Week 4- Palliative care + medication

Question 1

what is palliative care?

Answer 1

relieving pain without dealing with the cause of the condition

Question 2

what are the principles of palliative care?

Question 3

how do they identify people who would benefit from end of life care? what tools?

Answer 3

 Gold Standard Framework Proactive identification guidance (PIG) (primary care)
 AMBER bundle (secondary care)
 Supportive and Palliative Care Indicators Tool

Question 4

what groups of people need EoL care?

Answer 4

-advanced incurable conditions
-generally frail and
-existing conditions where they can have sudden acute crisis
-life threatening conditions due to sudden catastrophic accidents

Question 5

what happens when someone has been identified to need EoL care?

Answer 5

-Identification of carers and people important to them
-Holistic needs assessment
-provision of information
-advanced care planning
-regular review of needs
-multidisciplinary care

Question 6

what are some examples of conditions where people may benefit from palliative care?

Answer 6

 Cardiovascular e.g. heart failure
 Cancer
 Renal failure
 Hepatic failure
 Neurological conditions e.g. MS, PD, stroke
 COPD
 CF
 Dementia
 ….and many more

Question 7

what is the role of the pharmacists for EoL care?

Answer 7

 Drug choice
 Doses
 Legal aspects – off label use
 Interactions
 Side effects
 Regular medications – to continue or deprescribe – ethics, consent
 Pharmaceutical issues
-Compatibilities of drugs
-Diluents
-Rates of administration
-Syringe drivers
 Feeds and fluids

Question 8

what are some symptom relief in palliative care other than pain?

Answer 8

 Nausea and vomiting
 Excessive secretions
 Dry mouth
 Dyspnoea
 Pruritis
 Muscle spasm
 Sedation
 Headache
 Capillary bleeding
 Cough
 Diarrhoea
 Constipation
 Convulsions
 Insomnia
 Anxiety
 Hiccups
 Oral candidiasis
 Fungating malodourous tumours

Question 9

what is the most common symptom for palliative care?

Answer 9

-pain
-need to identify the severity and cause of pain which will direct the pain

Question 10

what is the most common analgesia in palliative care? what needs to be considered for it?

Answer 10

-opioids
Need to consider
 Previous opioid therapy
 Renal function
 Hepatic function
 Route of administration

Question 11

What is the dosing of the PRN dose prescribed along with long acting opioids?

Answer 11

1/10-1/6 daily dose every 4 hours

Question 12

what are some side effects of opioids?

Answer 12

-Constipation
 Regular laxatives most effective
-Nausea & Vomiting
 Initiation or dose increase
 Ensure adequate antiemetic therapy is available
 Switch opioids if if it doesn’t stop
 Drowsiness
 reduce dose or switch if not stoped

Question 13

what are the routes of administration for opioids?

Answer 13

 PO
 Transdermal
 Subcutaneous
-PRN
-Continuous subcutaneous infusion – AKA syringe driver
 Dose conversions may differ depending on route

Question 14

what is some advice for patients/carers for opioids?

Answer 14

 Storage- safe, not in warm place
 Keeping track of the dates patches applied
 Disposal- return to pharmacy
 PRN dose records
 Hospital admissions – PODS
 Order in good time
 supplies no longer required

Question 15

why do patients needing EoL care experience nausea and vomiting?

Answer 15

-could be due to the disease itself
-or medication they are taking
-nausea can be worse than vomiting
-serve itself can impair absorption

Question 16

what is the mechanism for nausea and vomiting?

Answer 16

-in vomiting the parasympathetic system acts on muscarinic receptors in the smooth muscles of the gut with acetylcholine as the main neurotransmitter.
-in the sympathetic system it acts on adrenergic receptor and as noradrenalin as the neurotransmitter.

Question 17

how do antihistamines work as a antiemetic?

Answer 17

Antihistamines e.g. cyclizine
-blocking H1 receptor- CTZ and vomiting centre
-sedation which can help with nausea

Question 18

how do anticholinergics work as a antiemetic?

Answer 18

anticholinergics (antimuscarinic) e.g. hyoscine
-inhibit cholinergic transmission centrally (M1 receptors)
-antispasmodic action in gut

Question 19

how do antidopaminergic work as a antiemetic?

Answer 19

antidopaminergic e.g. haloperidol
-block D2 receptors in CTZ
-antihistamine and anticholinergic action

Question 20

how do metoclopramide and domperidone work as a antiemetic?

Answer 20

-block D2 receptors in CTZ
-prokinetic effect on GI tract

Question 21

how do levomeproazine work as a antiemetic?

Answer 21

block D2, Ach, H1 & 5HT2 receptors . Nb weak action at each site

Question 22

how do Selective 5HT3 receptors antagonist work as a antiemetic?

Answer 22

Selective 5HT3 receptors antagonist e.g. ondansetron
-block 5HT3 receptors peripherally on vagal nerve endings and also centrally in vomiting centre.

Question 23

what are some interactions for antiemetics?

Answer 23

Antiemetic interactions
 Metoclopramide and haloperidol – extrapyramidal side effects
 Levomepromazine potential for EPSE – mix with care
 QT interval prolongation – ondansetron, haloperidol, metoclopramide, levomepromazine
 Cyclizine blocks prokinetic effect of metoclopramide
 Opioids antagonise prokinetic effects

Question 24

how do you manage anorexia that some patients experience during EoL?

Answer 24

-enticing foods
-manage cause e.g. nausea or constipation
-corticosteroid

Question 25

how do you manage dyspnoea that some patients experience during EoL?

Answer 25

Low dose opioid
-may diminish chemoreceptor response to hypercapnoea and hypoxia
-