Palliative Care

Question 1

What is palliative care?

Answer 1

Palliative care is an approach that improves the quality of life of the patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other peoblems: physical, psychosocial and spiritual.

Question 2

What are the 4 domains of personhood?

Answer 2

Question 3

Describe a holistic needs assessment.

Answer 3

• Physical
  
  • Symptoms, medication review, side-effects etc.
• Emotional
  
  • Psychological assessment.
• Personal
  
  • Needs related to a culture, ethnicity, spirituality, sexuality.
• Social support
  
  • Social care needs, welfare concerns, career assessments.
• Information and communication
  
  • Ensuring the mode of communication is appropriate, establishing a key worker, ensuring all plans and assessments are documented and shared appropriately with patient, significant others and MDT.
• Control and autonomy
  
  • Assessment of mental capacity, establishing preferred place of care and death.
• Out-of-hours
  
  • Identifying appropriate services, ensuring all relevant out-of-hours services are aware of patient preference.
• Living with your illness
  
  • Establishing rehabilitation needs, referral to other servies, planning end-of-life care, if appropriate.
• Aftercare
  
  • Bereavement risk assessment, family support.

Question 4

What questions should you be asking a palliative patient regularly?

Answer 4

• How are you coping?
• Are you worried about your partner?
• What are you finding hardest at the moment?
• Tell me about yesterday. Tell me what is was like 6 months ago.

Question 5

How do we close the information gap?

Answer 5

Question 6

What are the common symptoms managed in palliative care?

Answer 6

• Pain
• Breathlessness
• Anxiety and agitation
• Fatigue
• GI problems

Question 7

What is pain?

What are the components involved in total suffering?

Answer 7

Pain is an unpleasant sensory and emotional experience

Question 8

Which opioids can be used in palliative care?

Answer 8

• Morphine
• Oxycodone
• Diamorphine
• Fentanyl
• Alfentanyl
• Methadone
• Dihydrocodeine
• Hydocodone
• Tramadol
• Loperamide
• Tepentadol

Question 9

What are the benefits (for the prescribing doctor) of using morphine?

Answer 9

• Familiar
• Available
• Cost

Question 10

When should you not use morphine?

Answer 10

• Side-effect profile
• Transdermal route is preferred
• Occasionally cost

Question 11

State the equipotency of morphine to:

• SC morphine
• SC diamorphine
• Oral oxycodone
• SC oxycodone
• Fentanyl patch
• SC alfentanil
• Oral hydromorphone
• SC hydromorphone

Answer 11

Question 12

State the equipotency of oxycodone to:

• Oral oxycodone → SC oxycodone
• Oral morphine
• SC diamorphine
• Fentanyl patch
• SC alfentanil
• Oral hydromorphone

Answer 12

Question 13

What are the opioid side effects?

Answer 13

• Constipation
• Nausea and vomiting
• Sedation
• Vivid dream
• Hallucination
• Confusion
• Myoclonic jerks
• Respiratory depression

Question 14

How should you approach pain management in palliative patients?

Answer 14

• Tell what is wrong
• Think non-pharmacological
• Opioids
  
  • Equipotency
  • Side effects
  • Toxicity

Question 15

What adjuvant analgesia to opioids can be offered to palliative patients?

Answer 15

• Antiepileptic
• Antidepressant
• Other
  
  • Paracetamol
  • Ibuprofen
  • Steroid

Question 16

Describe the use of opioids in palliative patients for breathlessness.

Answer 16

• Effect is secondary to their effects on:
  
  • Ventilatory response to CO₂ and hypoxia (chemoreceptor).
  • Increase in respiratory flow and decreased resistive loading resulting in decreased oxygen consumption with exercise and at rest in healthy individuals.
  • Vasodilatory effect on pulmonary vascular pressures in animals has been demonstrated.
• Used to treat anxiety and pain, which are often an integral part of the dyspnoea cycle.

Question 17

Describe the central control of nausea and vomiting.

Include all components which have an impact on N&V.

Answer 17

• Emesis stops us from ingesting toxins.
• Vestibulo-cochlear system.
• CTZ is outside the BBB - detects peripheral toxins.
• Vomiting centre - functional entity in the brainstem.
• CNX and vestibular system (via CNVIII) input.
• Gag reflex triggers via XI and X.
• Autonomic reflex control.
• Higher centres - anxiety anticipation.

Question 18

Describe peripheral input to nausea and vomiting.

Answer 18

• Myenteric plexus - smooth muscle-parasympathetic cholinergic nerves → peristalsis.
• Neurohormonal regulation of the gut - H₂, D₂, 5HT₃.
• Distension → stretch receptors → sympathetic input to the CNS.
• G cells (via CNX and ACh) → gastrin → parietal cells → HCl + pepsin and enterochromoffin-like cells → histamine → HCl.
• Enterochromoffin cells → serotonin in response to damage, fatty and amino acids or toxins - induces nausea via vagal afferents to CNS.
• Serotonin → peristaltic and secretory reflexes.

Question 19

Which neurotransmitters are involved in emesis?

Answer 19

• Histamine H₁
• Muscarinic cholinergic (ACh)
• Dopaminergic D₂ receptors
• Serotonergic 5HT₃ receptors
• 5HT₄
• Neurokinin
• Cannabinoids
• Substance P
• GABA

Neurotransmitters exist in gut and centrally. Different antiemetics work on differing receptors. Target antiemetic to the likely cause.

