what are included in the advance care planning?
advance statement of wishes to inform subsequent best interest judgment
advance decision to refuse treatment
appointment of lasting powers of attorney for ‘health and welfare’, ‘property and affairs’
what are the characteristics for bone pain?
widespread dull ache/localized tenderness
worse on weight bearing/movement
treatement for bone pain
NSAIDs (diclofenac 50mg TDS)
radiotherapy
bisphosphonates (pamidronate)
features of visceral pain
dull, deep-seated
poorly localised
sometimes organ-related tenderness
sometimes spasmodic (bladder/bowel)
treatment of visceral pain
constant - analgesic ladder
stretch pain (liver capsule) - NSAIDs/corticosteriods
colic pain - anticholingeric eg Hyoscine butylbromide in bowel, oxybutynin bladder
features of raised ICP
dull oppressive
worst waking, coughing, sneezing
N+V
treatment of raised ICP?
corticosteriods to reduce oedema (16mg Dex PO OD)
NSAIDs
paracetamol
what are some features of neuropathic pain?
new area of abnormal sensation
dematome/lessdefined/band
altered sensation (numbness, hyperaesthesia)
autonomic change (pallor/sweating)
ins and needles/burning
treatment of neuropathic pains?
- Antidepressants (amitriptyline 10-75mg)
- Anticonvulsants (gabapentin 100-1200mg TDS/pregablin 25-300mg BD)
- Nerve compression- corticosteroids
what is step 1 of the analgesia ladder
Paracetamol: 1g QSD unless <50kg in which case you half the dose
step 2 of the analgesia ladder
- Co-codamol - 8/15/30mg strengths, mostly use strongest unless frail
- Codeine
- Dihydrocodeine
- Tramadol – can give hallucinations, not used in palliative care or if on tricyclic antidepressants
step 3 of the analgesia ladder
- Morphine – 1st line unless kidney failure
- Diamorphine
- Oxycodone ~ x2 morphine – better for kidney function and 2nd line after morphine if unwanted side effects occur from morphine
- Fentanyl ~ x3 morphine, does not affect kidney function
- Buprenorphine – does not affect kidney function
- Methadone – used in palliative care for pain
what are some adjunct to the analgesia ladder?
- NSAIDs – good for liver capsule pain
- Antiepileptic e.g. gabapentin, pregabalin
- Tricyclic antidepressants e.g. amitriptyline
- Antidepressants/social/psychological care
- Corticosteroids e.g. dexamethasone – mainly for oedema & liver capsule pain
- TENS/acupuncture/complementary therapies
what are the features of opioid toxicity
perisent nausea/vom drowsiness confusion myoclonic jerks halluncinations respiratory depression pinpoint pupils reverse with naloxone
what is the starting dose of MST in a pt previously on max co-codamol
MST 20mg + PRN of 3-4mg
what is the amount of PRN dose of morphine should you prescribe
1/6 of the long-release
what is the conversion rate of oromorph to subcut?
1/2
what is the conversion rate of oromorph to subcut diamorphine?
1/3
how much should you inc oromorph by daily?
1/3-1/5
what are the cause of mouth problem in palliative care
dry mouth
reduce oral fluid
radiotherapy
drug side (antiemeitc, antidepressant, opioids)
what are the consequence of mouth problem in palliative care
loss of taste weight loss halitosis dysphagia infection
management of mouthcare in palliative care
oral thursh
- treat with antifungal
- systemic (fluconazole 50mg OD 1 week)
- topical (nystatin 1mg QDS 1 week)
what are some causes of anorexia in palliative care
thrush nasuea constipation depression pain
management of anorexia in palliative care?
encourage but don’t force
dex 4mg OD but last 2-3 weeks
megestrol acetate (progesterone) 160mg OD lasts longer but fluid retention
