Palliative Care/ Oncology

Question 1

What is terminal agitation?

Answer 1

Agitation occurring in the last few days of life

Question 2

How is neutropenic sepsis diagnosed? Presentation? Time to administer antibiotics to treat?

Answer 2

Neutrophil count<1.0 x 10^9 + clinical sepsis/ pyrexia>38 degrees- usually a consequence of anti-cancer or immunosuppressive treatment, from clinical infection- CHEST, URINE, skin, GI, lines
Sometimes just fever- suspect in any patients presenting with a new clinical deterioration within 6 weeks of cytotoxic chemo
1 hour(piperacillin with tazobactam (tazocin)

Question 3

Medications can cause neutropenic sepsis? Tx?

Answer 3

Anti-cancer chemotherapy
Clozapine (schizophrenia)
Hydroxychloroquine (rheumatoid arthritis)
Methotrexate (rheumatoid arthritis)
Sulfasalazine (rheumatoid arthritis)
Carbimazole (hyperthyroidism)
Quinine (malaria)
Infliximab (monoclonal antibody use for immunosuppression)
Rituximab
Antibiotics + same as sepsis w/ extra precaution

Question 4

RFs ass w/ neutropenic sepsis? Investigations? What to do after 24-48 hours of IV antibiotics if clinically improving? If no improvement after 48 hours or 5 days? What might those high risk on chemo be offered?

Answer 4

Poor nutrition, mucosal barrier defect, central venous lines, abnormal host colonisation
FBC, U&E, creatinine, LFT, CRP/ ESR, coag screen
Septic screen: blood cultures, relevant swabs/ cultures, CXR
Consider adding second line antibiotics
Consider opportunistic infections e.g. fungal, PCP
Granulocyte colony-stimulating factor (G-CSF)

Question 5

Causes of malignant spinal cord compression? Presentation? Ix?

Answer 5

Malignancy- primary, secondary= most common
Mechanism= crush fracture, soft tissue tumour extension
Limb weakness below level of compression, bowel/ bladder dysfunction, radicular pain, abnormal neurological examination–> LMN signs at level of the lesion and UMN signs below that level
MRI WHOLE SPINE, can’t have= CT, +/- myelography

Question 6

Management of malignant spinal cord compression? Prognosis?

Answer 6

High-dose corticosteroids, definitive treatment; depends on patient and disease factors
Surgery; spinal decompression + spinal column stability
Radiotherapy- those unsuitable for surgery, can be used for pain control
Chemo- chemosensitive tumours
Hormone deprivation- newly diagnosed prostate cancer–> MSCC
Analgesia, laxatives, VTE prophylaxis, pressure sore prevention
Related to severity of neurological deficit at time of presentation, paraplegia + sphincter involvement= recovery uncommon

Question 7

Who is hypercalcaemia common in? Symptoms? Often ass w/ what? How is it diagnosed?

Answer 7

In advanced cancer- bone mets(breast, lung, kidney, thyroid, prostate,) production of ectopic PTHrp(parathyroid hormone related peptide) by cancer- esp squamous cell cancers
Thirst, constipation, depression + calculi(bones, moans, stones, abdominal groans)
AKI
Blood test, corrected >2.6= abnormal, >2.8 is usually symptomatic, PTH, ECG- shortened QT interval, imaging for bone mets if appropriate

Question 8

Tx of hypercalcaemia?

Answer 8

IV fluids- manage AKI, IV bisphosphonates- zolendronate, pamidronate(can take days to work), denosumab if resistant to bisphosphonates

Question 9

Level for mild hypercalcaemia? Moderate? Severe? Causes?

Answer 9

2.6-3.0, 3.01-3.39, >3.4 mmol/L
Osteolysis(lytic bone mets,) humoral(PTHrP in squamous cell lung ca,) dehydration, other tumour specific mechanisms

Question 10

Acute treatment for malignant hypercalcaemia? Persistent or relapsed hypercalcaemia of malignancy?

Answer 10

Correct dehydration- 0.9% saline 4-6L, dependent on clinical condition and past medical hx
Rehydration–> IV bisphosphonates= inhibits osteoclasts therefore reduces bone turnover, reduces calcium levels over several days
Zolendronic acid and pamidronate commonly used
Thiazides, calcitriol/ calcium supps, antacids, lithium
Denosumab= human MAB that inhibits RANK ligand inhibiting maturation of osteoclasts, furosemide

Question 11

Causes and signs of SVC obstruction?

Answer 11

Inside the vessel- thrombus or IV device
Inside the vessel wall- direct tumour invasion
Outside the vessel- tumour, lung cancer, lymphoma
Dyspnoea, chest pain- often at rest, cough, neck and face swelling, arm swelling, others- dizziness, headache, visual disturbance, nasal stuffiness, syncope/ dilated veins over arms, neck and anterior chest wall, oedema of upper torso, arms, neck and face, severe resp distress, cyanosis, engorged conjunctiva, convulsions and coma

Question 12

Ix and tx for SVC obstruction?

