Palliative Care Flashcards by Elizabeth McCabe

What are the expected physiological changes in the dying patient?

Changes in obs - low BP, low HR, low RR
Weakness and fatigue (no organic cause)
Decreased oral intake and swallow reflex
Decreased blood perfusion
Renal failure
Incontinence/retention of urine
Changes in mental state - confusion, disorientation, delirium

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What are the keys to success in palliative care?

MDT team work and communication
Good communication with family and other HCP
Seek advice or refer early to specialist palliative services.
Anticipate problems so immediate response can be made

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What route for medication administration is common in palliative care?

If appropriate and needed oral medication may be stopped
Lots = subcutaneous
May also use = buccal, rectal, topical
Should avoid IM as painful.

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What are the transitioning or early phases of death?

Bedbound
Incontinent
Decrease in ability/interest to eat or drink
Congitive changes - social withdrawal, decreased interest in world, disorientation

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What are the features of the middle phase of death?

Tracheal congestion
Further cognitive changes - slow to arouse, brief wakefulness/responsiveness
No oral intake - assist family to find alternative ways to care.

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How to communicate with the conscious patient?

Can be distressing to family
Awareness > ability to respond
Assume patient hears everything
Create familiar environment
Include in conversations
Touch

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What are the late phase patterns of imminent death?

Comatose
Temperature instability
Altered respiratory pattern
Mottling and cool extremities
Absence of peripheral pulses

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What is the general approach to care of a dying patient?

Transition to comfort care if not already in progress
Stop interventions and monitoring
Treat symptoms and educate as issues arise
Provide excellent oral and skin care
Be honest and present with family concerns/conflict
Attend to own emotional responses and support.

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What are some good ways of managing deaths in institutions?

Home like environment - privacy, intimacy, personal items, photos, remove monitors and unnecessary equipment
Continuity of care plans
Avoid abrupt changes of settings
Consider a specialized unit.

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What is the key components of spiritual care in palliative services?

Deeply personal
Life meaning and purpose
Religion/GOd

Often memory boxes, keepsakes, legacies etc

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What physical presentations have guidlines for dealing with in palliative care?

Respiratory tract secretions
Restlessness/agitation
Breathlessness
Nausea/vomiting
Pain

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What is the typical treatment for respiratory tract secretions at end of life?

Treat promptly
Educate family
Changing position of patient
Don’t over hydrate - reduce or stop parenteral hydration
Suctioning - rarely, carefully, gently
Cover or mask = music.

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What are considerable reversible causes of restlessness/agitation in palliative care?

Pain, positioning, breathlessness, nausea
Urinary retention/bladder spasm
Constipation
Severe anxiety, fear and unexpressed concerns
Drug/alcohol/tobacco withdrawal
Medication adverse effects

Psychological:
Permission to die
Reassurance of survivors well being

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How is nausea/vomiting treated in palliative care medically?

Injection formulation by syringe driver = metoclopramide, haloperidol, cyclizine, levomepromazine

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What is the typical treatment for breathlessness at the end of life?

Morphine

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What is the typical treatment for pain in palliative care?

Morphine
Not morphin if renal failure = oxycodone or alfentanyl.

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What is an emergency in palliative care?

An unexpected change in the condition of or the symptoms/circumstances in a patient with a life-limiting illness

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What are the different categories of palliative care emergencies?

Physical
Social
Spiritual
Psychological

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What are some key physical palliative care emergencies?

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Bone - pathological/crush fracture/mets
Hypercalcaemia
SVC obstruction
Spinal cord compression
MI
DVT/PE
Gastric/duodenal ulcer
Infection/neutropenic sepsis
Haemorrhage
Seizures

What is involved in planning for emergencies in palliative care?

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Counselling - signs and symptoms
Planning - hospital, who to contact
Appropriate support
Emergency medications at home
Provision of a plan with patients wishes

What is the relevant epidemiology of spinal cord compression?

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3 to 5% of cancer patients
10% patients with spinal mets
more common in some cancers - bowel, prostate

What are the causes of spinal cord compression?

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Typically extradural compression from a bony tumour in the vertebral body
80% of which are mets
+/- vertebral collapse
Most common site of compression = thoracic, lumbosacral, cervical or multiple.

What is the common presentation of spinal cord compression?

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Pain - back+nerve root, worse on movement, coughing, lying flat, can proceed by 6w.
Sensory disturance
Leg weakness = late signs, below level of lesion, stiffness/falls/gait disturbance
Sphincter problems - late sign and poor prognosis

What are the key clinical features of spinal cord compression?

