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Phase 3b > Palliative care > Flashcards

Palliative care Flashcards

(85 cards)

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1
Q

What is palliative care?

A

Holistic individual care to patients and family
Continues outside of traditional medicine including spiritual and other issues

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2
Q

What types of care does palliative care provide?

A

Supportive
End of life
Terminal

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3
Q

What is the focus of treatment in palliative care?

A

Patient centred goal setting
Realism
Honesty/hope
Enablement approach
Planning for the future
Community vs specialist inpatient vs outpatient vs hospital support team
Improving survival and QoL

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4
Q

Name 2 simple analgesia

A

Paracetamol
NSAIDs

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5
Q

How does paracetamol work?

A

Inhibits production of CNS prostaglandins

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6
Q

What should you check before starting paracetamol?

A

Liver impairment - reduce dose or consider avoiding if severe
Severe cachexia - less than 50kg max dose 500mg QDS
Slight dose reduction if dialysis dependent

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7
Q

How do NSAIDs work?

A

Inhibit COX the main enzyme in the synthesis of prostaglandins from arachidonic acid
Central and peripheral action

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8
Q

Name a selective NSAID and how this is better

A

Celecoxib
Safer for GI s/e

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9
Q

What should you check before starting NSAIDs?

A

Renal and platelet count
CI - GI bleeding or ulcer Hx, asthma
Concurrent medications - warfarin, digoxin, steroids

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10
Q

Name 2 weak opioids

A

Codeine
Dihydrocodeine
Tramadol

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11
Q

What is the problem with weak opioids?

A

Ceiling effect on analgesia
Maximum dose you can prescribe for weak opioids

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12
Q

Name 2 generic strong opioids

A

Morphine
Oxycodone
Buprenorphine
Fentanyl
Diamorphine

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13
Q

Name 2 specialist palliative care strong opioids

A

Hydromorphone
Alfentanil
Methadone

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14
Q

What should you consider before starting a strong opioid?

A

Tried before? If so, what happened?
Co-morbidities
Patient concerns
Age and frailty
Renal function
Will they take them as prescribed?
Are they driving?
Have you prescribed medications for side effects?

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15
Q

What are the common side effects of opioids?

A

Constipation
Nausea
Sedation
Dry mouth

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16
Q

Name a less frequent side effect of opioids

A

Psychomimetic effects
Confusion
Myoclonus

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17
Q

Name a rare side effect of opioids

A

Allergy
Respiratory depression
Pruritis

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18
Q

What is the issue with constipation as a side effect of opioids?

A

Difficult to get rid of as mechanism of this is the same as the mechanism for pain relief

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19
Q

What is respiratory depression with opioids a sign of?

A

Toxicity

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20
Q

What can you prescribe for the side effects of opioids?

A

Stimulant laxatives
PRN anti-emetic

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21
Q

What is the difference between background and breakthrough pain?

A

Background - pain at rest, ongoing pain
Breakthrough - transient exacerbation, can be predictable such as movement or unpredictable

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22
Q

What is the aim of pain management in palliative care?

A

Adequate background pain control and a way of controlling breakthrough pain

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23
Q

How should you prescribe opioids?

A

Always start low
Titrate dose according to pain and PRN usage

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24
Q

What is the general rule for PRN opioid dosages?

