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Palliative Care - Coggle Diagram
Palliative Care
Managing Condition
Goals of therapy:
- Reduce tumour growth
- Reduce inflammation and pressure
- Other contributing discomforts
- Symptom management
Treatments:
- Surgery
- Chemo
- Radiation therapy
Malignancy
Chemotherapy: Disease control to maintain quality of life (not cure)
- Convential chemo: Cytotoxic agents
- Hormonal therapy: anti-androgens (Bicalutamide), aromatase inhibitors (Anastrazole), GRH inhibitors (Goserelin) and SERMs (Tamoxifen)
- blocks hormones binding but response rate is slow thus used with chemo or surgery.
- Biologics: MAb treatment
- Trastuzumab for malignant cells
- Bevacizumab for angiogenesis
- Rituximab for host defence mechanism
- Tyrosine kinase inhibitor: Imatinib
Aim to provide symptom relief and maintain good QoL, balancing the risks and potential ADRs
Corticosteroids: Reduce inflammation and compression
- Dexamethasone: high potency and can prevent bowel obstruction due to tumour, symptoms, pain and compression on spinal cord
Skeletal Related Events
Bone Metastasis: patient will have
- Bone pains
- Weakened bones
- Hypercalcaemia (due to changes in bone metabolism)
- QoL related issues
- Decrease in indepedent function
- Anixety and depression (knowing that cancer had spread)
- Physical pain
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Paraneoplastic Syndromes
Indirect effects of malignancy - Common effects are:
- Hypercalcemia
- Venous thromboembolism
Hypercalcaemia: MOA depends on cancer type, but mainly due to PTH releasing peptides causing an increase in calcium resorption from bone
- Clinical features:
- Malaise and lethargy/flat
- Nausea and vomiting
- Drowiness and confusion
- Dehydration
- Treatment:
- IV fluids to correct dehydration
- Bisphosphonates
- Denosumab
- Frusemide (flush out calcium)
Venous thromboembolism: Decision to start treatment depends on patient and family wishes and risk of bleeding/clotting
- Prophylaxis: Most hospitalised patients but not recommended for community patients unless:
- At high risk (DOACs apix or rivaro) or LMWH
- Has multiple myeloma (Aspirin or LMWH)
- Undergoing surgery (Heparin or LMWH)
- Treatment:
- LMWH Heparin or Rivaroxaban for 5 -10 days, consider risk and continue up to 6 months for secondary prophylaxis.
- More than 6 months recommended for active cancer patients if they wish
Cardinal Manifestations
Factors that influence symptoms and clinical problem
- Common physical symptoms
- Common psychological symptoms
- Emotional distress
- Anxiety
- Depression
Symptoms are multidimensional - other factors can contribute to worsening or help symptoms (tired = less pain tolerance)
- Medicines can help but psychological and social interventions can be helpful.
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Pain
Peripheral sensitisation: changing sodium, calcium and potassium channels changes pain sensitivity.
- Inflammatory mediators can also cause hyperangesia
Neuropathic pain: burning, shooting, electric pain
- Caused by nerve damage, chemotherapy and viral infection
Management: Patients expectations - pain can be reduced but not eliminated
- non-pharmacological measures (mediation, yoga etc)
Treatments:
- Non-opioids - simple analgesics (panadol, NSAIDs and Aspirin)
- Opioids - Morphine and oxycodone, methadone and tramadol
- Gabapentin and Pregabalin - for nerve pain
- Sodium valporate and carbamazepine - for nerve both ascending and descending pathways
- Antidepressants - descending nerve pain
- Lignocaine and ketamine - nerve and central sensitisation
Breakthrough pain: unpredictable and occurs due to adequate background analgesia or fluctuation of pain
Incident pain: predictable cause by activity and may require PRN doses in the higher end
Fatigue
Experienced in 60-90% of patients
- Does not resolve with sleep
- Easily tired and reduced capacity to perform
Managament:
- Reduce intensity of activities
- Help patients adjust to lowered capacity and maximise function
Treatment:
- Corticosteroids may provide a boost of energy if required, but effect diminishes with repeated use.
- Stimulants have mixed effect.
