug only available as parenteral
174
Q

if changing from a syringe driver to something else, what should the dose first be converted to?

A

oral morphine

175
Q

how often can syringe drivers be changed?

A

24hrs

176
Q

for a patient that was previously well controlled on morphine but has now become unacceptably drowsy due to poor renal function, what changes could be made?

A

reduce morphine, change to fentanyl, change to buprenorphine

177
Q

true or false, pain control does not need to be stable for change to syrine driver?

A

true

178
Q

what fraction of an oral morphine dose is sc afentanil?

A

1/30 to 1/40

179
Q

afentanil is lipid soluble which makes it suitable for use in renal failure because it does not?

A

accumulate

180
Q

does pain have to be stable before being switched from oral to transdermal analgesia? yes or no

A

yes

181
Q

where pain is not stable, should oral morphine be switched to a syringe driver or a transdermal patch of another analgesic agent?

A

syringe driver

182
Q

name one resource that you can consult for more information about drugs that can be delivered within a syringe driver?

A

WM palliative care guidelines

183
Q

why is it not appropriate for oxycodone and cyclizine to be in the same syringe driver?

A

causes precipitation

184
Q

you should generally avoid mixing more than how many drugs in a syringe driver unless you have the stability data?

A

2

185
Q

some drugs and syringe drivers be prescribed anticipatorarily, true or false?

A

true

186
Q

syringe drivers will not give better analgesia compared to oral or transdermal formulations etc unless what 2 things are the case?

A

problems with absorption/ administration

187
Q

why should drugs for syringe drivers generally be diluted with WFI instead of 0.9% saline?

A

tends to be less stable

188
Q

tends to be less stable

A

no

189
Q

Review all medication
Only meds to control/prevent distressing symptoms. what meds may you stop?

A

eg iron, vitamins, insulin, antihypertnesives

190
Q

what might someone be able to place in their mouth if they are dehydrated and have a dry mouth?

A

ice

191
Q

Analgesia: usually morphine. name some alternatives

A

oxycodone, hydromorphone, alfentanil

192
Q

what are 3 first line anti emetics? (based on underlying cause)

A

haloperidol
metoclopramide
cyclizine

193
Q

which first line anti emetic is most suited to emesis that is chemical or opioid induced?

A

haloperidol

194
Q

which first line anti emetic might be appropriate for general emesis or if you are unsure of the specific cause?

A

cyclizine

195
Q

metaclopramide is a dopamine antagonist, why is it not appropriate to be used an as antiemetic in cases of obstruction?

A

also a prokinetic so speeds gut motility

196
Q

what is the 2nd line step for anti emesis?

A

add another first line or change to broad spec levomepromazine

197
Q

name a third line anti emetic drug and its class that is not commonly used in end of life?

A

ondansetron for 3 days, 5ht3 antagonist

198
Q

what can cyclizine and levomepromazine (Nozinan)cause when given in syringe driver?

A

infusion site irritation

199
Q

is 0.9% saline appropriate to be used as a diluent for cyclizine, yes or no?

A

no

200
Q

3 things to consider when changing morphine analgesia to alternative?

A

renal failure, liver failure, stable pain

201
Q

what different causes might there be for patients that are experiencing agitation or delirium?

A

opioids, increased calcium, infection, constipation

202
Q

name an antipsychotic drug that can be used for delirium?

A

haloperidol/ levomepromazine

203
Q

name 2 drugs that may be used for restlessness? where agitation and anxiety main features

A

midazolam/ levmepromazine

204
Q

what is the difference between the indications of high and low dose levomepromazine?

A

at high doses used for sedation and at low doses used as anti emetic

205
Q

what drugs might you consider for mycoclonic jerking or fitting?

A

midozolam or clonazepam (specialist only)

206
Q

what 3 pharmacological measures exist for terminal respiratory secretions aka death rattle?

A

hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium

207
Q

what non pharmacological measures can be used for death rattle?

A

positioning and reassurance

208
Q

which out of: hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium cross BBB?

A

only hyoscine hydrobromide

209
Q

which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium

crosses BBB, absorbed transdermally, paradoxical agitation, sedation?

A

hyoscine hydrobromide

210
Q

which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium

for colic with intestinal obstruction, may be used to control secretions. Does not cross BBB

A

hyoscine butylbromide

211
Q

which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium

for excessive respiratory secretions and bowel colic. Does not cross BBB. Unstable above pH6, avoid mixing with dexamethasone.

A

glycopyronnium

212
Q

Symptom control workshop

what is the rationale behind giving morphine for breathlessness?

