Palliative Care

Question 1

Barriers of recognising deterioration?

Answer 1

Denial
Lack of experience 
Emotions attached
May have several dips 
Complex/difficult
Lack of confidence 
Trying to maintain hope 
Use SPICT tool
Use Clinical Frailty Score

Question 2

Reasons for decline:

Answer 2

Unplanned admission
Reduced treatment
Performance status is poor
Significant weight loss

Question 3

Principles of symptom management:

Answer 3

Cause- Treatment? Cancer? Co-morbidity?
 Underlying pathological mechanism
Is it reversible?
What’s already been tried- effective/not
Impact of symptom on patients life

Question 4

Pain in advanced disease

Answer 4

Persistent 
May have more than one cause
Impairs function
Threatens independence 
Fear of death and suffering

Question 5

Neuropathic vs nonciceptive

Answer 5

Neuropathic is damage to the nervous system- CNS/PNS. Burning, shooting, stabbing, tingling, pins and needles etc.
Nonciceptive is due to a response to a stimulus.

Nonciceptive pain which is poorly treated can lead to neuropathic pain.
Cancer patients 40% have mixed.

Question 6

Analgaesia:

Answer 6

Opiates
Non-opiates- Paracetamol/NSAIDs
Adjuvants- Gabapentin, duloxetine (SNRI), amitryptiline, pregabalin, diazepam, dexamethasone, bisphosphonates.
Can use adjuvants at any level, since these drugs don’t have their primary function as pain relief. Some patients can use just adjuvants. ADR-dizzy, sleepy, unsteady.

Question 7

Adjuvant analgaesia:

Answer 7

Amitryptiline- start 10-25mg nocte
Gabapentin- 30.mg TDS over 3/7
Pregabalin- 75mg BD
Full benefit takes 5/7 and may need further titration.

Question 8

NSAIDs

Answer 8

Good for bone pain due to bone mets.
If no GI risk or no CV risk- ibuprofen/diclofenac/naproxen
GI but no CV risk- cox2-celecoxib
CV risk but less GI risk- naproxen/ ibuprofen

Prescribe PPI upfront as soon as NSAID prescribed.

Question 9

WHO ladder principles

Answer 9

Give drugs-
By mouth- reduce the infection, cheaper, not painful, allows pt control.
By the clock- need regular analgesia for regular pain- therefore steady pain control.
By the ladder- follow the ladder as opposed to using another drug on the same step; usually only change to a drug on same level if the drug is effective but with side effects.
Individual dose titration- Base of the pain of the patient, I.e. step three has no set dose.
Use adjuvants at any step.
Attention to detail.

Question 10

WHO ladder

Answer 10

Step 1 paracetamol, NSAIDs
Step 2 dihydrocodeine, code in phosphate, tramadol, cocodamol
Step 3 oxycodone, morphine, fentanyl, diamorphine.

Synthetic opioids gives less side effects sometimes but more expensive.

Question 11

Opioids pain control

Answer 11

Soft tissue- good repsonse
Visceral-good/partial
Bone- partial (NSAIDs, bisphosphonates and RT better)
Neuropathic- often poor (adjuvants better)
Incident (pain related to an event i.e. removing a chest drain, therefore need dose of immediate release short acting analgesia before the procedure)- moderate (analgesia, physio/OT etc better)

Question 12

Less than 50kg

Answer 12

Only allowed 50lmg paracetamol max dose

QDS

Question 13

Codeine prescribing:

Answer 13

Max dose of codeine is 240mg. This is eauivalent to 24mg morphine.
Can take as co-codamol or codeine phosphate.
so if going up the ladder change from codeine full dose to morphine.

Question 14

Morphine (oral)

Answer 14

IR (Immediate release)-
Oramorph- liquid 10mg/5ml or 100mg/5ml

Slow release
So morph capsules BD (5, 10, 15, 30, 100, 200mg)

Use IR alongside for breakthrough pain.

