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Year 5 > Palliative care > Flashcards

Palliative care Flashcards

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1
Q

Triggers suggesting patients are nearing end of life

A
  1. Surprise question: Would you be surprised if this patient were to die in the next few nonths/weeks/days?
    W. General indicators of decline, deterioration, increasing need or choice for no further active care
  2. Specific clinical indicators related to certain conditions
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2
Q

Common symptoms during life limiting illenss

A

pain
Breathlessness
Nausea and vomiting
Agitation
Delirium
Fatigue, weakness
Constipation
Anxiety and depression
Poor appetite
Drowsiness

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3
Q

Two situations in which a DNACPR decision should be made

A
  1. CPR willnnot be successful
  2. CPR may be successful
    a) but mat not be seen as clinically appropriate because of the likely clinical outcomes
    OR b) patient with mental capacity does not want to be resuscitated
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4
Q

Nociceptive vs neuropathic pain

A

noficeptive is arising from somatic or visceral tissue damage then reported by an intact nervous system
Neuropathic is from consequence of lesion or disease affecting somatosensory system. More likely allodynia, hyperaesthesia, electric shock, shooting, or burning pains.

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5
Q

Pain step ladder

A
  1. non-opioid, eg paracetamol, aspirin, NSAID with or without adjuvant
  2. Weak opioid (codeine) for mild to moderate pain, +/-non opiate, +/- adjuvant
  3. Strong opioid for moderate or severe pain (morphone) +/- non opioid +/-adjuvant
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6
Q

concept of total pain

A

Acknowledging physical, psychological, social qnd spiritual influence on persons pain perception and th effect it is having on a persons life. All areas to be addressed in orde to manage pain

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7
Q

weak opioids example and dose range

A

codeine 15-60mg QDS
tramadol 50-100mg QDS
*both metabolized to active metabolite, codeine metabolism very variable so wide range of responses

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8
Q

morphine use

A

first line strong opioid, if opiate naice, start 2.5_5mg PO up to QDS

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9
Q

Oxycodone use

A

semi synthetic opioid, safer than morphine in renal impairment (eGFR <30)

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10
Q

Fentanyl and alfentanil use

A

Strong opioids
Not orally available, transdermal, transmucosal or iv possinle
Safe in renal failure
Transdermal good if unable to swallow

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11
Q

Buprenorphine use

A

available as transdermal patch, useful if unable to swallow
Safe in renal failufe

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12
Q

Common side effects of all opiates

A

constipation (always coprescribe a laxative)
Nausea
Drowsiness initallt then wears off
Unsteadiness
Dry mouth
Immunosuppression
Sweating
Itch
Urinary retention
Dependence - but less likely when used correctly for pain

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13
Q

Signs of opiate toxicity

A

drowsiness, delirium, hallucinations, myoclonic jerkinf of the limbs, reduced resp rate
Reduced below 8= potentially life threatening toxicitiy
Just start low and titrate up carefully

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14
Q

Use of naloxone in pall care

A

if opiate recersl is necessary, naloxone can be used but at much lower dose than in recreational overdose as risk of severe reboound pain and pulmonary oedema.

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15
Q

converting codeine to morphine

A

codeine PO or dihydrocodein PO /10 –> morphine PO

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16
Q

Converting tramadol to oramorph

A

tramadol PO /10 –> morphine PO

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17
Q

Converting oramorph to subcut morphine

A

morphine PO /2 –> morphine SC

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18
Q

Oral morphine formulations

A

Immediate release = Oramorph, quick acting, lasts 2-6hrs
Modified release = designed to last 12hrs : This should be basically regular with oramorph for PRN topups (1/6 dose of MR)

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19
Q

Steroid side effects

A

deranged glycemic control
Immunosuppression
Psychiatric disturbance
Proximal muscle wasting
Osteoporosis
Peptic ulceration

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20
Q

Use of anticonvulsants as adjuvants

A

eg gabapentin, pregabalin, carbemazepine, valproate
For neuropathic pain
Common issues: Tremor, drowsiness, oedema

