WEEK 11 - Supportive Care/Palliative Care Flashcards
(17 cards)
What is supportive and pallative care
Supportive care - is ongoing support + care throughout pt cancer treatment
- can also be classed as pallative care
Traditional Pallative care - focuses on support for the last 12 months of life / cancer management
NOTE:
- Now recommended to provde care from time of diagnosis for every patient with advanced cancer
- Have supportive care MDT (many diff. HCP involved)
Supportive Care MDT
Supportive care MDT weekly, handovers daily
Need to think of pt holistically e.g. physio part of treatment plan
- Onco-endocrinology reviews – osteoporosis, Thyroid problems, fertility issues
- Psycho-oncology – look after in patient and out patients (many pts have depression due to condition, or underlying mental health conditions prior to cancer ~ need to be managed correctly)
- Pharmacists
What are the benefits of supportive and pallative care
Support throughout cancer journey can:
- Improve QoL,
- Reduce symtom burden
- Increase OS
- Reduce uneccesary hospital admissions
- Identify psychological concerns + provide supprot
- Provide adequate treatment for physical symptoms
What must be considered when managing patient with cancer
in terms of support
Consider:
- Cancer trajectory for that pt
- What the likely outcome is
- ADRs / effects
- Symptoms
- Is it curative or non-curative
- Rehabilitation
- helping pt manage symptoms, psot-treatment effects
- Post cancer Rx
- Pre-habilitation
- optimising pt fitness, function, health before undergo treatment
- Monitoring late-effects (>10+ years)
- e.g. bowel dysfunction from RT
List the 4 patient cohorts in cancer
- Curative (on SACT treatment)
- Incurable but treatable (on SACT treatment)
- have mor people living longer with this type of cancer - Best supportive and End of Life Care (off SACT treatment)
- Survivorship (off SACT treatment)
- no. of survivors are growing
NOTE:
- For all groups QoL issues still exist
- All these pts require supportive care but NHS have limited workforce
What factors increase complexity in cancer patients
- Fraility / old age (>70)
- need to optimise meds - Acute medical illness
- Polypharmacy
- assess appropriateness of meds
- DDIs - PK and PD
- cancer pts may have cachexia (lose body fat) = affects PK / PD
- can affect distribution + bioavailability of drug - SACT
- Renal and Hepatic Impairments
- treatment can cause acute injury
- natural decline with age / end of life - Availability of administration route
- Prognostic uncertainty
- determine if giving opiates or NSAID is correct thing to do
What Issues may patients experience during treatment
- Acute oncological issues
- e.g. SVCO, neutropenic sepsis - Nutrition issues
- Excercise / fatigue issues
- Rehabilitation needs
- Psychological issues
- Organ specific problems
- require specialists advice (MDT) - Control of pain and symptoms
What Issues may patients experience after treatment
- Chronic survivorship pain
- Long term effects of treatment
- Bone health and endocrinopathies
- Joint and soft tissue problems
- e.g. rheumatological issues - Psychosexual issues
- Financial toxicity
- uncertaninty, not being able to work - 2nd cancer risk
- due to immunosupressive drugs, DNA alkylating agents used = ↑ risk
What symptoms may cancer patients experiece
- Pain
- N&V
- Weight loss
- can be caused by cachexia = pt progressively loses muscle mass
- Hair loss
- less likely with immunotherapy and targeted drugs
- can use cold caps to reduce effects - Bowel and Bladder issues
- constipation (induced by opiates, pain meds)
- diarrhoea - Oral problems
- e.g. mucositis, dry mouth, thrush
- hard to eat, swallow may ne NG tube or IV fluids - Fatigue, tired, breathlessness
- teach pt breathing excercises - Loss of apetitie
- give nutritional supplements - Skin
- e.g. itching (morphine can cause), rash - Confusion, delirium
- intensified by opiates, anti-cholinergic meds - Psychological problems
- e.g. anxiety, depression
- Hiccups
- GI irritation from steroids
- Gabapentinoids, anti-pshycotics can help - Seizures
- Endocrine problems
- Abnormal bleeding
Pain Info
4 Causes, Total Pain Model, WHO Ladder
Very common in cancer pts
4 Causes:
1. Tumour growth - can cause neurpathic or nocieptive pain