Answer 12

May be clinical diagnosis, CXR(widened mediastinum or mass on right side of heart,) CT scan
Elevation of head and O2 therapy for symptomatic relief, high-dose steroids in acute SVCO e.g. dex 16mg OD, endovascular stenting, consider RT, CT- especially chemo-sensitive tumours e.g. small-cell lung cancer, anticoagulation; if central vein thrombosis present
(Can rapidly progress, life-threatening if acute, can develop chronically)

Question 13

Other oncological emergencies?

Answer 13

Brain mets- raised ICP, seizures, VTE/ arterial thromboembolism, pleural effusion, bowel obstruction, ask acute oncology team for advice, be aware of common SEs of systemic therapy and radiotherapy

Question 14

General SEs of chemo? Immunotherapy? Radiotherapy?

Answer 14

Fatigue, N&V, mucositis, myelosupression, sepsis, impact on renal and liver function, alopecia, taste change, unstable BMs, blood clots, infertility, allergic reactions
Multisystem inflammation- endocrine disturbance, tx= high dose steroids
Localised tx and SEs= dependent on anatomical site being treated

Question 15

What is stridor usually due to? Signs? Ix? Tx? Management?

Answer 15

A head and neck/ lung/ upper GI tumour
Noisy breathing- on inspiration, harsh breath sounds, breathlessness- not necessarily
Clinically, upper airway visualisation- ENT/ max-fax, upper airway imaging- CT
Active tx= ABC: oxygen/ heliox, high dose steroids- dex 16mg OD, urgent ENT review, stenting/ tracheostomy, radiotherapy
Palliation- high dose steroids, midazolam, opioids

Question 16

Who is massive haemorrhage common in? S+S?

Answer 16

Head + neck tumours, lung tumours w/ h/o bleeding, GI tumours w/ h/o bleeding, can be hard to predict, “herald bleed”- an episode of haemorrhage, often accompanied by abdominal pain, which may precede, by hours to weeks, a catastrophic haemorrhage
Large volume sudden blood loss, pt rapidly losing consciousness

Question 17

Tx massive haemorrhage?

Answer 17

Stop anticoagulation, if palliative- dark towels, remain w/ patient, midazolam 10mg stat, DEBRIEF W/ SENIOR

Question 18

S+S of opioid overdose? Ix? Tx?

Answer 18

Reduced level of consciousness, reduced RR/ SpO2, myoclonic jerks, pinpoint pupils, SEs= confusion, hallucinations, N&V, constipation
Clinical assessment, response to tx- naloxone, dose reduction
Naloxone- 400mcg in 10ml N saline, 20mcg every 2 minutes until resp function/ conscious level improves, close obs, review dosing and discuss with senior/ palliative care
(Tx in non-palliative contexts e.g. heroin OD= very different)

Question 19

Pitfalls in opioid overdose?

Answer 19

Toxicity vs SEs, sudden resolution of pain: ruptured abscess, pain intervention, renal/ hepatic impairment, opioid patches and fever, patients who “swig,” methadone, short half-life of naloxone- may need infusion, dying patients on opioids- naloxone unlikely to be appropriate, can precipitate sudden increase in pain

Question 20

What is tumour lysis syndrome? Who’s at risk? Renal saturation causes what?

Answer 20

Metabolic and electrolyte abnormalities and renal impairment- due to lysis of rapidly dividing cancer cells releasing intracellular contents into circulation
Usually days/ hours in to chemo
Usually chemosensitive lymphoma/ leukaemia
If dehydrated, renal impairment, prechemo, high urate and lactate
Hyperuricaema- can–> uric acid nephropathy and AKI
Hyperphosphotaemia, secondary hypocalcaemia, hyperkalaemia

Question 21

Presentation of tumour lysis syndrome? Ix? Prevention? Tx?

Answer 21

Weakness, paralytic ileus- constipation, vomiting, abdo pain/ cardiac arrhythmias- palpitations, chest pain, collapse/ AKI- reduce UO, lethargy, nausea
FBC, 25% increase in uric acid, phosphate, K+, 25% decrease in Ca2+, high creatinine and LDH
Prechemo IV fluids, avoid nephrotoxic meds, use allopurinol
Hydrate, correct high K+, rasburicase- oxidises uric acid, aluminium hydroxide(phosphate binder)

Question 22

What does approaching the end of life mean? Includes who? As well as?