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21
Q

Use of antidepressants for neuropathic pain

A

eg amitriptyline and duloxetine
SE: Sedation, dry mouth, postheal hypotension

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22
Q

use of NMDA antagonists for neuropathic pain

A

Ketamine this is a big new thing I think
SE: Dissociation, haemorrhagic cystitis

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23
Q

Use of bisphosphonates for bone pain

A

et pamidronate, zoledronic acid
SE: Flu like symptoms. Also very annoying to take

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24
Q

Use of topical agents for neuropathic pain

A

eg capsaicin, lidocaine, EMLA
May cause skin irritation

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25
Possible non pharmacological methods for pain relief
physiotherapy TENSmachine Acupuncture Radiotherapy Nerve blocks Neurosurgical options
26
Pathophysiology of nausea
Centrally by vomiting centre and chemoreceptor trigger zone - this is in floor of fourth ventricle, so very trigger-able by electrolyte disturbance (hyperfalcaemia, uraemia), or presence of drugs in blood (Plat chemo or opiates) Also higher cerebral areas triggered by raisedICP and anxiety Vestibular areas triggered by movements Autonomic afferents from gut can be triggered by stretch (bowel obstruction) or damage (eg radiotherapt)
27
prokinetic drugs action and indication
Trigger cholinergic system in wLl of GI tract and centrally on dopaminergic receptors at chemoreceptor trigger zone Indic: Gastric stasis, ileus, post chemo
28
Metoclopramide
=prokinetic Combined D2 receptor antagonist and 5HT4 receptor antagonist 10-20mg up to QDS oral or SC SE: Extrapyramidal effects, do not use in PD
29
Domperidone
D2 receptor antagonist Afts as prokinetic 10mg TDS oral Must be oral or rectal, otherwise possible arrhythmias SE: Gynaecomastia, galactorrhoea, amenorrhoea, EPSEs v rare
30
antipsychotics for emesis action and indication
act centrally on dopamine, histamine serotonin and anticholinergic systems at chemorecceptor trigger zone Indic: Chemical or metabolic causes of nausea
31
Haloperidol
0.5-1mg TDS po or SC D2 receptor antagonist T chemoreceptor zone SE sedation EPSEs, lowered seizure threshold
32
levomepromazine
antipsychotic for chemical or metabolic cause of nausea Acts on multiple receptors 6.25-12.5mg QDS po or SC Side effects: Drowsiness, antimuscarinic effects, lowers seizure threshold
33
Antihistamines for nausea action and indication
act on histamine receptors in CNS and gut Indic: Cerebral and vestibular causes of nausea, eg raised ICP
34
Cyclizine
antihistamine used for nausea caused by raised ICP or other cerebral/vestibulR cause 50mg TDS oral or SC Side effecrs: Drowsiness, caution in heart failure (anti muscarinic effect -> tachycardia), constipation
35
5HT3 antagonists for nausea action and indic
acts on 5HT3 receptors in gut and chemoreceptor trigger zone Use post op or post chemo or radiotherapy
36
Ondansetron
5HT3 antagonist for post op/chemp/radio nause fontrol 4-8mg BD po or sc SE: Constipation, headache
37
Steps for managing constipation in a hospice
1. Examination including PR 2. Treat exacerbating factors 3. Laxatives
38
Exacerbating factors for constipation
Drugs eg opioids, anti jistamines, anti cholinergic Encourage fluid intake and mobilizing Consider electrolyte derangement
39
Softening laxatives
Macrogols (laxido, movicol, lactulose): Osmotic action draws fluid into bowl and incr volume of stool which stimulates peristalsis. Need good hydration Docusate 100-200mg up to TDS. Surface wetter
40
Stimulant laxatives
senna: 7.5-15mg up to BD, stimulates large bowel Bisacodyl
41
when does malignant bowel obstriction occur
typically advanced cancer patients with abdominal and pelvic malignancies. 5.5-42% of those with ovarian carcinoma and 4.4-24% of those with colorectal cancer
42
Surgical treatments for malignant bowel obstrufiton
resection, stoma formation, stenting Consider both patient and pathology, eg much more successful in solely large bowel than large and small And fitness of patient to withstand and recover from major surgery
43
Decompression tube management of obstructed bowel
NG rube decompression and bowel rest, may be supportive symptomatically and allow recovey
44
Pharmacological management of malignant bowel obstriction