Question 15

Titrating opioids

Answer 15

Had full dose of codein so need to go up the ladder.
No point prescribing 24mg of morphine since equal to codeine full dose.
Therefore give 30mg of morphine over 24hrs.
This is prescribed as morphine 15mg slow release over 12hrs (BD)
As well as morphine immediate release (PRN-can repeat the dose after an hour if in pain but can’t give 24, if had 3 PRN in 2hrs then need to be reviewed but the doctor), safe dose to give is 1/6 of what they are having over 24hrs (total daily dose), I.e. 30/6-5mg.
Then can fine tune their dose.

Question 16

Example of increasing morphine dose.

NB pt on zomorph always needs a PRN of oromorph prescribed.

Answer 16

Pt comes in on 30mg BD and has 3 PRN of 10mg.
Per day they use 90mg (30+30+10+10+10)
Therefore new dose is 45mg BD.
New PRN dose is 90mg/6 which is 15mg.

A 30-50% increase in SR is generally considered safe. (18-30mg/24hr). Don’t increase everyday, look at situation, may have just had a bad day.

Question 17

Fentanyl patch

Answer 17

Replaces slow release zomorph, when pt has a steady state.
Change the patch and site every 3rd day to get a steady state. When initially starting takes 24hrs to reach the steady state, also takes 24hrs for fenaptanly to leave the system when patch is off.
Good if poor compliance.
Transdermal
Non-renal excretion
Use oramorph as PRN- work out morphine equivalent of the patch then convert into PRN.
Only come in certain strengths so sometimes pt may have more than one patch, should be side by side not on top of each other.

Question 18

Syringe driver of morphine

Answer 18

Same as zomorph but sub cut and the pump releases it slowly.
Prescribes the dose over 24hrs-only give half the dose, I.e. if 15mg BD, the syringe driver only put 15mg over 24hrs.
Titrate same way as zomorph.
Oral PRN to subcut PRN- need to half the dose since the potency is different.

Question 19

Morphine common side effects:

Answer 19

Constipation- Experienced by 95% of pts.
Nausea and vomiting- Experienced by 33.3% of pts, lasting only 5 days at the beginning. Prescribe PRN anti-emetic at the beginning so that if the pt needs it they can use it. Use metoclopramide- works on CRT zone and is prokinetic.
Drowsy- Can drive if regular prescription, so long as don’t feel so dizzy. Usually transient, lasting a few days, if persistent drowsiness then switch to oxycodone.
Dry mouth- advice sugar free gum, cold drinks etc.

Question 20

Uncommon of opioid prescription

Answer 20

Respiratory depression
Pruritis
Rash
Urinary retention
Confusion
Hypogonadism

Question 21

Anxieties about starting morphine:

Answer 21

Addiction- If used for genuine pain then highly unlikely to become addicted, although may develop some tolerance.
Tolerance/loss of effectiveness- Step down over a few days, not straight away.
End of the road/Last resort- Reassure there are other drugs and doses. Being in pain shortens a persons life.

Question 22

Opioid toxicity:

Answer 22

Pinpoint pupils
Hallucinations
Drowsiness
Vomitting
Confusion
Myoclonic jerking
Respiratory depression

Due to- quickly escalated dose, renal impairment, poorly opioid responsive pain but escalated, has had intervention to reduce pain (nerve block).

Question 23

Prescribing controlled drugs (TTO)

Answer 23

Name and pt ID
Write prescription
Then write the SUPPLY for the pharmacist. Drug name and formulation, number of tablets or amount of drugs in words and figures.
Drug name, form and strength in words and figures.
Cannot state take as needed.

NB if going home on oramorph then assume taking 2 PRN per day, therefore work out the number/size of bottle needed.

Question 24

Breathlessness

Answer 24

Mismatch between the pt perceived need to breathe and their ability to do so.
Treatable causes include- PE, anaemia, COPD, anxiety, pleural effusion, respiratory tract infection.

Question 25

Intractable breathlessness

Answer 25

Not readily reversible Pt doesn’t want to reverse it or is near end of life. Aim to reduce the perception of breathlessness. Position Use gravity to help breathing Trial of oxygen if hypoxic otherwise airflow fan sat by open window (cool branches of trigeminal nerve to convince the brain) Non drug approaches if feasible- OT. Otherwise consider low dose morphine (1-2mg) Also consider benzodiazepines to help calm down since breathlessness can be stressful (anxiety).