Answer 22

Likely to die within the next 12 months
Includes those whose death is imminent- hours- days
Advanced, progressive incurable conditions, general frailty and co-morbidities that mean they are expected to die within 12 months
Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
Life-threatening acute conditions caused by sudden catastrophic events

Question 23

What is involved in formal advanced care planning?

Answer 23

What they want to happen- advance statement of wishes(preferences, wishes, beliefs and values)
What they don’t want to happen- advanced decision to refuse treatment(ADRTs)
Who will speak for them- lasting power of attorney for health and welfare= submitted by the patients; gives someone else the power to make decisions about health and welfare(once they lose capacity,) or finance(registered with the office of the public guardian)

Question 24

What is the 2014 Court of Appeal judgement?

Answer 24

Presumption in favour of involving a patient in a decision whether to complete a DNACPR, unless consulting the patient is likely to cause physical or psychological harm(not just cause distress)
If CPR= deemed medically futile - the patient cannot demand CPR, but entitled to know the clinical decision

Question 25

Things to consider when recognising dying?

Answer 25

What has changed in the last few weeks/ days/ hours Has their level of function changed for the worse Is there evidence of progressive and irreversible organ failure Have relevant treatments/ interventions been effective Has the patient/ relevant others seen a decline or do they think they are dying - are the above things iatrogenic, are they reversible?

Question 26

Signs to look for when considering death?

Answer 26

Weight loss and poor appetite, fatigue and sleeping more, deteriorating mobility, social withdrawal, changes in consciousness, struggling with medications, worsening performance status and needing more assistance for ADLs CV changes= pulse strength, change in colour, mottle skin from peripheries Respiratory changes= noisy secretions, laboured breathing, apnoeic episodes and Cheyne- Stokes breathing

Question 27

What is Cheyne-Stokes breathing? What are the 5 priorities of care of the dying?

Answer 27

Cyclical pattern of breathing in which movement gradually decreases to a complete stop and then returns to normal 1) Possibility that a person may die within the coming days and hours is recognised and communicated clearly 2) Sensitive communication takes lace between staff and the person who is dying and those important to them 3) Dying person those identified as important to them are involved in decisions about treatment and care 4) The people important to the dying person are listened to and their needs are respected 5) Care is tailored to the individual and delivered with compassion

Question 28

Acronym for breaking bad news?

Answer 28

Situation: identify yourself to patient and loved ones, confirm responsible consultant and nurse in charge, describe how the person is today Background: what brought the person to hospital, what has happened to the person since they were admitted, what tx and intervention has happened, how has the person responses Assessment: because of what you have discussed today you believe the person is DYING (you have to be specific with this) in the next few hours to days (give your best estimate) Recommendations: Develop an individualised plan of care for last days of life, which incorporates the needs and wishes of the dying person. This plan will include: Ceiling of care Interventions that will and won’t be done Rationalise medications Pre-emptive prescribing +/- syringe driver Nursing care e.g. pressure areas and mouth care Fluid and nutritional support if appropriate DNACPR form to allow a natural death What to expect as death approaches Emotional, cultural and spiritual needs Preferred place of ongoing care: DOCUMENT IT

Question 29

5 key symptoms to control near the end of life? Medicines management in their last few days of life?

Answer 29

Pain, breathlessness, respiratory secretions, nausea/ vomiting, distress/ agitation (delirium) Pain= morphine 1.25-2.5mg SC or 2.5-5mg PO hourly (max 10mg/ 24 hours) Breathlessness= morphine 1.25-2.5mg SC or 2.5-5mg PO hourly (max 10mg/ 24 hours) Secretions= buscopan 20mg SC PRN (max 240mg/ 24 hours) Agitation= midazolam 1.25-2.5mg SC hourly max 15mg/ 24 hours Nausea= haloperidol 0.5-1.5mg 4 hourly max 5mg/ 24 hours

Question 30

What and what dose to prescribe for SOB, secretions, pain and nausea/ vomiting? Things to do for nutrition and hydration?

Answer 30

Look at flow charts in 'terminal care' lecture Mouth care- prevent feeling of thirst, support oral food and drink for as someone wants it and is able Regularly review for symptoms related to reduced fluid intake

Question 31

Things to do if a decision is made to use fluids?

Answer 31

Basic care with oral fluids and regular mouth care, regularly re-assess fluid status Agree an aim- understand patient and family view, trying to prevent dehydration/ tx dehydration-related symptoms Agree when you will review and when you would stop- review at least daily, symptoms not improving or developing complications from fluids Decide on a route and volume- SC not for fluid resus- 1 to 2 litres per 24 hours, SC= an effective route to manage dehydration, you may have good IV access, if you lose access what would you do(forward planning)

Question 32

3 Human rights involved in Ethics and the Law?

Answer 32

The right to life, the prohibition of torture or inhuman or degrading treatment or punishment, the right to respect for private and family life

Question 33

3 parts to the Civil Contigencies act of 2004? Describes what 2 types of responder?

