6. Palliative Care Flashcards

1
Q

What are the essential components of palliative care?

A
  • Effective communication
  • Team working
  • Complex decision making
  • Continuity of care
  • End of life care
  • Bereavement support
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2
Q

How is End of Life Care for adults defined?

A
  • This includes people who are likely to die within 12 months, people with advanced, progressive, incurable conditions and people with life-threatening acute conditions
  • It also covers support for their families and carers
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3
Q

What is IMPACT stand for regarding symptom control?

A
I: Identify concerns
M: Make an accurate assessment
P: Plan your action
A: Act
C: Continuously re-evaluate
T: Talk to other HCP
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4
Q

What are approaches to pain management?

A
  • Analgesics
  • Anaesthetics
  • Palliative
  • Neurological
  • Supportive care
  • Inhibition of pain transmission
  • Psychotherapeutic apporaches
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5
Q

What is a Opioid Rotation?

A
  • switch from one opioid to another

- aim is to provide a better balance analgesia and side effects

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6
Q

What are the considerations before opioid conversions?

A
  • calculate the 24hrly requirements
  • convert back to oral morphine
  • then convert to alternative opioid
  • ensure adequate breakthrough
  • consider a dose reduction
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7
Q

Describe Fentanyl patches

A
  • not any more effective as an analgesic than morphine
  • mu receptor agonist
  • 50-100x more potent than morphine
  • constant drug delivery for 72 hrs

Indication

  • stable and chronic pain
  • opioid responsive
  • When oral route is not available
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8
Q

What is Hydromorphone?

A
  • analogue of morphine
  • 7.5x more potent
  • only one major active mtabolite (H3G)
  • indicated as an alternative strong opioid in cases of intolerable adverse effects with morphine
  • problems at large dose
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9
Q

What is Oxycodone?

A
  • 1.5-2x more potent than morphine orally
  • Available as quick and slow release formulations
  • K-opioid receptor agonist
  • titratable
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10
Q

What is Oxycodone?

A
  • mixed pharmacology (NMDA and opioid activity)
  • variably long half life and potential for accumulation
  • useful when there is a complex element of neuropathic pain
  • available as tabs, liquid injection and suppository
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11
Q

How do you start methadone?

A
  • give morning dose of MR opioid
  • continue to use breakthrough doses of opioid for 24 hrs
  • 30mg stat methadone 6 hr after morning opioid
  • give prn doses methadone 3hrly
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12
Q

What are Bone Targeted Agents (BTA) for bone pain?

A

Biphosphonates

  • have been shown to reduce the incidence of skeletal complications
  • inhibit osteoclast activity
  • Consider Strontium Ranelate
    : radioactive isotopes
  • Denosumab
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13
Q

How is Antidepressants used in Palliative care europathic pain?

A
  • Potentiates inhibitory pathways
  • Amitriptyline
    : start at 10mg
    : usually need at least 50mg
  • limited by side effects
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14
Q

How is Anticonvulsants used in Palliative care europathic pain?

A
  • Activates pain suppression pathways
  • Sodium Valproate
    : 200-1000mg daily
    : 4~5 days to steady state
    : no clinical trials
  • Carbamazepine
    : common adverse effects
    : drug interactions
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15
Q

How is Gabapentin used in Palliative care neuropathic pain?

A
  • increases GABA synthesis in CNS
  • licensed for neuropathic pain
  • caution in renal impairment
  • Two dosing regimes
    : day 1 300mg ON
    : day 2 300mg BD
    : day 3 300mg TDS
    : then up to 600~1200mg TDS
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16
Q

How is N&V treated in Palliative care? (steps)

A

Document the most likely cause

Treat reversible causes

Prescribe the most appropriate anti-emetic

Review every 24hrs

Check cause / route if poor response

Add or substitute second line agent

Continue indefinitely if necessary

17
Q

What is Metoclopramide and how is it dosed?

A
  • Nausea

10mg TDS-QDS or
30-100mg / 24 hr CSCl

18
Q

What is Cyclizine and how is it dosed?

A
  • Targets Vomitting centre

50mg TDS or
100-150mg / 24 hr CSCl

19
Q

What is Haloperidol and how is it dosed?

A

CTZ anti-emetic

  • for most chemical causes of vomitting e.g morhpine, hypercalcaemia, uraemia
  • blocks dopamine receptors
  1. 5-3mg ON or
  2. 5-10mg / 24hr CSCl
20
Q

What is Levomepromazine and how is it dosed?

A
  • effective broad spectrum anti-emetic
  • high response rate
  • low dose 12.5-50mg / 24hrs
  • can give SC
  • useful in agitation and restlessness
  • S/E = sedation and anticholinergic
21
Q

What are second line drugs for anti-emetics?

A

Anti-secretory

  • Hyoscine Butylbromide 80-160mg / 24hr CSCl
  • reduces GI motility and secretions
22
Q

Give an example of Sedative drug

A

Midazolam

  • Short acting
  • Activates GABA
  • Half life prolonged in some patients
  • Dose CSCl 30mg/24hr
  • Useful in patients with Epilepsy or fitting due to brain metastases
23
Q

Describe Hypercalcaemia of malignancy in Palliative care

A
  • 10% of patients with cancer develop hypercalcaemia
  • Poor prognosis

Clinical features
- dehydration, polydipsia, pruritis, N&V, constipation, fatigue, confusion, myopathym, cardiac complications

Treatment

  • Rehydration
  • Biphosphonate
24
Q

Describe use of Corticosteroids in Palliative care

A

Indications

  • inflammation
  • cerebral oedema, metastases
  • N & V
  • Spinal cord compression
  • Analgesia

Caution in

  • diabetes
  • psychosis
  • peptic ulcer disease