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MK SR INDEX CASES CANCER CARE > End of life care > Flashcards

End of life care Flashcards

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1
Q

Basic principles of prescribing opioid analgesia in Palliative Care: How should PRN and potency be adjusted?

A
  • PRN Morphone should be one-sixth of total 24hr dose

* Potency (PO:SC = 2:1)

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2
Q

Analgesia in Palliative Care: 65yrs, Carcinoma of breast
• Takes: morphine modified release 30mg BD
• Admitted to hospital with urine infection

Please prescribe her analgesia

A

Regular opioid:
• Dose: 30mg modified release
• Frequency: 12-hourly (BD)

PRN opioid:
• PO: morphine immediate
release 10mg four-hourly
• SC: morphien injection 5mg fourhourly

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3
Q

Analgesia in Palliative Care: Patient with gastric cancer taking Oxycodone modified release 100mg BD, Admitted with vomiting

What should she be prescribed regular & PRN?

A

Regular opioid:
• Dose: oxycodone 100mg
CSCI/24hrs#
• Frequency: over 24hrs

PRN opioid:
• PO: ?
• SC: oxycodone injection 15mg-20mg four hourly PRN

#Note frequency of dose important ie
csci is over 24hrs
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4
Q

Analgesia in Palliative Care: Patient with Fentanyl
transdermal patch 25micrograms/hour

What would you want to know?
How do you work out a PRN dose?

A 
• Check renal function
• Consult patient and BNF
• Fent 25mcg/hr = ~90 oral
morphine in 24hrs
• PO morphine PRN dose ~15mg
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5
Q

Controlled Drug prescriptions must include which elements?

A 
DRUG
• Name
• Formulation: liquid, tablet, capsule, patch etc
• Dose: in words and figures
• Frequency
• Strength: eg 10mg in 5mL, 10mg tablets
• Total quantity (words & figures)

YOU: Prescriber signature, date, address [professional]

PATIENT: name & address, date of birth, hospital/NHS number

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6
Q

Analgesia in Palliative Care: Syringe drivers - what is an appropriate starting dose?

A
  • Morphine 10mg/24hrs
  • Oxycodone 5mg/24hrs
  • Alfentanil 500micrograms/24hrs

In renal failure: use fentanyl or alfentanil

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7
Q

Complete a MCCoD:
• 64 years, admitted to hospital with chest infection.
• Underlying diagnosis of squamous cell lung cancer, bone metastases.
• Deteriorated despite IV antibiotic. Commenced on
PCPDP.
• PMHx: eczema, hypertension

A 
I(a) Lower respiratory tract infection
(b) Metastatic squamous cell
carcinoma of the lung.
(c) -
II -
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8
Q

Complete a MCCoD:
• 54yrs
• Cardiac failure, EF 25%
• PMHx: multiple MIs, angioplasty + stent; Has CRT-P, Diabetes.
• Admitted with pulmonary oedema, deteriorated despite treatment and died suddenly.

A

I(a) Cardiac failure
(b) Ischaemic Heart Disease
(c)
II Diabetes

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9
Q

Complete a MCCoD:
• 73yrs male
• Admitted with dyspnoea. Found to have pulmonary embolism,
• Deterioration, hospice admission or end of life care 29th July 2018
• Mesothelioma diagnosed 2017
• VATS surgery 2018 (Jan)

A

You must refer this death to Coroner as mesothelioma

industrial disease

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10
Q

Delirium in palliative care: What is delirium?

A
  • Acute confusional state
  • Change in alertness, altered consciousness, impaired cognition
  • Fluctuant /Reversible course
  • Change from normal baseline
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11
Q

What factors can precipitate delirium?

