Palliative Care

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What are the treatment options for neuropathic pain?
Morphine or fentanyl (not fully effective)
Amitriptyline or fentanyl
Pregabalin, gabapentin
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What are the 4 different types of pain?
Neuropathic
Bone
Somatic
Visceral
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What are the treatment options for bone pain?
Morphine or fentanyl
Celecoxib and other NSAIDs (impacts renal function)
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With what co-morbidities should NSAIDs be avoided?
Renal. Cardiac or hepatic failure
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What are the 4 steps of the analgesic ladder?
1. Non-opioids + adjuvants (paracetamol, NSAIDs)
2. Opioids for mild to moderate pain + above (tramadol)
3. opioids for moderate to severe pain + above (morphine, fentanyl)
4. Invasive treatment + above (surgery)
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What is the WHO method for cancer pain relief?
By mouth (oral)
By the clock (regular)
By the ladder (step wise)
For the individual (tailored)
Provide breakthroughs (PRN)
Use adjuvants (other)
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What is the dosing regimen for morphine?
Start with 2.5mg elixir every 4 hours
Increase by 2.5mg when needed, to a maximum of 10mg
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How long does slow-release morphine tablets last?
12 hours
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How much oral morphine is a 25 microgram/hour fentanyl patch equivalent to?
60-90mg of oral morphine in 24 hours
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What is the calculation for changing from oral to subcutaneous opioids?
Need to half the oral dose in 24 hours
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What is the breakthrough morphine dose?
1/6 of daily morphine dose
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What is the calculation to go from an oral codeine dose to an oral morphine dose?
Codeine dose/10
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What is delirium?
Abrupt onset, fluctuation in symptoms with impairment of consciousness leading to changes in orientation, mood, concentration, and sleep
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List causes of delirium
Infection
Liver/renal failure
Medications
Metabolic disturbances
Hypoxia
Cerebral mets
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What is the management for delirium?
Treat the cause
Ensure safe environment
Minimise staff changes
Orientating aids: clock, personal items
Emotional support and family
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When should medications be used for delirium? What should be used?
If symptoms are severe use antipsychotics to calm or pacify the patient rather than sedate

Haloperidol 0.5 mg–1 mg every 2 hours when required until control achieved (max 5mg/24 hours)
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What are the causes of nausea?
Organ specific: bowel, brain, liver
Biochemical or infection: renal, liver, UTI
Emotional: anxiety, pain, depression
Treatment/toxins: radiotherapy, chemo, morphine
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What is the approach to treating nausea?
1. Diagnose and treat the reversible
2. Use one targeted anti-emetic at a time and titrate to maximum dose before trying another
3. Chart regular anti-emetic as well as PRN in nausea persists
4. Review every 24 hours
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What are the 5 areas that can be targeted to treat nausea?
Vomiting centre which is central to:
Cerebral cortex
Area postrema
Vestibular nuclei
Gut wall/viscera
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What can cause nausea in the cerebral cortex? What medications can be used to target this area?
Raised ICP, low Na, pain, anxiety, smell/sight/sound

Dexamethasone
Lorazepam
Aprepitant
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What can cause nausea in the vestibular nuclei? What medications can be used to target this area?
Movement, direct tumour effect

Prochlorperazine
Cyclizine
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What can cause nausea in the gut wall/viscera? What medications can be used to target this area?
Constipation, surgery/chemo/DXT, drugs (e.g. opioids, anticholinergic, antibiotics)

Metoclopramide
Domperidone (safe to use in Parkinson’s as it doesn’t cross BBB)
Dexamethasone
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What can cause nausea in the area postrema? What medications can be used to target this area?
Renal failure, hypercalcaemia, DXT, drugs (e.g. opioids, NSAIDs, SSRI, antibiotics, digoxin, chemo)