- Nociceptive = deep, visceral pain
- Neuropathic = due to nerve damage
- Somatic = due to bone metastasis
2. Anticancer treatment
- CIPN = damage to nerves in feet, apply chilly patches for 60 min
- Mucositis, flare up post SACT, RT
- Steroids given for post flare
3. Combination of above
4. Non-cancer cause
Total Pain Model:
- Pain cant be managed properly without considering all factors on model
- Need to look at pt as whole consider physical, social, spiritual and psychological factors not just pain meds
WHO Pain Ladder:
- 3 steps (Non-opioid, Weak opioid and Strong Opiod)
- Weak opioid / step 2 is missed in cancer pain e.g. codeine, tramadol
- toxic, can cause constipation
- Mild to moderate pain: step 1
- Moderate to severe pain: straight to morphine (step 3)
NOTE:
- If Pain is going consider weening down
- If Meds causing ADR consider an alternative
- Opioid pain conversion varies, not always 1:1 ratio
What is Breakthrough cancer pain (BTcP)
What is it, 2 Types of BTcP
BTcP - spikes of pain = need to take extra / rescue dose of analgesia
- pt may have controlled background (ongoing) pain
Types of BTcP:
1. Predictable = movement induced
- e.g. if have fracture hip, know if patient gets out of bed, does physio etc. will get incident pain
- may give pain dose before move
2. Spontaneous = no preticipating factors
- could be due to nerve or muscular spasms, frequency varies
What 4 pharmaceuticals may be used in pallative care for pain
i.e. Common Analgesics
- Paracetamol
- not evidence based
- risk of hepatotoxicity: elderly, low weight, renal impairment
- can be given IV or roally
- reduced dose given if < 50kg
- NSAIDs (inc. COX-2 inhibitors)
- careful use in CT pts, > 65
- nephrotoxic risks e.g. AKI
- CV risks
- Opioids
- Risks of dependancy + harm (as dose increases)
- Reveiew pts on high doses, affects QoL and fucntion
- Morphine = 1st choice (cheapest)
- Oxycodone = 2nd line alternative
- Fentanyl = potent - transdermal (TD)
- Buprenorphine - (TD)
- Syringe pump - end of life, can’t swallow - Neuropathic Agents (e.g. anti-depressants, gabapentinoids)
- e.g. Amitripityline = 1st line
- e.g. Gabapentin, Pregablin - Steroids
- used in short bursts due to potential SE
List adverse effects of opioids
- Constipation
- N&V (prescribed Metoclopramide)
- Dry mouth (due to anti-cholinergic effects)
- Respiratory Depression
- reversed using low dose naloxone - Light headedness, unsteady (↑ fall risk)
- Hyperalgesia (pt become more sensitve to pain stimulus)
- Sweating
- Delerium, hallucinations
- Psychological dependance
- Immunosupression (spc. fentanyl)
- Fertility
Opiod Extra info
- Give pt info about:
- addiction, tolerance, SE, why used, when to use, follow ups
- fentantly patches should not be cut
- fenetanyl shouldnt be exposed to heat
Seek specialist advice if:
- pt dose titrated 3x and still no benefit
- dose exceed 120mg PO daily
- abnromal renal / hepaic fucntion
What are the considerations when using analgesia
- Good analgesic stewardship
- weening pt of high doses
- reviewing pt doses / meds regularly
- monitoring for SE and efficacy
- not to continue opioids long-term
What are challenges pharmacy team may face when looking after cancer patients
- Increased complexity: multimorbidity and polypharmacy
- frequent reviews of meds - Managing SACT drug interactions
- and interactions with RT - Use of high-risk medicines
- e.g., opioids
- prevent dependency, adverse effects - Limited evidence base- focus should be on creating the evidence
- opions ma vary amongst pallative/support care teams
BTcP Management
Need to ensure background pain is well managed before giving additional doses
Consider:
- Is pain short lasting, resolves quickly = no point giving analgesia top up because medication will linger in body and potentially cause SE
- Morphine can work for 4 hours or longer (esp. in pt with organ failure)
- SE pt feeling sleepy or drowsy, as BTcP lasts 10min to 1hr
- BT top up opiod will be same opiod pt uses for long term management
Novel drugs:
- Short acting fentanyl preparations
-reduce tiredness effects, short lived in body
- Very expensive = GP reluctant to prescribe = limited to morphine and oxycodone as primary pain mgmt