A 
D: Drugs, Dehydration
E: Electrolyte /Endocrine Imbalance
L: Level of pain
I: Infection /Inflammation
R: Respiratory Failure
I: Impaction
U: Urinary retention
M: Metabolic disorder ( Liver/Renal failure, Hypoglycemia)
  • Change of environment
  • Sensory deficit
  • Falls
  • Immobility
  • Sleep Deprivation
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12
Q

Symptoms of Delirium

A

• Cognition : concentration, disorientation, fluctuating
consciousness

• Perception : hallucinations

• Impaired Physical function : mobility, appetite, agitation,
restlessness, sleep disturbance

• Social behaviour : combative, lack of cooperation with
reasonable requests, withdrawal

• Attention : difficulty maintaining attention span

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13
Q

4 features of hyperactive delirium

A
  • Aggressive, restless, agitated
  • Increased state of arousal
  • Hallucinations, delusions
  • Sleep disturbed, , hyper vigilant
  • Uncooperative, combative
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14
Q

4 features of hypoactive delirium

A
  • Withdrawn, quiet, sleepy
  • Less active / inert
  • Poor concentration
  • Reduced mobility /movement
  • Mimics depression
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15
Q

How does the onset differ between delirium, depression and dementia?

A

Delirium: hours to days

Depression: gradual weeks o months

Dementia: gradual months to years

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16
Q

How does the course differ between delirium, depression and dementia?

A

Delirium: fluctuant, reversible with treatment

Depression: recent changes in mood persistent, worse in morning

Dementia: show chronic progression, irreversible

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17
Q

How does sleep differ between delirium, depression and dementia?

A

Delirium: disturbed sleep with no set pattern, some day night reversal

Depression: early morning awakening, hypersomnia, disturbed

Dementia: disturbed +/- individual pattern occurring most nights, nocturnal wandering

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18
Q

How does mood differ between delirium, depression and dementia?

A

Delirium: fluctuant emotions, labile, may have outburst of anger, fearfulness or crying

Depression: withdrawn, persistently low, worthlessness, anhedonia, hopelessness, suicidal

Dementia: depressed, apathy more common

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19
Q

How does perception and cognition differ between delirium, depression and dementia?

A

Delirium: Fluctuation in alertness, cognition, Perception,
hallucinations, illusions

Depression: Low self esteem & guilt, Suicidal / self harm
Agitated depression OR withdrawn, reduced motivation/interest

Dementia: Delusions +/-
Hallucinations – LBD
Wandering /agitated or withdrawn, co-existent
depression

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20
Q

How do you assess a patient for delirium?

A

Altered arousal: observe for sleepiness or hyper-alertness, wake them up and talk to them - are they able to follow conversation?

Disordered thinking: “what’s going on today? Anything strange or different?”

Change in baseline: acute onset, fluctuant course, not my mom/dad

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21
Q

Formal tools for assessing delirium

A

DSM-5 Criteria
CAM - confusion assessment method
4AT
AMTS

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22
Q

Describe the confusion assessment method (CAM) tool

A
  1. acute onset and fluctuant course
  2. inattention
  3. disordered thinking
  4. altered consciousness

Must have presence of 1,2 AND
Either 3 OR 4

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23
Q

DSM-5 Diagnostic Criteria for Delirium

A

A. Disturbance in attention and awareness
B. Develops over a short period of time, Fluctuates in severity
during the course of a day
C. Additional disturbance in cognition not accounted for by
another neurocognitive disorder;
D. Disturbances A and C must not be occurring secondary to
coma;
E. Caused by a somatic factor, medication intoxication or
withdrawal