Question 26

Common causes of N+V in cancer pts:

Answer 26

Opioids, NSAIDs, ABx, diuretics, SSRIs Chemotherapy Anxiety GI obstruction (abdominal pain, ab distension, [faeculant, bile like vomit depending on the level of obstruction, nausea improves with vomiting]. Infection GI constipation, gastritis, ulceration Raised ICP (Early morning headache, dizzy, slowed movement, visual changes/other neurology, projectile vomiting [on movement and worse in morning]) Pain Radiotherapy Electrolyte imbalance (hyperCa2+ common- constipated, confused, [persistent nausea with low volume vomit which does not resolve the nausea]) Renal impairment Hepatic impairment Widespread cancer Gastric stasis Meninges disease (meningitis picture w/o temperature)

Question 27

Vomiting

Answer 27

8th nerve nucleus feeds into the CTZ and VC (vomiting centre) CTZ- fed by toxins in the blood. Have dopamine and serotonin receptors. VC- fed by higher cerebral centres (I.e. anxiety, seeing something horrible). Also fed by autonomic afferents. Have Ach and Histamine receptors.

Question 28

Ondansetron

Answer 28

Use for chemo, radio or laparostomy, where ther is an increase in serotonin release. Cyclizine- bowel obstruction and raised ICP

Question 29

Chemo induced N+V

Answer 29

Common Increased risk if <50yrs, type of chemo Due to the peak of serotonin Use before and at the beginning of chemo. Mild- dexamethaosn and metoclorpamde Severe- dexamethasone, metro and ondansetron

Question 30

N+V route and regime

Answer 30

Give sub cut Regular antiemetic Combine two which have different effects/ work at different sites, but not tow which have opposite actions I.e. prokinetic/not. ``` Non pharmacological approaches- Advice and realistic aims Hyponksis Small meals Acupuncture ```

Question 31

Constipation in cancer pts:

Answer 31

Dosease related- immobility, reduced food intake, intra ab disease Reduced fluid intake/ increase fluid loss Muscle weakness Intestinal obstruction Medication (diuretics, opiates, buscupan, ondansetron) Biochemical (hyoerCa2+, hypoK+) Pain, lack of privacy, diverticulitis

Question 32

Laxatives

Answer 32

Senna- stimulant. Reduce bowel transit time. Docusate- softener. Increase water penetration of stool. Osmotic- lactukose- can cause flatulance/ bloating therefore in cancer care give the ladino sachet. Simulator/softener combined- sodium picosulfafe- used commonly in cancer care.

Question 33

Malignant Bowel obstruction-

Answer 33

Can have laparotomy but might not be ideal in a cancer pt. Multi level can mean surgery is tricky. Causes; mechanical (tumour pressing or present), functional (infiltration of the plexus). Comes on gradually. Venting gastrostomy used to decompress Endoscopy good stenting ``` Inoperable- Rest bowel initially Limit oral fluids, give IV infusion NG tube if large vomit Correct electrolytes Use analgesia, antiemetic, anti secretory drugs (still get these secretions if not eating). ``` ``` Inoperable but not resolving: Stop nil by mouth Aim to reduce symptoms Control pain and nausea Minimise vomiting Permit oral rehydration Prognosis can be weeks to months ```

Question 34

Factors indicating death is imminent

Answer 34

``` Bed bound Drowsy Impaired cognition Difficulty taking oral meds Decided fluids and food intake Increasing symptom burden Chain stoke breathing- longer pauses between breaths Death rattle (secretions breathing) due to normal secretion build up since reduced swallowing or muscles for coughing. Change the position of the pt to help drain this. Reassure the family the pt is unaware of it. Late stage sign. ```

Question 35

5 priorities of care of a dying person

Answer 35

Possibility of death is recognised and communicated Sensitive communication Involve those important to the pt in the decisions The needs of family and others are also recognised Ensure each pt has individual plan of care

Question 36

Recognising dying phase-

Answer 36

