End of Life Care

Question 1

What is palliative care?

Answer 1

The active total care of patients whose disease is not responsive to curative treatment.

Control pain, other symptoms and psychological, social and spiritual problems.

Goal to achieve best quality of life for patients and families.

Question 2

What are the 5 priorities for EOL care?

Answer 2

RECOGNISE
COMMUNICATE
INVOLVE
SUPPORT
PLAN AND DO

(Came from removal of Liverpool Care Pathway and the subsequent guidance from One Chance to Get It Right)

Question 3

Recognising dying, prognostic factors?

Answer 3

– ‘Would I be surprised if the patient were to die in the next 12 months?’ or more recently in the next few months, weeks, days?
– 2 or more unplanned admissions in the last 6 months
– Poor or deteriorating performance status
– Persistent symptoms despite optimal therapy
– Secondary organ failure arising from an underlying condition

Indicators:

• ALBUMIN LEVELS
• Ca+ CHANGES
• CHANGES IN PERFORMANCE STATUS
• SPICT tool

Question 4

Signs and Sx of dying?

Answer 4

• reduced intake of food and fluids
• difficulty swallowing meds
• reduced function/mobility
• altered appearance; gaunt, pale, cold
• changes to respiration, terminal secretion
• terminal agitation

Question 5

Symptoms in the last 48 hours of life you may want to prescribe for?

Answer 5

• Noisy and moist breathing
• Urinary dysfunction; incontinence
• Retention
• Pain
• Restlessness and agitation
• Dyspnoea
• Nausea / vomiting
• Sweating
• Jerking, twitching, plucking Confusion

Question 6

Would should be considered as anticipatory meds?

Answer 6

The four A’s
Prescribe them subcutaneously.

• Analgesic
• Anxiolytic
• Antiemetic
• Anti-secretory

Question 7

Name 4 drugs and their dosing as the 4As?

Answer 7

• Analgesic
  For pain, dyspnoea
  eg morphine sulfate 2.5mg subcut hourly prn
• Anxiolytic
  For dyspnoea, restlessness, anxiety
  eg midazolam 2.5mg-5mg subcut hourly prn
• Antiemetic
  For nausea
  eg haloperidol o.5-1mg subcut prn or cyclizine 50mg subcut max tbs
• Anti-secretory
  For death rattle
  eg glycopyrronium 200-400micrograms subcut hourly prn

OR
nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide

respiratory secretions: hyoscine hydrobromide
bowel colic: hyoscine butylbromide

agitation/restlessness: midazolam, haloperidol, levomepromazine

pain: diamorphine is the preferred opioid

Question 8

What are the 3 classes of anti-emetics and name examples from each?

Their side effects?

Answer 8

DOPAMINE ANTAGONISTS

• promethazine (SE: dry mouth, sedation)
• metoclopramide (SE: extra-pyramidal Sx like dystonia, facial grimacing; diarrhoea)
• chlorpromazine

ANITHISTAMINES

• diphenhydramine
• cyclizine

SEROTONIN ANTAGONISTS
- ondansetron (SE: constipation, headache)

OTHERS
- dexamethasone (SE: sleep disturbance, rarely psychosis, glucose intolerance)

Question 9

When would you choose each antiemetic?

Answer 9

Cyclizine is a good first line anti-emetic for intracranial causes of nausea and vomiting. Raised ICP from metastases can stimulate H1 receptors in the cerebral cortex, causing the symptoms of nausea and vomiting. H1 receptor antagonists, such as cyclizine, are a good choice to combat these symptoms.

Dexamethasone can also be used to reduce nausea and vomiting in the context of raised ICP.

Domperidone and metoclopramide are useful for nausea and vomiting when caused by gastric stasis.

Metoclopramide and haloperidol are useful for nausea induced by drugs (such as chemotherapy) and toxins.

Ondansetron is good for chemically mediated symptoms, for example, from opioids.

Question 10

4 key components when verifying a death?

Answer 10

Confirming death on the wards:

1. Absence of a central pulse on palpation and of heart sounds on auscultations: observed for a 5min duration.
2. Absence of pupillary responses to light.
3. Absence of a corneal reflex.
4. No motor response to supraorbital pressure.

Check for pacemakers or ICDs.

Question 11

What are the 6 broad vomiting syndromes / types / causes?

Answer 11

Reduced gastric motility
- May be opioid related
- Related to serotonin (5HT4) and dopamine (D2) receptors
(metoclopramide and domperidone)

Chemically mediated
- Secondary to hypercalcaemia, opioids, or chemotherapy
(ondansetron, haloperidol and levomepromazine)

Visceral/serosal
- Due to constipation
- Oral candidiasis
(Cyclizine and levomepromazine first-line,
anti-cholinergics eg hyoscine can be useful)

Raised intra-cranial pressure
- Usually in context of cerebral metastases
(cyclizine, dexamethasone)

Vestibular
- Related to activation of acetylcholine and histamine (H1) receptors
- Most frequently in palliative care is opioid related
- Can be motion related, or due to base of skull tumours
(cyclizine first line, refractory: metoclopramide or prochlorperazine or atypical antipsychotics: olanzapine or risperidone)

Cortical
- May be due to anxiety, pain, fear and/or anticipatory nausea
- Related to GABA and histamine (H1) receptors in the cerebral cortex
(anticipatory nausea is clear cause then short acting benzodiazepine eg lorazepam OR cyclizine
Ondansetron and metoclopramide can also be trialled