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24
Q

Non Pharmacological Management of delirium

A
  • Calm, constant environment
  • Correct sensory deficit
  • Familiar objects & people
  • Simple communication/reassure in lucid intervals
  • Avoid moving patient between rooms
  • Fewer interruptions
  • Avoid catheterisation, restraints
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25
Which reversible causes of deliruim should be treated in palliative patients?
Treat potentially reversible causes EVEN in palliative patients - Infections: UTI, pneumonia, sepsis - metabolic: Ca, Na, HF, RF, hypoglycaemia - dehydration and nutritional deficiencies - psychological distress, pain - constipation, urinary retention
26
Pharmacological Management of delirium: what works?
``` Haloperidol • Oral & s/c syringe driver • 500 micrograms stat, PRN • Dose range 0.5 mg - 3 mg • Lower doses in elderly ```
27
Pharmacological Management of delirium: What cautions must be think about when prescribing haloperidol?
* Parkinson’s Disease, Levy Body Dementia | * Prolonged QT interval, torsade de pointes
28
Pharmacological Management of delirium: what should be avoided?
• Benzodiazepines WORSEN delirium • No adequately controlled trials to support the use of Benzodiazepines in Delirium • Lorazepam associated with increased side effects
29
Strategies to prevent delirium
* Orientate * Hydration / nutrition * Reassure – use lucid intervals * Correct sensory deficit * Encourage visits from family * Familiarize with surroundings * Encourage mobility * Establish sleeping pattern
30
List 3 benefits of early palliation
``` Better QOL Less depression Less aggressive EOLC Low symptom burden ```
31
Causes of sudden onset breathlessness
asthma pulmonary oedema pneumonia pulmonary embolism
32
Causes of breathlessness arising over several days
exacerbation of COPD pneumonia bronchial obstruction by tumour SVC obstruction
33
Causes of breathlessness with gradual onset
``` congestive cardiac failure anaemia pleural effusion primary/secondary lung carcinoma ascites ```
34
Dyspnea in patient with underlying malignancy: how can we determine the cause
malignancy related: directly or indirectly unrelated: pre-existing pulmonary or cardiovascular disease treatment related: directly or indirectly
35
How can malignancy cause dyspnea?
Directly: - pulmonary: lung primary or metastases, lymphangitis spread, lobar collapse, haemorrhage - cardiac: pericardial effusion - other: SVC obstruction, dyspnea of malignancy Indirectly: - PE from hypercoagulability - pneumonia from immunosuppression
36
How can treatment for malignancy cause dyspnea?
Radiation: pneumonitis, pulmonary fibrosis, pericarditis Chemotherapy: lung toxicity (bleomycin, methotrexate etc), cardiac toxicity (anthracyclines, paclitaxel, Herceptin) Indirectly: pancytopenia resulting in respiratory infection or severe anaemia, higher risk of CAD with chest wall radiation
37
Treatment of dyspnoea in palliative patients
Treat potentially reversible causes of Dyspnoea EVEN in palliative patients Examples: Large airway: strent Small airway: bronchodilators Decreased gas exchange: ?PE -> LMWH RT pneumonitis: dexamethasone
38
Palliation of Breathlessness | Non pharmacological
* Positioning * Room temperature, air circulation * Behavioral techniques, relaxation, distraction * Energy conservation / Pacing * Controlled breathing * Loose clothing * Mouth care * Walking Aids
39
Palliation of Breathlessness | pharmacological management
* Bronchodilators * Nebulised saline * Carbocistiene * Dexamethasone Benzodiazepine if anxiety unmanageable or EOL (less evidence for this)
40
Palliation of Breathlessness: What is the role of oxygen?
Oxygen no better than air in palliation A fan may be equally effective Only for hypoxic patients Formal assessment for O2 use
41
Define Cachexia
Multifactorial syndrome associated with protein and muscle loss, as well as systemic inflammation. Traditionally described as involuntary loss of more than 10% of premorbid body weight, Accompanying anorexia. Increases with disease progression. Can be caused by Cancer, AIDS, heart failure, COPD
42
Factors exacerbating anorexia in cancer patients
- dry mouth from mouth breathing and oxygen therapy - drugs: opioids, iron, NSAID - disease processes - mouth ulcers, candida, mucositis - treatment related: post-chemo or radiation - anxiety, depression, pain