A

1/10th - 1/6th of 24 hour dose

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25
What is the conversion from oxycodone to morphine?
Oxycodone is twice as potent as morphine Need double the amount of morphine as oxycodone OR Need half the amount of oxycodone as morphine
26
What is the conversion of codeine and tramadol to morphine?
Codeine and tramadol are 1/10th as potent as oramorph
27
What are the indications for opioid patches?
Intolerable side effects Oral route difficulties - compliance/dysphagia Renal impairment
28
What should you not use patches for and why?
Acute/unstable pain Takes minimum of 3 days to reach analgesic concentrations when first increased
29
What should you do in renal impairment with opioids?
Either stay on current opioid and - Reduce dose - Reduce frequency Or switch opioid to more renal-friendly option With help from palliative care
30
Name a more renal friendly opioid
Oxycodone Fentanyl Buprenorphine Methadone Alfentanil
31
What is the conversion from oral forms of opioids to injectable?
Injectables are twice as strong as oral
32
Name 3 types of adjuvant analgesia
Antidepressants -> amitriptyline, duloxetine Antiepileptics -> pregabalin, gabapentin Antispasmodics -> baclofen, tizindine Steroids -> dexamethasone Benzodiazepines -> clonazepam, diazepam Local anaesthetics -> topical lidocaine plasters Bisphosphonates -> zolendronic acid
33
What can antidepressants be used for in pain relief?
Neuropathic pain
34
What can antiepileptics be used for in pain relief?
Neuropathic pain
35
What can antispasmodics be used for in pain relief?
Muscle spasms
36
What can steroids be used for in pain relief?
Compression syndromes
37
What can benzodiazepines be used for in pain relief?
Spasms, ?neuropathic pain
38
What can local anaesthetics be used for in pain relief?
Focal areas of pain
39
What can bisphosphonates be used for in pain relief?
Bone pain
40
How should you approach a palliative care emergency?
Context is key On-call understand all plans for palliative patients Communication
41
Name 3 major medical emergencies that are more common in palliative care
Febrile neutropenia SVCO Stridor Hypercalcaemia Spinal cord compression Opioid overdose Massive haemorrhage
42
When should you consider neutropenic sepsis/febrile neutropenia?
Following chemotherapy 2-3 weeks (day 10 when WCC drops lowest) Haematology patients Bone marrow infiltration - pancytopenia
43
What are the S&S if febrile neutropenia?
Clinical sepsis and/or pyrexia > 38 Clinical infection - chest, urine, skin, GI, lines Neutrophil count < 0.5
44
What is the management of febrile neutropenia?
IV access Broad spectrum Abx Close observation Fluid resuscitation Investigations
45
What investigations should you do in febrile neutropenia?
FBC, U&Es, LFTs incl albumin, CRP, lactate, cultures
46
What is SVCO?
Superior Vena Cava Obstruction External blockage from mass rather than intrinsic obstruction
47
When should you think of SVCO?
Lung cancer/tumour involving RUL or mediastinum
48
What are the S&S of SVCO?
Facial swelling, redness Periorbital oedema, engorged conjunctivae Arm swelling Breathlessness Distended veins on chest
49
How do you diagnose SVCO?
CT chest Findings correlate with clinical presentation
50
What is the management of SVCO?
ABCs High dose steroids - dexamethasone 16mg OD, buys time whilst get more definitive treatment, reduces tumour associated oedema Consider anti-coags Stenting - interventional radiology Radiotherapy/chemo Discuss with other specialties
51
When should you consider stridor?
Head and neck tumour Lung/upper GI tumour
52
What are the S&S of stridor?
Noisy breathing on inspiration Harsh breath sounds Breathlessness -> can be late sign of decompensation
53
How do you diagnose stridor?
Clinically Upper airway visualisation - ENT/max-fax Upper airway imaging - CT
54
How do you manage stridor?
ABC - O2, heliox (less dense than air so reduces resp work required when high ventilatory demand/upper airway obstruction) High dose steroids - dex 16mg Urgent ENT/oncology review Tracheostomy - new airway Stent - open airway Radiotherapy
55
When should you consider malignant hypercalcaemia?
Specific types of cancer Cancer which has spread to bone -> breast, lung, kidney, thyroid, myeloma
56
What are the S&S of malignant hypercalcaemia?
Acute - thirst, confusion, constipation, global deterioration Chronic - depression, abdominal pain, constipation, calculi (bones, stones, moans, groans) Can seem like they're dying
57
How is malignant hypercalcaemia diagnosed?
Blood test Corrected calcium > 2.6 abnormal Corrected calcium > 2.8 symptomatic
58
How do you manage malignant hypercalcaemia?
IV fluids -> immediate, acts as diuretic so get dehydrated quickly, lowers serum Ca, short term and symptom benefit IV bisphosphonates -> returns Ca to bone, longer term ?Denosumab -> if resistant to bisphosphonates, with specialist advice