A

prolongs breath, increases capacity of air intake and reduces perception of breathlessness

213
Q

Breathlessness is a common symptom in patients with?

A

advanced HF
COPD
lung cancer

214
Q

breathlessness is the perceived mismatch between what?

A

motor command from respiratory centre and ability of respiratory centre to respond.

215
Q

what might an appropriate dose in opioid naive patients of morphine MR for breathlessness?

A

10-30mg

216
Q

what might an appropriate dose in opioid experienced patients of morphine for breathlessness?

A

increase opioid dose by 25-50% and titrate

217
Q

T/F No significant respiratory depression titrating opioids and benzodiazepines together

A

true

218
Q

name an alternative drug, class and dose to morphine that would be appropriate to treat symptomatic breathlessness?

A

short acting benzos
lorazepam 0.5-1mg SL (unlicenced)

219
Q

are benzos licensed for use in breathlessness, yes or no?

A

no

220
Q

what non pharmacological support could you provide to ease the symptoms of breathlessness?

A

physio

calm manner

fan or open window so air hits face

short frequent meals

relaxation training

aromatherapy

treat anxiety and depression if present

encourage social interactions

peer group support

excercise

221
Q

apart from morphine and benzos are there any other pharmacological measures that can help ease breathlessness?

A

corticosteroids, levomepromazine, bronchodilators, oxygen, nasal prongs

222
Q

why might nasal prongs not be suitable to treat breathlessness?

A

another tube, noisy, drying, intrusive

223
Q

how to treat nausea?

A

Antiemetic medication may be required, such as metoclopramide or ondansetron

224
Q

how can hypercalaemia be a result of some tumours?

A

tumour might release PTH-RP which releases calcium from bones

225
Q

name some cancers that -> hypercalcaemia

A
  • Breast cancer and multiple myeloma
  • Squamous cell cancers lung, cervix, head and neck
226
Q

name some symptoms of (tumour induced) hypercalcaemia

A

vomiting
polyurea
dehydration
thrist
fatigue
confusion
constipation

227
Q

name a suitable bisphosphonate that can be used to treat hypercalcaemia?

A

pamidronate IV

228
Q

the dose of bisphosphonate will depend on what 2 parameters of the patient?

A

calcium level and renal function (90mg)

229
Q

what should the patient be aware of if started on bisphosphonates?

A

ONJ, avoid invasive dental treatment, report pain, swelling, gum infection

230
Q

true or false, some patients can experience myoclonic jerking from opioids and therefore a switch may be best for them?

A

true

231
Q

Aspirin may need to be reviewed in the context of what?

A

any potential bleeding risk with an underlying malignancy.

232
Q

why might platinum based chemo lead to mycoclonic jerking?

A

not preserving magnesium

233
Q

What is the symptom called ‘death rattle’? and how to treat it?

A

Respiratory secretions in the dying phase
bubbly, or noisy breathing
repositioning the patient, suctioning secretions, and moistening the patient’s mouth and lips.

234
Q

3 medications for death rattle?

A

anticholinergics
Hyoscine hydrobromide
Hyoscine butylbromide or
Glycopyrronium

235
Q

does dexamethsone work well when put in a syringe driver, yes or no?

A

no

236
Q

can anticholinergics such as glycopyrronium be put in same syrinige driver with morphine?

A

no - dont mix them with other medications in the same syringe driver. prevents drug interactions and ensure accurate dosing.

237
Q

instead of delivering dexamethasone in a driver, how else might you give it?

A

stat dose

238
Q

true or false, at low doses midazolam and morphine together in a syringe driver do not pose any problems?

A

true

239
Q

what 2 drugs cannot be mixed with cyclizine in a syringe driver?

A

hyoscine and oxycodone

240
Q

Symptom control in palliative care lec

What are the 4 types of total pain?

A

physical
social
psychological
spiritual

241
Q

What is physical pain?

A
  • pain due to disaease locations
  • patients can experience other symptoms (nausea)
  • there is a physical decline and fatigue in patients with physical pain
242
Q

What is psychological pain?

A
  • grief and depression, anxiety and anger
  • may arise with adjustment to a patients condition
243
Q

What is social pain?

A

experience of pain as a result of interpersonal rejection or loss, such as rejection from a social group, bullying, or the loss of a loved one

244
Q

What is spiritual pain?

A

feeling that the pain arises as a punishment for previous wrongdoings

245
Q

What are 3 features of pain assessment?

A
  • history
  • examinations
  • investigations
246
Q

What are features of reassessment in pain assessment?

A
  • response of pain to each treatment
  • any new pains that have appeared
247
Q

what to remember about step 1: NSAIDs?