43
Effects of anorexia/cachexia in cancer patients
* Impaired immune response * Impaired wound healing * Weakened skeletal muscles * Weakened respiratory function and mobility * Poor cardiac contractility * Reduced quality of life * Poorer prognosis
44
Management of anorexia in cancer patients
``` •Address factors reducing intake •Little & often •High protein / energy meals •“What you fancy” •Food fortification and supplements •Food & fluids separately •Appetite stimulants: Alcohol, Antidepressants, Dexamethasone (glucocorticoid) 2mg mane with PPI, (Megestrol acetate) ``` Down-regulation of the inflammatory response: •NSAIDs •Inhibition of IL-6, TNF-a •Managing insulin resistance?
45
Causes of nausea and vomiting in palliative cancer care
* Gastric stasis, outflow obstruction, squashed stomach * Bowel obstruction * Pharyngeal candida * Radiotherapy & chemotherapy * Brain tumour or metastases * Metabolic - hypercalcaemia, uraemia, tumour toxins * Drugs (opioids, NSAIDs, iron) * Pain, cough * Anxiety/fear of treatment
46
Non pharmacological management of nausea and vomiting in palliative cancer care
* Control malodour (tumour, colostomy, ulcer) * Avoid strong food smells * Someone else cooks * Calm, unhurried meals * Small portions * Acupressure bands
47
Which drugs stimulate N/V via gastric irritation?
Antibacterials, Corticosteroids, Iron, NSAIDs
48
Which drugs stimulate N/V via gastric stasis?
* Antimuscarinics (e.g. Tricyclic antidepressants) | * Opioids
49
Which drugs stimulate N/V via central stimulation?
* Opioids * Antibacterials * Cytotoxics
50
Which drugs stimulate N/V via 5HT3 receptor stimulation?
* Antibacterials * Cytotoxics * SSRIs
51
Causes of N/V via central stimulation (dopamine, serotonin, NK1)
uraemia hypercalcaemia morphone
52
Causes of N/V via GI tract (serotonin, dopamine, stretch receptors)
abdominal radiotherapy chemotherapy distension
53
Causes of N/V via 8th nerve nucleus (AChM, H2)
motion sickness | vertigo
54
Causes of N/V via cerebral cortex (GABA, serotonin, D2)
fear, anxiety, anticipatory nausea
55
Which anti-emetics work as D2 antagonist?
metoclopramide, domperidone, haloperidol, olanzapine, levomepromazine
56
Which anti-emetics work as H2 antagonist?
Cyclizine | Levomepromazine
57
Which anti-emetics work as muscarinic antagonists?
Cyclizine Olanzapine Levomepromazine
58
Which anti-emetics work as 5HT antagonists?
5HT2: Olanzapine Levomepromazine 5HT3: Ondansetron
59
Which anti-emetic works as NK1 antagonists?
Aprepitant
60
How does metoclopramide act as a pro kinetic?
D2 antagonist (Upper GIT, CTZ) 5HT4 agonist (Upper GIT) Triggers cholingeric system in GIT wall Crosses BBB
61
Indications for metoclopramide as pro kinetic
Gastric stasis/upper GI dysmotility Early in bowel obstruction Delayed N&V due to chemotherapy
62
Side effects and cautions of metoclopramide as pro kinetic
``` Diarrhoea Extrapyramidal reactions (avoid in Parkinsons disease) ```
63
Indications for domperidone as pro kinetic
Gastric stasis/upper GI dysmotility
64
Key difference between pro kinetics metoclopramide and domperidone
metoclopramide crosses the BBB whereas domperidone does not
65
Action of Cyclizine
* AchM (antimuscarinic antihistamine) * directly on vomiting centre * Decreases activity in vestibular system
66
Indications for Cyclizine
* Raised ICP | * Motion induced nausea and vomiting
67
Cyclizine: Side effects/cautions
* Mutual antagonistic effect with Metoclopramide | * Severe cardiac failure (tachycardia)
68
Action of Haloperidol as anti-emetic
* Potent D₂ antagonist * Acts directly on CTZ * May have some gastric prokinetic effect
69
Indications for Haloperidol as anti-emetic
* Metabolic causes (e.g. renal failure, hypercalcaemia) * Morphine induced sickness * May help obstructive vomiting in small doses
70
Side-effects and cautions for Haloperidol as anti-emetic
* Some sedation | * Avoid if possible in Parkinsons disease
71
Action of Olanzapine as anti-emetic
* Antagonist at * Multiple D receptors * Muscarinic receptors * Multiple 5HT receptors * H₁ receptors
72
Indications for Olanzapine as anti-emetic
Chemotherapy induced nausea and vomiting resistant to other drugs
73
Cautions and side effects of Olanzapine as anti-emetic
Can cause: •Drowsiness •Orthostatic hypotension
74
Action of levomepromazine as anti-emetic
Antagonises D₂, 5HT₂ₐ, muscarinic receptors