Haloperidol
Ondansetron
Phenothiazine
Aprepitant
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What medications can be used to target the vomiting centre?
Levomepromazine (can cause sedation)
Cyclizine
Hyoscine
Aprepitant
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What is the only anti-emetic safe to use in patients with Parkinson’s? Why?
Domperidone – does not cross the BBB
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What anti-emetic should be avoided in a patient with Parkinson’s?
Metoclopramide
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What are the causes of constipation?
Diet
Debility
Drugs
Disease
Depression
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What are the treatment options for constipation? Their actions? Their characteristics?
Stool softeners
1. Lactulose (small vol + sweet)
2. Macrogol
3. Docusate

Stimulants
4. Senna
5. Bisacodyl (tablet or suppository)

6. Enemas
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What percentage of cancer patients experience breathlessness?
46%
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What are reversible causes of breathlessness?
Pneumonia
Pleural effusion
Pneumothorax
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What are non-pharmacological methods of alleviating breathlessness?
Chest drain
Positioning
Fan
Cold water or citrus fruit
Relaxed breathing
Distraction (music, TV, massage)
Loose clothing
Breathing exercises
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What are pharmacological methods of alleviating breathlessness?
O2 – if O2 saturation is low
Airflow – if SOB with normal sats
Opioid – reduce cardiac workload and anxiety
Benzodiazepines – reduce anxiety related with breathlessness
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What are the signs someone is in their last days of life?
Reduced conscious level
Minimal eating and drinking
Difficulty with oral medication
Bedbound
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What are the signs someone is in their last hours of life?
“Death rattle”
Increasing pallor
Deeply unconscious
Cool or cyanosed peripheries
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What drugs should be prescribed for what 5 symptoms at the end of life? What route should these be?
Pain (1) + breathlessness (2): morphine 2.5-5mg Q1H or fentanyl 12-5-25mcg Q1H
Nausea + vomiting (3): antiemetic (based on cause) + haloperidol 0.5-1mg Q4H
Agitation/distress (4): midazolam 2.5-5mg Q1H or haloperidol 0.5-1mg Q4H
Resp secretions (5): busco
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What observation chart should someone in the active process of dying be on?
Te Ara Whakapiri
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What is the process for the verification of death?
No sign of breathing for >1 minute
Absent central pulse (carotid, femoral, and brachial for 5-10 seconds)
No heart sounds
Pupil dilated and uncreative to light
Repeat after 10 minutes

Place Te Wai symbol on patient’s door and entrance to wards
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What can acute severe breathlessness near the end of life be caused by? Management?
Commonly triggered by anxiety/distress and is multifactorial

Non-pharmacological: loose clothing, fans, treat distress
Pharmacological: midazolam 5-10mg or morphine 5-10mg
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What can acute severe pain near the end of life be caused by? Management?
Sensory or emotional experience

Paracetamol/NSAIDs/opioids – IV
Morphine 5-10mg
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What is the management for acute severe haemorrhage near the end of life?
Stay with the patient, put pressure on it, call for help

Morphine 5-10mg – used to reduce distress +/- awareness
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What is the management for overwhelming distress near the end of life?
Relieve distress/suffering

Midazolam 5-10mg
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What is the management for terminal agitation?
Consider and treat reversible causes (e.g. urinary retention > put in catheter, ?blocked catheter)

Agitation may be physical and/or existential

Haloperidol or midazolam – titrate up as needed
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What are the basic principles in managing palliative care emergencies?
1. Have a plan (anticipate)
2. Be the calmest person in the room
3. Ask for help
4. Have confidence/knowledge to give enough drugs
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Other cards in this set

Card 2

Front

What are the 4 different types of pain?

Back

Neuropathic
Bone
Somatic
Visceral

Card 3

Front

What are the treatment options for bone pain?

Back

Preview of the front of card 3

Card 4

Front

With what co-morbidities should NSAIDs be avoided?

Back

Preview of the front of card 4

Card 5

Front

What are the 4 steps of the analgesic ladder?

Back

Preview of the front of card 5
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