palliative care
Download
Skip this Video
Download Presentation
Palliative Care

Loading in 2 Seconds...

play fullscreen
1 / 30

Palliative Care - PowerPoint PPT Presentation


  • 356 Views
  • Uploaded on

Palliative Care. Dr Rachel Dawson. Objectives. Increase your confidence in dealing with palliative care cases. Content. Who is a palliative care patient? Presentation/ likely symptoms Palliative care emergencies Help available Medication – what, when & how much to use

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Palliative Care' - roch


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
palliative care

Palliative Care

Dr Rachel Dawson

objectives
Objectives
  • Increase your confidence in dealing with palliative care cases
content
Content
  • Who is a palliative care patient?
  • Presentation/ likely symptoms
  • Palliative care emergencies
  • Help available
  • Medication – what, when & how much to use
  • Setting up a syringe driver
  • Case studies/ ethical dilemmas
a patient for whom the objective of any treatment is to offer symptom relief only
A patient for whom the objective of any treatment is to offer symptom relief only
  • For example –

- Any end-stage chronic illness; cancer, heart failure, renal failure, COPD, MS ….

- Dementia

- Old age

  • It is NOT just for cancer patients
common symptoms pepsi cola
Common Symptoms(PEPSI COLA)
  • Pain
  • Drowsiness
  • Breathlessness
  • Nausea / Vomiting
  • Constipation
  • Anxiety/ Agitation / Restlessness/ Confusion – remember carer
  • Dysphagia
  • Other symptoms are more common in certain scenarios e.g. ascites in ovarian cancer
palliative care emergencies
Palliative care Emergencies
  • Hypercalcaemia
  • Spinal cord compression
  • SVC obstruction
  • GI obstruction
  • Haemorrhage – esp Upper GI
  • ( Raised ICP)
palliative care emergencies hypercalcaemia
Palliative Care Emergencies – Hypercalcaemia
  • Calcium > 2.6mmol/l
  • Suspect if known bony mets or any common tumour; Breast/ kidney/ myeloma/ lung or CRF
  • Symptoms – non-specific : thirst, constipation, N/ V, Abdo pain, anorexia
  • Management – STOP any calcium (!) & admit for re-hydration & IV Pamidronate
palliative care emergencies spinal cord compression
Palliative Care Emergencies – Spinal Cord Compression
  • Incidence of ~5% of all cancer patients – 70% occur in T spine
  • Always suspect if known bony mets/ common metastasising tumours
  • Symptoms include – pain / leg weakness/ constipation/ incontinence
  • Management: ADMIT – IV Dexamethasone, MRI & RTx
palliative care emergencies gi obstruction
Palliative Care Emergencies –GI Obstruction
  • Can occur with any cancer – not just physical obstruction
  • Symptoms include – V (faeculent), Constipation (empty rectum), Abdo distension, Pain
  • Management - ? Admit, ? NGT, Consider stopping prokinetic (dom/ met) & switch cyclizine/ haloperidol, buscopan. Soften stool & consider dexamethasone
palliative care emergencies svc obstruction
Palliative Care Emergencies –SVC Obstruction
  • Rare – 75% are due to 1y lung cancer. ~3% lung cancers develop SVCO
  • Symptoms – periorbital oedema, SOB/ stidor, neck or arm swelling. Usually dilated veins can be seen on chest wall.
  • Management – Treat breathlesness/ anxiety with opioid +/- BZD. ADMIT – IV dexamethasone & RTx
palliative care emergencies haemorrhage
Palliative Care Emergencies-Haemorrhage
  • Rare, but most common with upper GI (Remember steroids)
  • Usually fatal
  • Need to anticipate / warn carer
  • Management – Midazolam +/- diamorphine to alleviate suffering
palliative care emergencies 7
Palliative Care Emergencies(7)
  • Raised ICP – presents with drowsiness/ headache/ V. Can usually be anticipated. Mx= dexamethasone 16mg/day
  • In essence emergency drugs include – Diamorphine, Anti-emetic, Midazolam & Dexamethasone
help available
COMMUNITY