analgesia to manage pain parenterally Anticholinergics eg hyoscine butylbromide or octreotide to reduce GI secretions Steroid eg dex 6-8mg BD SC to reduce bowel swelling Anti emetics
45
What anti emetic if partial obstruction (intermittent opening and passing flatus) and no colicky pain
prokinetics eg metaclopramide
46
Antiemetics for patients with complete obstrufiton or bad pain
cyclizine/haloperidol/levomepromazine (not a prokinetic)
47
Treatment options for dyspnoea
1. Specific disease management, eg drain plural effusion 2: Non pharm intervention: Breathing training, walking aids, exercise, handheld fan 3. Pharm trearmenr: Oxygen and opioids, maybe anxiolytics
48
Prevalence of cough with advanced disease
very common 43% or general cancer patients, more of lung
49
Management of cough
1. Treatment of cause - radio, chemo, steroids 2. Anti-tussives eg simple linctus, codeine, morphine
50
Patients who get malignant spinal cord compression
25% of patients with lung cancer 16%of patients with prostate cacner 11% patients with myeloma Often from Mets in bone of spine
51
Signs and symptoms of malignant spinal cord compression
tumour causes direct or indirect pressure on spinal cord leading to Acute onset radicilar pain Pain exacerbated by neck extension/coughing Weakness is late sign, moves from flaccid paralysis to spasticity Sensory changes Bowel/bladder dysfunc Basically cauda equina
52
Management of malignant spinal cord compression
immediate high dose (16mg) dexamethasone Confirm diagnosis with same day MRI Urgent assessment to consider surgery, radiotherapy or conservative treatment Not a good prognostic sign
53
superior vena cava obstruction who and how
extrinsic compression by metastases in upper mediastinal lymph nodes Lung cancer responsible for 80% of cases And occurs in 15% of lung cancer patients
54
Signs and symptoms of superior vena cava obstruction
dyspnoea Neck and facial swelling, worst in morning Trunk and arm swelling Sensation of choking Thoracic and neck vein distension Facial oedema and plethora Tachypnoea
55
Management of superior vena cava obstruction
High dose Dex 16mg daily Then SVC stent insertion and maybe chemo/radio if wanted
56
Malignant hypercalcaemia numbers
Corrected Ca > 2.6 Emergency if >3
57
Malignant hypercalcaemia who and why
Commonest life threatening metabolic disorder associated with cancer 10-20% of patients with cancer 50% of patients with breast and myeloma, also common in lung and renal Associated with metastatic disease 80% of those with malignant hypercalcaemia will die within a year, median survival 3-4 months Common mediator = cancer secreted parathyroid hormone related protein
58
Signs and symptoms of malignant hypercalcaemia
mild: Polyuria, polydipsia, fatigue, lethargy, mental dullness, anorexia, constipatipn = non specific as anything (moans, stones, bones, groans) Severe: Nausea, vomiting (-> dehydration), ileus, delirium, drowsiness, coma
59
Management of malignant hypercalcaemia
rehydrate w IV fluids Bisphosphonates eg zolendronic acid 4mg over 15 mins IV -takes at least 3 days to improve Ca enough to make symptomsmbetter
60
What to do if severe haemorrhage is terminal
One person stay with patient and call for help dark coloured towels Focus on sedation and comfort Administer an anxiolytic
61
Risks for severe haemorrhGe
tumour near blood vessel Herald bleed/pulsation under tumour Infection/inflammation in tumour Recent radio/chemotherapt Clotting disorders Drugs
62
Severe distress at time nearing death
Carefully assess to look for driver of agitated restlessness If no signs of pain and not improving with analgesia, not hypoxic, not constipated and not distressed then consider whether delirium/fear importanCe of calm, consistent approach First line: Haloperidol and midazolam 2nd line: Levomepromazine 3rd line: Phenobarbital and propofol
63
Tranexamic acid
Can be quite helpful for Reducing volume and frequency of bleeds for something eroding into venous areas/capillary bed. Will have little impact on an arterial bleed
64
Key approach to managing a dying patient
Recognise- appropriate recognition of active dying or high risk of dying Communicate and involve - patient, those close to them, the team. Think how preferences and views may inform plan Plan and do - to manage symptoms now or concerns in future Support - consider other needs and ant other professionals needed Review - regularly to ensure plan is achieving goal and diagnosis of dying remains correct

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