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Back pain +/- tender vertebrae on percussion
Leg weakness/altered gait
Lesions above L1 = UMN signs and sensory level
Lesion below L1 = LMN signs and peri-anal numbness (Cauda equina syndrome)

What is the investigation of choice for spinal cord compression?

MRI - for compression Other: X-ray 80% Bone scan = mets but not compression

What is the management for spinal cord compression?

May require oncology referall Steroids ASAP = dexamethasone 16mg Analgesia Radiotherapy Urgent surgical debulking Urinary catheter/bowel regime

What are the typical outcomes of spinal cord compression?

Prognosis = degree of deficit at diagnosis Most walking on admission - leave walking Is function lost may permanently lose ability to walk.

What is considered malignant hypercalcaemia threshold?

Corrected serum calcium conc above 2.65mmmol/L

What is the relevant epidemiology of malignant hypercalcemia?

10% of all cancer patients Up to 20% without bone mets Most have disseminated disease Poor prognosis: median survival 3-4 months Less than 80% 1yr survival

What is the relevant pathogenesis of hypercalcaemia?

Osteolytic hypercalcaemia - inc osteoclastic bone resoprtion Humoural - systemic release of PTH, prostaglandins, cytokines and TNF Reduced renal clearance 1,25-dihydroxy vitamin D secretion (some lymphomas) Ectopic secretion of authentic PTH (very rare)

What are the common symptoms of malignant hypercalcemia?

Dehydration (thirst/polydypsia) Pruritis Anorexia/weight loss N&V Constipation/ileus Fatigue Confusion/delirium, seizures, psychosis, coma Bradycardia, atrial arrhythmias, prolonged PR internal, Reduced QT internal, wide T waves.

What is the management of malignant hypercalcaemia?

Rehydration: 2-3L 0.9% saline/24hrs Calcium lowering agents - bisphosphonates Withdrawl hyperCa2+ promoting drugs - thiazide diuretics, Vit A/D

How are bisphosphonates used for malignant hypercalcaemia?

Example - zolendronic acid, Reduce bone resorption (osteoclasts) Dose adjust if renal impairment Works in up to 80% Side effects = flu-like symptoms/pyrexia, rare osteonecrosis Recheck: 5-7days after treatment

What is the typical treatment for neutropenic sepsis?

Tazocin +/- gentamycin

How common is haemorrhage in palliative care?

Affects 20% patietns with advanced cancer COntributes to death in 5% Catastrophic external haemorrhage is less common than internal hidden haemorrhage

What is the relevant aetiology of haemorrhage?

Direct - related to tumour itself e.g local bleeding from fungating tumours, erosion of vessels Indirect - haematemesis, melanea, haemoptysis, Drugs (Steroids, NSAIDs, warfarin), low platelet.

What is the typical management of haemorrhage?

Anticipate - often preceded by smaller bleeds, DNAR, counselling patients Establish support at home Dark tiles and dark towels PRN benzodiazepines /sedation

What medication may be given for non-acute haemorrhage management?

Topical - adrenaline or tranexamic-soaked gauze, silver nitrate, haemostatic dressings Systemic-antifibrinolytics (tranexamic acid and haemostatic agents (etamsylate) Other - embolisation, diathermy, radiotherapy.

What is the aim of treatment if an acute massive haemorrhage is not immediately fatal?

Local control if possible Sedation of a shocked, frightened patient - midazolam 10mg SC/IM/IV or buccaly Dark towels Reassurance Follow-up support for family and staff

Define SVC obstruction

External compression of and/or thrombosis of SVC by mediastrinal lymph nodes or tumour in region of right main bronchus Mainly caused by lung cancer, lymphoma

What are the signs of SVC obstruction?

Venous hypertension Headache Visual changes Dizziness Swelling of face/neck/arms

What are the signs of SVC obstruction?

Engorged conjunctivae Periorbital oedema Non-pulsatile dilated neck veins

What is the management of SVC obstruction near to death?

Opioid Oxygen Keep bed at 30 degrees Dexamethasone Furosemide 40mg PO/IV Treatment for anxiety or seizures Crisis medications

What investigation and management may be done for SVC obstruction with a better prognosis?

CXR Chest CT Stent for extrinsic compression Stent and thombus for obstruction Anticoagulant for thrombus associated SVCO

What is the typical prognosis of SVC obstruction?

Typically a few days without treatment Measured hours to days prior to onset.

What is a social crisis in palliative care?

Very common - carer fatigue, difficult symptoms, psychological distress Important to plan and predict in advance Can happen at the end of life

Palliative Care Flashcards

(47 cards)