``` Cold extremities Skin changes Shallow breathing Decreased consciousness Decreased urine output/incontinence Agitation/restless ```

Question 37

5 common end of life symptoms and medication

Answer 37

Breathlessness morphine 2.5-5mg Pain morphine 2.5-5mg SC PRN Secretions- glycopyronium 200-400 microg SC prn N+V- levomepromazine 2.5-5mg SC PRN Agitations/restlessnesS- midazolam 2.5-5mg SC PRN or levelmepromazine 6.25-12.5mg SC PRN if DELERIUM or psychosis. Should prescribe and send home with all these drugs but they may not need to use all of these. If using more than 2 doses of drugs in 24hrs then give in a syringe driver.

Question 38

Food and drink cancer pt

Answer 38

Don’t make the pt nil by mouth Warn of aspiration Hydration- Offer good mouth care- dry from reduced intake, meds and breathing through mouth Nurse give oral care Offer artificial saliva

Question 39

Neutropenic sepsis

Answer 39

``` Develops 7-10 days post chemo Needs to be treated within first hour of admission with IV ABx to avoid progressing to late stage. Get FBC within 30mins but if looks really unwell then give ABx w/o results. Late stage- Hypothermia Tachycardia Hypotension Cold ``` Can progress to organ failure.

Question 40

Tumour lysis syndrome

Answer 40

More common in haematology malignancies.

Question 41

SVCO

Answer 41

More common in respiratory pts.

Question 42

Hyperca2+

Answer 42

More common in breast or squamous cancer, since pts living longer so more time to increase. Less likely to present with moans, stones, groans. More likely to get N+V and confusion.

Question 43

Metastatic spinal cord compression

Answer 43

Very bad effect on QoL

Question 44

Blood transfusions consent and ID:

Answer 44

``` Need to formally consent only the first time, then just reminder. Document they have been consented. Why are we doing it? Procedure Risks Benefits Any questions Happy to go through? ```

Question 45

Risk of Blood transfusion:

Answer 45

Transfusion reactions: Mild reaction (common) Serious anaphylaxis TACO Risk of being given the wrong blood (ensure blood is matched) Blood borne viruses, bacteria, prion disease (ensure donors are screened) Cannot donate blood after a blood transfusion.

Question 46

Benefits of blood transfusions:

Answer 46

If lose blood in theatre or post surgery; will replace the blood and treat anaemia.

Question 47

Taking blood transfusion samples:

Answer 47

Group and screen- Look for blood group (ABO) and screen for antibodies- need blood -ve for the antigens. X match- mix donor with pt blood look for haemolysis. Larger 6ml EDTA blood bottle. Blood bank need 2 blood bottles, 1 sample can be historic. If they don’t have historic then need to take 2 separate venesections completely before starting the next.

Question 48

Haemolysis screen

Answer 48

``` LDH increases Bilirubin increases Hb goes down Haptoglobin decreases Spherocytes seen on blood film DAT (direct Coombes test- +ve suggests immune mediated) ```

Question 49

Transfusion process

Answer 49

``` Decision and consent Request Sample taking Sample and request receipt Testing Component selection Component labelling Component collection Prescription/authorisation Administration, no rioting for any reactions/documents. ```

Question 50

Informed consent:

Answer 50

Risks Benefits Alternatives

Question 51

Major Haemorrhage

Answer 51

Loss of more than 1 blood volume within 24hrs. Dial 2222- Activated only by consultant, specialist registrar or Sr Nurse, if consultant off site. This will vary slightly depending on ward. Has TXA been given. Is the TXA infusion required now? Are we anticipating low Ca. Wish to avoid lethal triad- coaggulopathy, hypothermia and acidosis.

Question 52

TACO RF

Answer 52

``` Low body weight (<50kg) Renal impairment Cardiac failure Fluid balance +ve >60yrs old Peripheral oedema ```

Question 53

Breaking bad news:

Answer 53

S- set up P- perception (how much does the pt understand) I- invitation (is it ok for me to share the scan results?) K- knowledge (avoid jargon, chunking and checking) E- empathy and emotion S- summary and strategy (safety netting) Need to give a warning show in the early stages.