75
Indications for levomepromazine as anti-emetic
* Broad spectrum – helps with many causes of vomiting * Anxiolytic * (Used in larger doses for agitation at the end of life)
76
Cautions and side effects of levomepromazine as anti-emetic
Drowsiness at doses >25mg/24hrs – therefore not used first line
77
Action of ondansetron as anti-emetic
* 5HT₃ antagonists | * Block effect on vagal nerve
78
Indications for ondansetron as anti-emetic
* Developed to control sickness associated with highly emetogenic chemotherapy * Any situation where 5HT₃ is released in excess: * Radiation induced damage to GI mucosa * Intestinal distension * Severe renal impairment with platelet release of 5HT
79
Side effects of ondansetron as anti-emetic
* Headache | * Constipation
80
Action of Aprepitant as anti-emetic
* Potent NK₁ inhibitors | * Act at CTZ
81
Indications for Aprepitant as anti-emetic
* Delayed phase of chemotherapy induced emesis | * Combination therapy with Dexamethasone and 5HT₃ inhibitor
82
Side effects/cautions for Aprepitant as anti-emetic
Lassitude, constipation, decreased appetite, dyspepsia, headache, hiccups
83
Actions and indications of dexamethasone as anti-emetic
* Direct action on vomiting centre, * Direct anti-inflammatory effect on damaged tissue * Reduces expression of serotonin receptors * Reduces swelling around solid tumour mass * Short term relief of ICP due to brain metastases (use up to 2 weeks)
84
Side effects/cautions for dexamethasone as anti-emetic
* Arousal/disturbed sleep * Psychosis * Hyperglycaemia * Myopathy * Increased susceptibility to infection
85
Actions and indications of lorazepam as anti-emetic
Action: GABAmimetic (cerebral cortex) Indications: •Chemo related and post op nausea and vomiting •? Anxiolytic for anticipatory nausea
86
Side effects/cautions for lorazepam as anti-emetic
* Drowsiness * Can cause respiratory depression * Paradoxical agitation (<10%, risk in psychiatric comorbidity)
87
Choice of antiemetic Raised intracranial pressure or vestibular irritation
Start with centrally acting drug, e.g. Cyclizine
88
Choice of antiemetic | Chemical cause of vomiting (CTZ), such as Morphine, hypercalcaemia, renal failure
Start with drug acting principally at CTZ, e.g. Haloperidol
89
Choice of antiemetic | Gastritis, gastric stasis, functional bowel obstruction
Start with a prokinetic, e.g. Metoclopramide
90
Management of constipation
* Ask about bowel function frequently * Increase fluid intake * Increase fruit/fibre in diet * Encourage mobility * Assist to toilet/raised toilet seat * Provide privacy
91
How do direct stimulant laxatives work?
Direct stimulants •Act by direct contact with submucosal and myenteric plexus, stimulating peristalsis •Increase water secretion into bowel lumen •Softer, larger stool stimulates bowel
92
How do softener laxatives work?
* Act as detergent, allowing water to penetrate stool | * Softer, larger stool stimulates bowel
93
How do osmotic laxatives work?
* Retain water in bowel lumen | * Softer, larger stool stimulates bowel
94
List 3 oral laxatives and how they work
Softener: •Docusate tablet or liquid (100-200mg BD) Osmotic: •Macrogol (Movicol or Laxido, in 100ml water) Direct stimulant: •Senna tablet or liquid, 7.5-15mg nocte Combination: •Sodium picosulphate tablet or liquid 5-15mg nocte Reversal of opioid induced constipation: •Methylnaltrexone SC (stop other laxatives) •Naloxegol PO (evidence lacking in palliative patients)
95
List 3 rectal laxatives and how they work
Suppositories •Glycerine (stool softening) •Bisacodyl (rectal stimulant) Enemas •Phosphate (osmotic) •Sodium citrate Microlax (osmotic) •Arachis oil (softening, avoid in peanut allergy)
96
“Spinal regime” for laxatives in palliative care Lack of peristalsis due to malignant spinal cord compression or neurological disease
•Alternate nights: Senna 1-2 tablets PO Following mornings •Glycerine suppository •Bisacodyl suppository •Microlax enema
97
Bowel obstruction in palliative care: what is Medical management?
Likely to represent peristaltic failure, Try to get the bowel going… •Metoclopramide via CSCI, 30-100mg/24hrs •Stool softening laxative (stop stimulants) •Consider Dexamethasone 6mg SC OD for 5-7 days with Ranitidine 300mg/24hrs CSCI May resolve partial proximal obstruction May precipitate colic or vomiting in complete obstruction
98