Question 20

What might you elicit in a nausea history

Answer 20

1. Intermittent postprandial, early satiety, bloating, full, small undigested food, relieved by vomiting?
2. Persistent, worse with food and smells and unrelieved by vomiting?
3. Intermittent, bile, altered bowel habit, cramps, faecal vomit?
4. Early morning and associated headaches?
5. Vertigo or worse on movement / turning head?
6. Agitation and anxiety or anticipation?
7. Bile, bleeding, undigested food, faecal?
8. Drugs ?recent changes - SSRI, opioids, NSAIDs?
9. Other associated symptoms - pain, fever.
10. Toxins - infection / metabolic disturbance.
11. D&V ?infectious
12. Constipated? Gastric stasis or squashed stomach?
13. Features of increased intracranial pressure?
14. Where is the disease? Peritoneal or brain mets?

Question 21

What should you look out for on examination of a palliative patient with nausea?

Answer 21

• Obstruction - distension ?bowel sounds.
• Jaundice
• Ascites
• Organomegaly
• Epigastric tenderness
• Dehydration
• Sputum production
• AF/ sepsis
• Signs of opioid toxicity?
• ?Hypotension

Question 22

What should you do over and above hx and examination in a nauseated patient?

Answer 22

• Check drug chart
• Relevant bloods:
  
  • Calcium
  • U&E
  • LFT
  • FBC
• AXR if acute obstruction
• Urinalysis / MSU
• Look at any scan reports to see if they explain the symptoms.
• Assess if surgical candidate in obstruction.

Question 23

What are the non-pharmacological options for management of nausea?

Answer 23

• Avoid food smells and strong smells.
• Small bland meals frequently.
• Peppermint tea / caps.
• Positioning during meals.
• Ask family not to pressurise the patient to eat.
• Encourage fluids
• Ginger tea?
• Accupuncture / sea bands for accupressure.

Question 24

Which drugs should be used as anti-emetics?

Answer 24

• Domperidone - prokinetic. Does not cross the BBB so is good in elderly or px with Parkinsons. PR or PO only. QTC↑ - no longer OTC.
• Metoclopramide - central acting + prokinetic, EPSE common.
• Cyclizine - useful for motion / ↑ICP. Potential for abuse, IV reactions, onfusion, dry mouth can limit use.
• Haloperidol - no effect on gut; use in metabolic or toxin-related nausea as has central effect on CTZ.
• Levomepromazine - effective but sedating.
• Ondansetron - good for short-term use: post-op / chemo / XRT but profoundly constipating if >3 days.
• Aprepitent

Question 25

What are the principles of prescribing antiemetics?

Answer 25

* Give regular antiemetics instead of prn. * Check - is an alternative route required? * Is it possible to direct antiemetic to cause? * Stop emetogenics. * Reverse the reversible (infection, constipation, metabolic disturbances, decrease ICP, treat pain, anxiety and acid reflux). * Are they subacutely or fully obstructed? * Surgical candidate? (Drip, suck and refer). * Rest the gut, consider IV fluids +/- NG drainage.

Question 26

What percentage of bowel obstruction is caused by malignancy?

Answer 26

* 15% of bowel obstruction is caused by malignancy. * 30% of people with ovarian cancer. * 20% of people with bowel cancer. * Peritoneal disease.

Question 27

Describe the treatment ladder for bowel obstruction.

Answer 27

Question 28

Describe how to treat subacute bowel obstruction.

Answer 28

* Malignant bowel dysfunction often present. * Consider metoclopramide or domperidone with close review - if increasing colic, stop - risk of perforation. * Consider parenteral route - can swap back to PO. * See if bowel can be moved - PR+/- enema and consider codanthramer (used for constipation in palliative care). * Docusate (stool softner) alone to keep bowels soft if colic. * Reccommend easily digestible food or fluids.

Question 29

What drugs should be used to paralyse the gut in bowel obstruction?

Answer 29

* Hyoscine (butyl bromide also helps colic - hydrobromide works as antisecretory). * Cyclizine (can add haloperidol if persistent nausea) or levomepromazine. * Rest drip and suck (where appropriate). * Consider NG with aspiration. * Octreotide. * Dexamethasone where lymph nodes, mass, squashed stomach / hepatomegaly.

Question 30

What are the surgical options for bowel obstruction?

Answer 30

* Venting gastrostomy / ?RIG / stent. * Palliative surgery should be considered for patients with advanced cancer and intestinal obstruction. * Mortality high (12-30%), survival time short, high incidence of enterocutaneous fistulae. * Surgery is usually contraindicated in multilevel obstruction. * TPN decisions can be complex. * Look at performance status.

Question 31

Describe the examination of a patient who is constipated.

Answer 31

* **Needs a PR** * **​**Is there stool moving through? * Is this obstruction versus dysfunctional gut? * **Full abdo exam** * **​**Often palpable stool in left iliac fossa * Feel for peritoneal disease * Feel for ascites

Question 32

Describe the treatment for palliative constipation.

Answer 32

* PR / examine abdomen ?obstruction / dysfunction. * Suppositories / enemas where vomiting. * Soften - docusate. * Stimulate - senna, bisacodyl. * Gentle and does a little of both but need to drink a lot - laxido. * Do it all (soften and stimulate) and easy to take but carcinogenic. * Also picolax, methlnaltrexone, fybogel - bulks. * Reduce contributing factors, push fluids, privacy. * Avoid lactulose (except liver failure) as bloat, cramps.