59
When should you consider malignant spinal cord compression?
Cancer which has spread to bone - breast, lung, kidney, thyroid, prostate Primary lesions affecting spine less common
60
What are the S&S of malignant spinal cord compression?
Depends on level - paraesthesia/sensory loss, weakness/functional loss, cauda equina, loss of bladder/bowel function Back pain - red flag when waking up from sleep not on movement Can be non-specific - off-legs with pack pain common
61
How do you diagnose malignant spinal cord compression?
MRI spine - gold standard If can't have MRI - CT +/- myelography
62
How do you manage malignant spinal cord compression?
High dose steroids - Dex 16mg Nurse lying down Radiotherapy Surgery
63
What can cause a major haemorrhage in palliative care?
Head and neck tumours Lung tumours with Hx of bleeding GI tumours with Hx of bleeding Tumours near large blood vessels - direct invasion
64
What often occurs before a major haemorrhage in palliative care?
Herald bleed Small bleed before
65
What are the S&S of a major haemorrhage?
Large volume of rapid blood loss Rapidly loses consciousness
66
How do you diagnose a major haemorrhage?
On sight Consider in case of patient suddenly becoming shocked
67
How do you manage a massive haemorrhage in palliative care?
Stop anticoagulation Very dependent on care patient wanted -> medical emergency Tx if appropriate If palliative likely terminal event - dark towels, remain with patient, midazolam 10mg stat
68
When should you consider an opioid overdose in palliative patient?
On strong opioids Change in condition including sudden improvement in pain
69
What are the S&S of opioid toxicity?
Reduced level of consciousness Reduced RR < 8/SpO2 Myoclonic jerks Pinpoint pupils
70
How do you diagnose an opioid overdose?
Clinical assessment Response to treatment
71
What is the management of opioid toxicity?
Naloxone -> different in palliative Don't want to completely reverse opioid action as don't want them in pain Dilute 400 micrograms in 10ml N saline and 20mcg every 2 mins until RR/conscious level improves Close observations Review dosing and discuss with senior/palliative care re need for further naloxone
72
What is end of life care?
Likely to die within next 12 months
73
Who is offered end of life care?
Patients whose death in imminent (hours to days) Advanced, progressive, incurable diseases General frailty and co-morbidities that mean they are expected to die within 12 months Those at risk of dying from sudden acute crisis in existing condition Life-threatening acute conditions caused by sudden catastrophic events
74
What is advanced care planning?
Discussion with patients and those important to them about their wishes and thoughts for the future
75
What is formal advanced care planning?
What they want to happen - not legally binding, advanced statement of wishes What they don't want to happen - advanced decision to refuse treatment, legally binding Who will speak for them - lasting power of attorney for health and welfare
76
What are the signs that someone may be dying?
Weight loss and poor appetite Deteriorating mobility Needing more assistance for ADLs Social withdrawal Changes in consciousness Fatigue and sleeping more Struggling with medications CVS changes - pulse strength, change in colour, mottled skin Resp changes - noisy secretions, laboured breathing, apnoeic episodes, Cheyne-Stokes breathing
77
What are the 5 priorities in care of the dying?
Recognition Communication Involving family and patient Needs of those identified as important to dying person actively explored, respected and met Individual plan agreed and delivered with compassion
78
What are the 5 key symptoms that can be controlled in the dying person?
Pain Breathlessness Respiratory secretions N&V Distress/agitation (delirium)
79
What medication can be given for pain?
Morphine
80
What medication can be given for breathlessness?
Morphine
81
What medication can be given for secretions?
Buscopan
82
What medication can be given for agitation?
Midazolam
83
What medication can be given for nausea?
Haloperidol
84
What should you always do in terms of nutrition and hydration for those dying?
Mouth care -> keep clean and moist Support oral food and drink for as long as someone wants it and is able - enjoyment not quantity Regular review for symptoms related to reduced fluid intake
85
What should you ensure if the decision is made to use fluids?
Ensure no harm to patient Agree an aim Agree when you will review and when you would stop Decide on a route and volume Basic care still needed - support with oral fluids and regular mouth care, regular review to assess fluid status

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