Bowel obstruction in palliative care: what is Medical management of colic?
May represent mechanical obstruction Stop prokinetics and stimulant laxatives Use CSCI: •Opioid for pain •Cyclizine and/or Haloperidol for nausea/vomiting •Hyoscine butylbromide for colic 30-120mg/24hrs •Consider nasogastric tube (only for large volume frequent vomits)
99
Pain management in palliative care: 46yrs female with Carcinoma of lung and Widespread cutaneous metastases. Pain in skin metastases; dull ache; constant * What is pain? * What type of pain do you think this person is describing? * What else would you want to ask? * What analgesics would you use?
* Nociceptive pain * Recognise * Assess: Pain history: [type], severity •Treat Non-opioids: paracetamol, ibuprofen Opioids: morphine
100
Pain management in palliative care: 70yrs male with lung cancer with right axillary mass, Shooting pain with pins and needles down right arm. ``` What type of pain do you think this person is describing? What else would you want to ask? What analgesics (groups) might you use? ```
Neuropathic pain * Recognise * Assess: Pain history: [type], severity * Treat: Neuropathic analgesics
101
Total pain: management
pharmacological •As nociceptive/neuropathic pain •But caution: potential to escalate drugs with no benefit (be prepared to reduce) ``` Non-pharmacological •TENS, acupuncture •Physio •Counselling •Address social issues •Manage anxiety/depression •Distraction ```
102
Pain management in palliative care: What practical things do you need to consider when choosing a painkiller?
* Costs * Mode (ease) of delivery & dosing – PO, SC, TD, CSCI * Toxicities (more later in renal disease) * Regular, route, re-assess (titrate) * Potencies PO:SC (IM) * 2:1 for morphine, oxycodone
103
Pain management in palliative care: Starting dose for syringe driver opioids
- morphine 10mg/24hrs - Oxycodone 5mg/24hrs - Alfentanil 500micrograms/24hrs
104
Pain management in palliative care: Starting dose for syringe driver non-opioids
- ketorolac 30-90mg/24hrs | - ketamine 100-500mg/24hrs
105
Pain management in palliative care: special considerations for opioid prescribing
* Driving * Tolerance, Dependence, Addiction? * Travel abroad * Patient Information Leaflets * What questions/concerns do you think a patient may have when starting opioids for the first time?
106
Pain management in palliative care: Management of Total pain at end of life "pain crisis"
Requires rapid, multi-modal treatment escalation Environment, family/friends Analgesia: •Opioid – one hourly & CSCI •Ketamine CSCI Sedative anxiolytics •Midazolam PRN & CSCI •Levomepromazine
107
Pain management in palliative care: List 4 drugs that could be used for muscle spasm and spasticity
baclofen, clonidine, clonazepam, tizanidine, gabapentin, ?Sativex
108
painful syndromes in end-stage renal disease? What might you ned to consider about pharmacokinetics/dynamics?
* Renal osteodystrophy * Muscle spasms, cramp, restless legs * Diabetic problems – neuropathy * Ischaemic pain (IHD, PVD), calciphylaxis * Medications affecting renal perfusion: NSAIDS * In dialysis: some medications removed (fentanyl is not) - paracetamol, tramadol, morphine, gabapentin
109
Analgesia in end-stage renal disease: What might you need to consider about pharmacokinetics/dynamics?
* Medications affecting renal perfusion: NSAIDS * In dialysis: some medications removed (fentanyl is not) - paracetamol, tramadol, morphine, gabapentin Opioids •Avoid morphine & oxycodone where possible •Oxycodone with caution – use small doses with the increased time between Safer opioids: •Tramadol low dose is fine •fentanyl, alfentanil, hydromorphone
110
Consequences of unmanaged | lymphoedema
Cellulitis, pain, reduced mobility, body issues and psychological impact, skin conditions, leg ulceration, social & financial impact, clothing & shoe issues, cost burden to the NHS.
111
Main causes of Lymphoedema in End of Life
- Often – Limb dependency - Cancer mass (internal or fungating tumours) causing an obstruction to the lymphatics - Consequence of cancer treatments - Low albumin If sudden development, evaluate for DVT or SVCO
112
Lymphorrhea
Lymphorrhea is an abnormal flow of lymph that drains externally from disrupted lymphatic vessels or is retained within a wound

MK SR INDEX CASES CANCER CARE (16 decks)

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