District Nurses ->LCP

Macmillan Nurses

Hospice at home ->LCP

Consultants

Pharmacist – Twycross/ Pall care BNF

Bradford Cancer Support ->benefits

HOSPITAL

Consultants

Specialist nurses

2nd opinion

Help Available
medication what when how much to use
Medication – What, When & How Much to Use
  • Analgesia
  • Antiemetic
  • Anticholinergics
  • Sedatives/ Anxiolytics
  • Anti-inflammatory
  • Others – secretions, mouth care & constipation.
analgesia
Analgesia
  • Tailor analgesic choice to type of pain – may need a combination
  • Give clear instructions
  • Gradually increase dose
  • Give regular dosage +/- PRN
  • Consider potential SE & co-prescribe
  • Follow up to ensure ok
analgesia types of pain
Analgesia – Types of Pain
  • ‘Standard’ = WHO Analgesic ladder = Opioid
  • Bony pain – consider NSAID, RTx, Bisphosphonates
  • Neuropathic – Opioids, Gabapentin, Pregabalin
  • Abdo Spasm – Anticholinergics
  • Muscular – NSAID, Baclofen, BZD’s
analgesia types
Analgesia - Types
  • Non-opioids: Paracetamol, NSAID
  • Weak Opioid : Codeine, Dihydrocodeine, Tramadol
  • Strong Opioids : Morphine (1st line), Diamorphine, Fentanyl, Oxycodone, Hydromorphone, Methadone
  • Others – Ketorolac; Ketamine
analgesia choice
Analgesia – choice
  • Choose on basis of type of pain, route of delivery & previous analgesia used
  • 1st line build up ladder to morphine.
  • Start regular oromorph eg 5-10mg qds + prn.
  • Review amounts used & convert to MST. Can then convert to diamorphine as necessary.
  • Switch to oxycodone/ hydromorphone / fentanyl if morphine SE
  • REMEMBER to co-prescribe + PRN
antiemetic
Antiemetic
  • Likely to be used a co-prescription or to reduce established nausea.
  • Try simple meds 1st line
  • 1st line = Cyclizine, Stemetil, Metoclopramide
  • Consider other choices if co-existing symptoms e.g. Haloperidol, Dexamethasone, Levo
  • Can use combinations.
  • Doses may be higher eg 60-100mg metoclopramide over 24hrs.
  • Avoid Metoclopramide if obstruction
agitation anxiety
Agitation/ Anxiety
  • Consider reversible causes inc pain
  • Consider non-drug treatments
  • Consider underlying depression
  • Medication: Haloperidol, BZD’s
  • Short-acting BZD’s eg lorazepam s/l
  • Sedating BZD’s eg Midazolam s/c
  • Sedatives eg Phenobarbitol
other meds
Other meds
  • Secretions– consider hyoscine patch or s/c
  • Constipation – try & avoid with co-prescribing

- Prescribe regular laxatives

- Remember Co-danthrusate/ docusate

- Seek nurse advice/ involvement

  • Mouth Care – consider saliva sprays/ gel
other meds dexamethasone
Other meds - dexamethasone

Has multiple uses at different doses & compatible in syringe drivers

  • Anorexia - 2-4mg/ d
  • Raised ICP – 16mg/d
  • Gut obstruction – 4-8mg/d
  • Hiccoughs – 4-12mg/d
  • Anti-inflammatory – 4 –16mg/d
medication example
Medication example

If opioid naïve a good starting point for oral route:

  • Oramorph PRN & convert OR 10mg MST bd, then review. PLUS…
  • Cyclizine 50mg tds. PLUS…
  • Movicol1 sachet 2-4x per day – consider volume
  • Review regularly & if problems – seek help
syringe drivers when what how
Syringe Drivers – When, What , How
  • When

- Try & anticipate

- Team decision

- Can always be stopped

- Ensure family aware.

- Communicate well

- STOP all other meds (special considerations – Insulin)

slide26
What

- Diamorphine (5-10mg if naïve) – 15 amps

  • Cyclizine (150mg) &/or Metoclopramide (60mg) – 15 amps
  • WFI x10-20 amps
  • +/- Midazolam – 20-30mg/24hrs initailly – 15 amps
  • Ensure stat doses available & instructions to increase after 24hrs if necessary.
  • Special instructions eg GI haemorrhage.
slide27
How

- Inform/ Involve family in decision

- Inform DN’s or H at H

- Prescribe meds

- Write up instructions – Syringe driver & stat sheet. Be clear.

  • Inform LCD – fax
  • Ensure follow up in place – timing/ who
other considerations
Other considerations
  • Always ensure the person still wishes to remain at home.
  • Keep family informed & advise re action to take in event of death
  • Benefits – DS1500
  • Level 6 care/ Continuing care – poor prognosis
  • LCD/ OOH form/ Gold Line
  • DNR form for transport
conclusion
Conclusion
  • Hopefully confidence increased
  • Information packs include:

- Handout

- Yorkshire cancer network booklet

- Dose comparisons of Strong Opioids

- Syringe driver compatability info

- Local pharmacy info (exemption form)

- Forms – DNR, Level 6, LCD, Syringe driver, PEPSI COLA + DS1500 advice.

  • Marie Curie Talks
ad