Download Palliative care: Analgesia Nausea and Vomiting

Palliative care:
Analgesia
Nausea and Vomiting
Breaking bad news
Dr Edward Davis
11.04.2012
Objectives
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Analgesia
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Nausea and vomiting
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Types of analgesia
Indications
Routes
Conversions
Syringe drivers
Causes
Treatment
Breaking bad news
Brainstorm Types of analgesia in
palliative care
Morphine
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Sevredol
Oramorph
Zomorph
MST
Diamorphine
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Traditionally used in community setting
Oxycodone
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Oxynorm (short acting)
Oxycontin (long acting)
Patches
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Buprenorphine
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BuTrans (lower doses, 7 days)
Transtec (higher doses, 96 hours)
Fentanyl patch
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72 hour
Abstral
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Lozenge
Breakthrough for cancer pain
Moving patients
Dysphagia
Need to be
Alfentanil
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Used if volume of Diamorphine too great for
Syringe driver
Conversions
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Useful table in Palliative care handbook
Scenarios
Scenario 1
Mr Jones is a 45 year old man with
metastatic lung cancer. He is taking 80mg of
Oramorph daily for pain relief. You feel it is
appropriate to commence him on a long
acting oral morphine preparation. What
preparation would you commence, at which
dose, and how much would you recommend
he takes for breakthrough pain?
Scenario 2
Mr Jones mediastinal disease worsens and
causes him dysphagia. He is now taking
50mg BD of MST and has required 20mg of
breakthrough Oramorph in the last 24hours.
He is not keen on taking so many tablets.
What analgesic preparations would you
consider commencing? What dose would
you commence and what would his
breakthrough dose be.
Scenario 3
Mr Jones is now bed bound and his analgesic
requirements continue to increase. He is struggling
to take oral medications and you feel that he is
approaching the end of life. You decide a syringe
driver should be commenced. He now has a
150mcg/hr fentanyl patch and had required 320mg
of oral morphine for breakthrough. What preparation
would you use in the driver and at which dose? What
would the breakthrough dose be?
Nausea and vomiting
Common causes
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Drugs
Biochemical
Infection
Cancer tx
Vestibular
Constipation
Intestinal obstruction
Raised ICP
Anxiety
Features
Cause
Large vol, infrequent, relief after
Gastric stasis
Similar to above but forceful vomiting
Gastric outflow obstruction
Low volume vomiting , fullness
Squashed stomach syndrome
Food sticking, vomit after drinking/eating
Oesophageal obstruction
Nausea, faecal vomit, abdo pain, colic
Bowel obstruction
Nausea or sudden vomiting on movement
Vestibular
Nausea in waves, predisposed by previous
experience, relieved with distraction
Anxiety
Constant nausea, variable vomiting
Chemical induced
Treatment
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Treat reversible cause
Antiemetic
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Regular and max dose
s/c or po
Target cause
Review and revise
Treatment 2
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Non pharmacological
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Calm environment
Avoid food smells
Cool fizzy drinks
Ginger/ peppermint
Carbohydrate food
Acupuncture
Metoclopramide
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Prokinetic and central
Use
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Gastric stasis
Opioids
10mg TDS, 30-120mg/24hr
Cyclizine
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Anticholinergic
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Use
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Vestibular and vomiting centre
Vestibular
Raised ICP
Bowel obstruction
50mg TDS PO, 150mg/24hr
Beware in syringe driver
Haloperidol
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Central
Use
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Biochemical
Drugs
1.5-5mg nocte
Ondansetron
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Central
Use
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Chemo/ RT
Post op nausea
8mg
Levomepromazine
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Multiple receptor sites
Use
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EOL
Uncertain cause
Second line
6mg-12mg nocte
Breaking bad news
SPIKES
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Robert Buckman
Useful structure to bear in mind
S: Setting up
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Know all the facts
Set a time
Bleep free
Privacy
P: Perception
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Check patient understanding
“It would help me to know what you
understand about your illness?”
I: Invitation
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Respect patients who do not want to know all
information
“Are you the type of person who likes
detailed information, or would you like a
general overview?”
K: Knowledge
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Warning shot
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“I am sorry to tell you”.
Level of vocabulary and knowledge of patient
Non technical
Chunking and checking
Avoid “there is nothing more we can do”
Encourage questions
E: Emotions
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Empathy
Observe for emotion
“How are you feeling?”
Identify the reason for the emotion
Acknowledge and understand patient’s
emotions
Silence is golden
Allow for pauses
S: Strategy and summary
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Summary and plan
Patient’s concerns
Support available
Summary
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Analgesia
Antiemetics
Breaking bad news
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SPIKES
Thanks for listening