A
  • need gastroprotection especially if also receiving steroids or SSRIs
  • contraindications like renal function
  • alternative routes like orodispersible piroxicam or s/c diclofenac
248
Q

for what weight px is paracetamol dose reduction needed?

A

<50kg or malnourished

  • high tablet burden (up to 8 tablets a day)
249
Q

why is step 2 - codeine difficult drug to use?

A

effects individuals very differently
in analgesic and side effects

250
Q

in what px are low dose formulations of buprenorphine useful in?

A

opioid naive

251
Q

T/F: buprenorphine is relatively safe in renal and liver impairment?

A

true

252
Q

what class drug is tamadol and how does it work?

A
  • opioid and non opioid action (adjuvant/additional role as well) - can show a lot of side effects
  • serotonin and noradrenaline reuptake inhibitor
253
Q

why is morphine the gold standard/ reference opioid in step 3?

A
  • familiar
  • cheap
  • easy route of administration
  • no other opioid proven to be more effective (this does not mean if morphine is ineffective that others wont)
254
Q

morphine SEs?

A

Constipation
* Nausea
* Drowsiness, confusion
* Myoclonus
* Sweating
* Pruritis

255
Q

name 2 morphine long term effects?

A

HPA suppression
immunosuppression

256
Q

how may acute severe tox/ OD of morphine present?

A

respiratory depression

reduced consciousness

pinpoint pupils (but not very helpful diagnostic)

257
Q

Why is morphine toxicity a concern in renal impairment? (cycle)

A

renal impairment -> morphine toxicity -> serious drowsiness -> dehydration -> further worsen renal impairment

258
Q

What is background pain and how is this managed?

A

Continuous levels of discomfort or baseline pain which is prevented with MR morphine such as ZOMORPH

259
Q

What is breakthrough pain and how is this managed?

A

Comes on suddenly, lasts for short periods, and is not relieved by the patient’s normal pain management instead given immediate release formulation like ORAMORPH

260
Q

difference between zomorph and oramorph in terms of what pain theyre prescribed for?

A

zomorph: background pain
oramorph: breakthrough pain

261
Q

What is zomorph?

A

A modified release formulation of morphine

262
Q

What is oramorph?

A

Immediate release morphine given for breakthrough pain

263
Q

What is incident pain?

A

occurs predictably after specific movements

  • swallowing
  • coughing
264
Q

What is spontaneous pain?

A

Pain in the absence of a stimulus
unpredictable
- bladder spasm

  • stabbing neuropathic pain
265
Q

diamorphine is another step 3 med. why is it good for admin high doses?

A

as its a concentrated formulation

3x more potent than oral morphine

266
Q

T/F:
oxycodone is
as effective as morphine
2x more potent than oral morphine (lower dose)
better tolerated than morphine in some patients
opioid switching is justified

A

true

267
Q

why avoid oxycodone in severe hepatic impairment

A

liver metabolised

268
Q

why is fnetanyl good in terms of SE profile?

A

has fewer SE especially constipation
doesnt accumulate in renal impairment

269
Q

with morphine: remember rescue doses and warn px about what?

A

constipation and nausea - offer treatment

also drowsiness and driving advice

270
Q

What are important warnings about fentanyl?

A

VERY strong analgesic with risks of toxicity

if accidentally sticks to someone else like bed partners or toddlers, it can cause severe side effects

271
Q

how does transmucosal fentanyl compare to oral morphine IR?

A

faster onset of action, shorter duration of action
- 15 minute onset

  • last about an hour
272
Q

4 example drug names of transmucosal fentanyl?

A
  • Actiq
  • Effentora
  • Abstral
  • Nasal sprays eg Pecfent
273
Q

why is transmucosal fentanyl titration challenging?

A

Difficult to convert dose from morphine therefore need to titrate up regardless of how high morphine dose was

274
Q

Using strong step 3 opioids: which drug to use?

A

morphine 1st line
other options if not tolerated
fentanyl if renal impairment

275
Q

why use ORAL opioids eg
Codeine
Tramadol
Morphine,
Oxycodone

A

first line

276
Q

why use SC opioid eg
Morphine,
diamorphine,
oxycodone,
Alfentanyl

A

dying
vomiting
speed of onset of action

277
Q

why use TRANSDERMAL opioid eg
fentanyl
buprenorphine

A

vomiting
px preferences

278
Q

why use TRANSMUCOSAL opioid eg
fentanyl

A

speed of onset of action

279
Q

why use SPINAL opioid eg
morphine
diamorphine
bupivocaine

A

systemic SEs

280
Q

What are features of methadone in symptom control?