Answer 33

1) Defines the obligations of certain organisations to prepare for various types of emergencies 2) Provides additional powers for the government to use in the event of a large scale emergency 3) Provides supplementary legislation in support of the first 2 parts NHS, Police, Fire services, local authorities and more... Mostly utilities and transport organisations

Question 34

What does the CCA Act (2004) define an emergency as? It requires organisations to do what?

Answer 34

Event/ situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK or war or terrorism which threatens serious damage to the security of the UK Maintain arrangements to warn the public, and to provide information and advice to the public, if an emergency is likely to occur or has occurred Assess the risk of emergencies occurring and use this to inform contingency planning Put in place emergency plans, business continuity management arrangements, arrangements to make information available to the public about civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency Share info with other local responders to enhance coordination Cooperate with other local responders to enhance coordination and efficiency

Question 35

3 levels of incident classification?

Answer 35

Major e.g. terrorist attack Critical e.g. power outage at a hospital Business continuity incident e.g. flood within a NHS property

Question 36

What are national incidents supported by? Function of ICCs?

Answer 36

Incident Coordination Centre based in London, National one is supported by 7 regional ones Coordinate action, manage information, provide a clear focal point for the response and expert advice and guidance

Question 37

The Joint Emergency Services Interoperability Programme(JESIP) is covered by what 5 blocks?

Answer 37

Gather information and intelligence, assess risks and develop a working strategy, consider powers, policies and procedures, identify options and contigencies, take action and review what happened

Question 38

What is an incident? Reputational management?

Answer 38

Declared as per the CCA (2004)- an event/ issue that comes from within an organisation and prevents all or some core services or functions from running normally External event that causes a significant increase in demand for services and/ or prevents them from operating normally Not declared- event that while not impacting the day to day running of your organisation risks long-term viability through significant damage to reputation

Question 39

5 steps in how crisis comms are managed?

Answer 39

Signal detection, probing and prevention, damage containment, recovery, learning and evaluation

Question 40

What is a single point of contact?

Answer 40

Useful in the management and response to critical incidents- applicable in broader medical practice- ensures responded to in appropriate timescale, allows for monitoring of response times and logging of all requests and information provided, prevents time being spent on duplicate work, establishes trust and reliability during rapidly evolving and uncertain situation

Question 41

What is major trauma?

Answer 41

Serious and often multiple injuries where there is a strong possibility of death or disability

Question 42

Key principles in major trauma primary survey?

Answer 42

Control catastrophic haemorrhage, airway with C-spine protection, breathing with ventilation, circulation with haemorrhage control, neurological status, exposure/ environment (CABCDE)

Question 43

Difference between primary, secondary, tertiary and quaternary blast injuries? Commonest causes of preventable or potentially preventable death? Priorities are what?

Answer 43

Blast disrupts gas filled structure, impact airborne debris, transmission of body, all other forces Bleeding, multiple organ dysfunction syndrome, CR arrest Prevent hypoxia, acidaemia, traumatic cardiac arrest, or tx correctly

Question 44

ATMIST in relation to major trauma?

Answer 44

Age, time, mechanism, injuries, signs(observations,) treatments

Question 45

Tx of catastrophic haemorrhage?

Answer 45

Clear any clots obscuring bleeding source, direct pressure, more direct pressure, indirect pressure, tourniquet, haemostatic agents i.e. ceelox

Question 46

How to apply tourniquet for haemorrhage? Expected time frame for securing an airway in major trauma?

Answer 46

Above as high as possible, twist rod until bleeding stops, ensure stopped and no distal pulse, add 2nd one above first if cannot stop 45 minutes

Question 47

Absolute indications for intubation?

Answer 47

Inability to maintain and protect own airway regardless of conscious level, to maintain adequate oxygenation with less invasive manoeuvres (PaO2<10kPa,) inability to maintain normocapnia- spontaneous PaCO2<4.0kPa or >6.0kPa, deteriorating conscious level>/= 2 points on motor scale, significant facial injuries, seizures

Question 48

In the presence of burns or a blast injury, consider what? Early intubation considered in the presence of what?

Answer 48

Whether or not the airway is compromised or at risk of compromise Hypoxaemia or hypercapnia, deep facial burns, full thickness neck burns

Question 49

Relative indications for intubation?

Answer 49

Haemorrhagic shock- particularly with evolving metabolic acidosis, early and repeat blood gas analysis will aid in this decision making, agitated- hypoxia and hypovolaemia cause agitation, multiple painful injuries, transfer to another area of hospital/ expected clinical course e.g. vascular angio/ theatres/ GITU