Dyspnoea
SOB, feels like lungs crushing and cannot breathe a full breath
- Severity is subjective and varies in intensity
- Very common symptom in advanced disease
Treatment:
- Medical gas
- Low dose morphine 10-20mg: reduce sensation of breathlessness
- Fans
Nausea and Vomoting
Up to 70% of cancer patients
- Nausea can be persistant and associated with anxiety
- Highly distressing and reduces oral intake and nutrition
Treatment:
- Metoclopramide for GI nausea
- Haperidol for CNS nausea
Pathophysiology
Abnormal cell division:
- Hyperplasia: increased proliferation to normal control mechanisms
- Neoplasia: abnormal control differentiation, maturation and growth
- Neoplasm: formation of abnormal cells due to neoplasia
Malignancies:
- Carcinoma: epithelial tissues
- Sarcoma: non-epitheial tissues
- Leukaemia: liquid tumours
Cell cycle:
- Checkpoints prevent problems and trigger apoptosis
- Attempts to repair if problem is found
- Apoptosis is triggered if repair is not possible
- Tightly regulated programmed cell death
Genetic mutations: that cause uncontrolled growth
- Evading apoptosis
- self-sufficient growth signals
- Insensitive to anti-growth signals
- Metastasis
- Unlimited replication
- Angiogensis
ALL based on oncogenes and tumour supressor genes mutations
- Oncogenes: promote abnormal cell growth - only one allele mutation is required
- TSG: supress cell growth - both alleles must have mutated
Tumor Growth:
- EGF, PDGF and VEGF interact with receptors to promote or inhibit cell growth/proliferation
Angiogensis:
- Driven by VEGF to form new capillaries for blood flow
- Blood flow uneven and structurally weak vessels
Metastasis: spreading of cancer cells via lymphatics or blood vessels
- 85% of mortality due to metastasis
End Phase Symptoms
Days before death
- Anticipatory prescribing: prescribing medicines according to predicted conditions to treat early
- Subcut adminstration: maximum 2mL bolus
- used if lack of consciousness
- peripheral shutdown
- Subcut pumps can be used to provide continous treatment and 3-4 drugs can be adminstered together.
Restlessness and agitation: can be due to drugs or withdrawal of drugs
Treatment: treat symptomatically
- Try BZD (clonazepam 0.2-0.5mg or midazolam 10-20mg subcut in 24 hours)
- Try Antipsychotics (haloperidol 0.5-1mg subcut in 24 hours)
Delirium: Presents as quiet and often missed
Treatment: risperidone or haloperidol daily
- Midazolam subcut for breakthrough delirium
Death rattle: caused by build up of saliva and respiratory secretions
- Distressing to family and others (sounds like they dying at the moment)
- Treatment: positioning is main stay and first line
- Hyoscine and Glycopyrrolate to block formation of new secretions but doesn't clear existing secretions thus more secretions present, less effective it becomes
- stop drugs if no improvement in 12-24 hours
Classification
- Dying doesn't mean not living - we need to help them live the best life they have left
- Improving QoL and resolving/supporting friends and family facing problems
- Treating pain and other problems (physical, psychological and spirtual
- Provides greater choice and control for the patient and family
- 70% of people want to die at home, thus we need to reduce hospitalisation and keep the patient at home/in social activities
- Palliative care doesn't mean withdrawal of all active treatment.
- Consider medicines that only benefit for long term and treat the conditions that can cause immediate symptoms.
- Highly depends on the patient goals of treatment and decisions
Futility of Treatment
Medicine purpose in palliative care must be clearly defined
- Definition of purpose may differ between health professionals and patient.
- Purpose must include:
- Goal present
- Action and acitivty to achieve the goal
- Certain that action will fail to achieve goal and acceptance
Medical treatment is under no duty to use or continue use to prolong life in a morbid/vegetative state.
Treatment Goals
- Enhance QoL
- Relief pain and other symptoms
- Neither hasten or postpone death
- Can use treatments to prolong life if patient desires
- Provide finanical relief with lower costs
Malignant Disease
- Prostate most common diagnosis in males
- Breast cancer most common diagnosis in females
- But lung cancer is most common cause of death for both genders mainly due to difficulty is managing and treating
ATSI more suspectible to cancer risk: 1.1 - 1.3 times more likely for diagnosis and death respectively
- But types of cancer varies between states: Qld has more sun thus skin cancer more prevelant.
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Deprescribing
- Reduce pill burden
- Reduce DDIs
- Reduced ADRs
- Reduced cost
- Improve function, QoL and adherence