A
  • very effective analgesic
  • effects opioid and NMDA receptors
  • no dose conversion with morphine

Seek specialist advice before stopping, pausing, ommitting or changing dose

initiation and titration requires specialist supervision

281
Q

What is an adjuvant?

A

a medicine with primary indication that is not an analgesic but has some analgesic effect

Used with conventional analgesics

282
Q

What is neuropathic pain and its characteristics?

A

Arising from injury to the nervous system

  • burning
  • tingling
  • shooting disturbance
283
Q

What are examples of adjuvants for symptom control?

A

corticosteroids

antidepressants - amitriptyline

antiepileptics - gabapentin

bisphosphonates

NMDA receptor blockade (glutamate receptor blocker)

antispasmodic

muscle relaxant

284
Q

What factors affect the choice of adjuvant for analgesia? [6]

A
  • Evidence from clinical trials
  • Availability
  • Side effects
  • Cost
  • Onset speed
  • Prescriber familiarity
285
Q

4 Limitations of the WHO
ladder?

A
  1. Designed for advanced cancer pain, but used more broadly
  2. Does not incorporate anaesthetic techniques
  3. Middle rung may not be distinct or necessary
  4. No focus on non pharmacological
286
Q

3 medicines for breathlessness management

A

opioids
oxygen
benzos

287
Q

Ethics, law, palliative care continued

What are the four criteria to determine if a person lacks capacity for a particular decision?

A

The ability to understand information related to the decision.

The ability to retain the information for long enough to use and weigh it up.

The ability to use and weigh up the information relevant to the decision.

The ability to communicate the decision in some way.

288
Q

What is the “best interests” approach?

A

Best guess as to what they would chose if they
were able

XNot what you would chose or think is best

289
Q

What are the 6 steps involved in making a best interests decision?

A
  • Encourage participation and enable the person to take part.
  • Consider whether the decision can be delayed until the person has capacity.
  • Identify all relevant circumstances.
  • Find out the person’s views, past and present wishes, feelings, beliefs, and values.
  • Consult with friends, family, Attorney or Deputy, if applicable.
  • Avoid discrimination.
290
Q

Who makes best interests decisions? (other than px when they have capacity)

A

HCP when px lacks capaity
- Family are “advocates”, not decision makers.
- Taking into account family members knowledge of patient wishes and preferences
- If no “advocate” for patient, then appoint an IMCA for important decisions (life changing/threatening treatments, changes in place of residence)

LPA for health (if appointed)

291
Q

What is an Advance Decision to Refuse Treatment (ADRT)?

A

decision relating to a specific treatment in specific circumstances that involves refusal, not a request, for treatment. It can be written or verbal, must be written, signed, and witnessed if it includes a refusal of life-sustaining treatment, and will come into effect only when the individual has lost capacity to give or refuse consent. It is legally binding and should be shared with family and the Multi-Disciplinary Team (MDT).

292
Q

What is a Lasting Power of Attorney (LPA)?

A

legal document that states in writing who can make decisions for a person if they lack capacity.
can cover property, financial affairs, health, and welfare.
only comes into force when the patient lacks capacity, and the appointed person must make decisions in the patient’s best interests, taking into account their views and attitudes..

293
Q

what is DNACPR and AND?

A

do not attempt CPR
allow natural death

294
Q

Ethical analysis of CPR
beneficience
maleficience
justice
autonomy

A

Beneficence: aims to restart cardiac and respiratory function

Maleficience: may cause brutal rib #, ventilation, anoxic brain injury, and poor survival and discharge rates even after successful CPR

Justice: not in the interests of distributive justice to offer CPR if it is deemed “futile”

Autonomy: consent for CPR is required, and patients should be informed about DNACPR. Patients should be the decision-maker, not their family. They are entitled to a second opinion on the issue of futility but not offered a decision regarding treatment where it is deemed futile.

295
Q

T/F:
The subcutaneous dose of morphine is half the total daily oral dose.

A

true
SC morphine should be presribed PRN for breakthrough pain for that px (SCRIPT)
should be 1/6 of the regular 24hr dose
prescribe an antiemetic PRN in case

296
Q

what would you prescribe with morphine sulphate 80mg over 24hrs in syringe driver for px with nausea and vomiting?

A

Cyclizine 150 mg with haloperidol 2.5 mg over 24 hours

297
Q

Breathlessness can be treated with which ONE of the following drugs?

Gabapentin
Haloperidol
Hyoscine butylbromide
Metoclopramide
Midazolam

A

Midazolam SC

Health 32 (11 decks)

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