Transcript Palliative Care - Swindon GP Education

PALLIATIVE CARE
By Hannah Wright
GPST1 Teaching 17th April 2013
OVERVIEW
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General overview of end of life care
Cases around prescribing at end of life (and some
for symptom control out of interest)
Handouts on dosing opioid drugs and antiemetics
GENERAL PRINCIPLES
Need to take a good history and examination
 Importance of continual reassessment
 Take into account other features (not just physical)
as can affect symptoms and response to treatment:
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Spiritual
 Emotional
 Psychological
 Social
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Make sure side effects are not worse than the
symptoms themselves
 Ensure good communication with patients and their
relatives.
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END OF LIFE
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Important to recognise
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Main symptoms noted at end of life:
Pain
 Agitation/terminal restlessness
 Nausea/vomiting
 Respiratory secretions (“death rattle”)
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Dont forget:
Stop all unneccessary meds
 DNACPR and have that discussion with relatives
 Spiritual needs for patients or relatives
 Warn families if will need referral to coroner
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PRESCRIBING AT EOL
PRN prescriptions
Drug
Morphine
sulphate
Symptom
Route
Pain
s/c
Dose
2.5-5mg
Frequency
prn
Syringe driver prescriptions
Dr H.Wright has prescribed a syringe
driver containing the following medications:
1) Diamorphine 10mg
2) Midazolam 10mg
Signature
H.Wright
CASE 1
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79 year old man with metastatic prostate cancer (bony
mets). Admitted for terminal care. Unable to swallow
medications.
Relevant DH:
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Zomorph 90mg bd
Not needing oramorph as pain well controlled
You decide to set up a syringe driver containing morphine.
What dose do you prescribe? What PRN dose would you
give?
In the community, diamorphine is used. What dose would
you put in the driver? What PRN dose?
PAIN
Causes
 Physical:
Nociceptive
 Neuropathic
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Non-physical
Assessment
 History
 Examination
 What is causing the pain?
 Contributing factors
Management
 Medications in use
and/or tried before
 WHO analgesic ladder
 Neuropathic agents
OPIOIDS
Doses
 Start with IR then switch to MR depending on requirements
 PRN dose is 1/6 total daily dose
 PRN oral doses take around 30 mins to have an effect
Side effects
 Constipation
 Nausea
 Drowsiness
 Hallucinations
 Respiratory depression
 Toxicity
Preparations
 IR tablets/liquids
 MR preparations
 Injectable
 Patches (Butrans)
OTHER OPIOIDS
Hydromorphone
Diamorphine
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Used in the community
3 times more potent than
morphine
More soluble than morphine
Oxycodone
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Different side
effect profile
Better in renal
impairment
Twice as potent
as morphine
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May be safer in renal
impairment
15x more potent than
oramorph
Fentanyl
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Many preparations – buccal, s/l, s/c, patch
Used in severe renal failure
Alfentanil
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Better than high dose fentanyl due
to volume
30x more potent than oramorph,
10x diamorphine
CASE 2
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88 year old lady with end-stage COPD and osteoarthritis
admitted for terminal care. Semi-conscious, taking sips of
fluid only.
Relevant DH:
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Butrans 20microgram patch weekly
Oramorph 5mg prn (uses it very infrequently)
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On examination, appears comfortable and not in pain.
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What would you do? What would you prescribe?
****LEAVE THE PATCH ON****
CASE 3
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35 year old lady with metastatic breast cancer,
including brain mets.
Approaching end of life and seems agitated at
times, particularly on movement.
What would you consider using to manage her
agitation/restlessness?
She had previously mentioned that she wants to be
more sleepy at the end of life. Would any agent in
particular stand out?
RESTLESSNESS
Causes
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Physical discomfort
Drugs
Infection
Brain involvement
Biochemical abnormalities
Psychological distress
Medications
 Diazepam
 Haloperidol
 Midazolam
 Levomepromazine
 Clonazepam
 Phenobarbital
General management
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Discuss with patient and discuss any psychological distress
Involve and support family
Relieve physical discomfort
Drugs
CASE 4
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81 year old lady with very locally advanced gastric
carcinoma and constant nausea and vomiting.
Relevant DH:
Allergic to cyclizine
 Tried ondansetron and did not like it
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What would you try next and via what route? What
would be important to know about this lady?
She is unable to keep any oral medications down.
What would you suggest now?
CASE 5
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44 year old lady with metastatic breast cancer. In
hospice for symptom control and rehab. Having
active chemotherapy and finding vomiting very
debilitating. However, wants minimal tablet burden.
Relevant DH:
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On 150mg tds cyclizine but still vomiting
What could you suggest?
Her vomiting is controlled by levomepromazine
6.25mg ON.
NAUSEA AND VOMITING
Causes
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Mechanical (e.g. obstruction)
Irritants (e.g. Chemo)
Metabolic (inc drugs)
Raised ICP
Anxiety
Vestibular disorders
General management
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Treat cause
Non-pharmacological methods
– ginger, acupuncture
Medications
Medications
 Cyclizine
 Metoclopramide
 Domperidone
 Dexamethasone
 Ondansetron
 Hyoscine hydrobromide
 Prochlorperazine
 Haloperidol
 Levomepromazine
SECRETIONS
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The “death rattle”
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Usual drugs:
Hyoscine hydrobromide (also useful in colic and bowel
obstruction)
 Glycopyrronium
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Generally more distressing for relatives than for the
patient.
CASE 6
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66 year old man with locally invasive rectal carcinoma –
eroding buttock. Recognised as being end of life. Agitated,
starting to struggle with oral medications.
Current medication:
Oxycodone MR 120mg bd
 Midazolam sublingual PRN 2.5mg (using around 3 doses/day)
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What would you do?
CASE 6 CONTINUED
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Say he had a CSCI containing oxycodone and midazolam
10mg but still needed multiple breakthrough doses of
midazolam, what would you consider doing?
The next day you review him. He has required 12.5mg
levomepromazine on top of that in the syringe driver and 2
breakthrough doses of 25mg oxycodone s/c.
What, if anything, would you do next?
 But
don’t worry ... As GPST3s we will all
get a week at the hospice.
 And
if you work in Swindon, the team are
more than happy to offer advice over the
phone. There is a Consultant on call 24/7
and they are great resources.
CASE FOR INTEREST
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27 year old lady with metastatic cervical cancer –
widespread bony metastases and severe pain as a
consequence
Increasing doses of fentanyl and oramorph
breakthrough – at its peak she had 200mcg
patches and 120mg oramorph breakthrough, using
around 10/day.
WHAT NEXT??
KETAMINE
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For severe pain poorly responsive to opioids (but not licensed)
Should only be used by specialists and ideally need hospice
admission to establish regular dose.
Can restore opioid sensitivity so need to be careful they don’t
become toxic from other opioids they are taking.
Can cause a dysphoria.
She was discharged home still with 200mcg fentanyl patches
and 20mg QDS ketamine. For the first time in months, she was
relatively pain free.
USEFUL WEBSITES
www.palliativedrugs.com
 www.pallcare.info
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