S1: Emergencies in Palliative Medicine

Emergencies in palliative care include cardiac arrest,seizures ,sepsis etc. Emergencies are
situations which, if left untreated, will immediately threaten life.

Slide 2 ppt

In palliative care they can be caused by :

● Cancer
● Treatment
● Coexisting disease

General Principles :
● Anticipate - who is at risk?
● plan - communication, preparation
● Avoid - correct the correctable, prophylaxis

Sometimes we need to decide whether a patient needs to be sent to a medical hospital.

But if they have diffuse cancer leave them to die at home.

So we should always ask patients what their wishes are and what should happen.

During meetings with pts, we ask what their wishes are and do what they want to do during or
after their death.

how to make decision in PC :

we use score :
ECOG score used also in onco dept - pts also in onco txt.
During oncology patient level is usUalLy 0 ,1 or 2
bad condition - score 3 and 4 - should not be given any chemo.

Score is important because it should be noted down during or visit. If the stage of pt increase or
change in short time we have to find out why and we should look for reasons.

If we had patient in palliative care stage 4 or 5, we expect them to die in a short period of time.
We can consider his reason - and talk about death and what place and time he prefer.

PC EM :

● hypercalcemia
● SVCO
● spinal cord compression
 ● hemorrhage or bleeding
● seizures or fitting

SVCO: Superior Vena Cava Obstruction

Svc is located in chest right side.

Especially obs with lung cancer and other cancers. Which can be caused by metastasis closing
svc which closes the blood to the heart.
Huge tumor on the chest which closes VC on the chest.

We can observes vessels on chest and edema of the neck and head.
(pic shows before chemo and after chemo of the lung cancer)

How to check for edema ?

Compare old pics (ID)
Check for pitting

we have :
- external compression
- intraluminal thrombosis
- direct invasion of vessel wall

clinical ppt :
- breathlessness
- stridor
- cough
- headaches
- edema of the head, neck, trunk and arms
- venous distension
- dysphagia
- head discomfort
- coma/death

Diagnosis:
Ct scan and other intervention to confirm diagnosis like Bronchoscopy ,biopsy to identify cancer
- most useful - CT with contrast or MRI
- also imp to obtain tissue diagnosis in pts with sus malignancies for guiding future txt
- pts with pleural effusion = thoracentesis with cytological analyses
- bronchoscopy, transthoracic needle aspiration biopsy, mediastinoscopy

Medication for patient with cancer in palliative Care

What medications makes tumours smaller in the chest? –Steroids
To make tumor smaller to reduce the SVCO it causes.

We use dexamethasone (each dose Per 8mg ) and taper dose before giving chemo or radio.

Breathlessness give morphine and then maybe add benzodiazepines if anxious.

We start them small dose and increase dose as per need arises.

Prognosis of SVCO symptoms

Prognosis is very poor when we observe SVCO

Management
Corticosteroid
Radio
Chemo
Morphine and benzo if needed
Also heparin ,when the vessel is closed it wont get to heart the proper way.

Why small dose of morphine?

- check if other comorbidities then dose need to be reduced more.

Doses:
Small dose of morphine - 2.5mg every 4hrs po vs 1mg sc or iv.
Heparin - LMWH - 1mg/kg twice a day sc.
20% mannitol iv.

Hypercalcemia
- huge level of Cal in blood
- there is no special symp which can give us info that it's hypercal
- dec qof
- consider non-malignant causes such as hyperparathyroidism
- main reason - with bone metastases
- high risk in cancers with bone metastases - that's why hypercal can happen
- symptoms are nonspecific
- if pts have cancer, pts can have anorexia, nausea, vomiting - typical symp of cancer
diseases. but we have to be aware that hyper cal can happen and we need to check the
Cal levels in accordance.
- cases :
- metastases to the bone
- more metastases which works more effectively

in the X Ray :
- less bone density
- right arm - there is no other pices of the bone, bone has disappeared.
lady visited dr becoz she had arm pain for 6 mths. meds given but didn't work. she had
abnormal possibility to move elbow? arm is narrower at the end. there is edema and had a
tumor hyge which destroyed 12 cm of the bone. not typical case. she had lung cancer and had
metastases

diagnosis :
high Cal - check renal fn - high cal can destroy renal fn. also check albumin and check with
formula. esp with caner ts - becoz albumin levels are very less in cancer pts.

hypercalcemia severity :
symp are not typical and txt is very easy
● 1 L NaCl every 6-8 hours
● after infusion - furosemide or other diuretic to promote excretion
● mineralocorticoid - hydrocortisone. also given dexamethasone
● and check every day Cal level.
● Calcitonin -
● bisphosphonate - also given hypercal txt
○ given today, will only start working in 2-3 days. so other drugs given first
○ also used as a phosphonate
● PC pt at home - Zoledronic acid - given beoc infusion takes only 15 min
● in hospitals - pamidronate - 2 hrs to infuse
AE :
- osteonecrosis of the jaw - had to treat becoz very high pain and very uncomfortable for
the pt.
management :
- prognosis is poor and can make it worse. we have to be prepared. check renal fn and
Cal level each 3 weeks and modify txt
- survival <3 months with txt

at risk :
- cancer pts
- breast lung, lymphoma

BLEEDING :

what to do with the bleeding wound in the 1st pic :

there is a fistula that leads to the mouth.
orally or IV meds to stop the bleeding.
tranexamic acid and _ put on the wound, to stop the wound. how to stabilize the wound :
gastroscopy package? tube through nose will be unconfortable
2nd pic:
near the jaw. cancer which destroyed the subcut tisse.
breast cacner amd huge change and there is bleeding wound, cancer cells destoyed the area
Ofc hyPercalcEmia deC qol
We consIder this in Patient with bone cancer or metaStasis to bone
It doesn’t happen often
If happen it dec qol and prognosis

Its symptoms are nonspecific

(Slide 13)
Its basically the typical symptoms of cancer

What Can cause it ?

Bone metastasis
Osteoclasts which work effeCtively

Xray of hypercalcemic patient shows :

Less bone density
Bone mass just disappear(it completely destroyed the mass of bone )
This caused the calcium levels to increase In our blood
We checked for corrected blood calcium, and check for renal function as high level ca cause
renal damage
We also checK albumIn (level of albumin is always lower in hypercalcemic patient )
(Slide 16)

Management
Hydration with IV saline from the First moment upto first 3 days or longer
Furosemide to promote ca excretion after rehydration
2nd line - mineralocortIcoid like hydrocortisone
If that's not there use dexamethasoNe.
Calcitonin should be used only for short time because the effects reduce with more usage.
(Slide20)

Bisphosphonate - first line medical therapy.

When we are aware hypercalcemia can happen we can give bisphosphonates

Why do We give saline and furoSemide and hydro before bisphosphonates ?

Cause they take time to act about 2 d

(Slide 18)

Zolidronic is better for at home nurse because it’s infusion time is 15 mins compared to
pamidronate which is infused for 2hrs.
In hospice or hospital we prefer pamidronate as infusion takeS 2 hr
Prognosis for patient with hypercalcemia is really poor. Survival is less than 3 months.
(Slide 22)

Who is at risk?
Patient with cancer that spread to bone : breast ,lung and lymphoma cancers

Bleeding
Likely sources:
● Surface bleeding
● Erosion of an artery
● Haematuria
● Vaginal
● Rectal
● Epistaxis
● Haemoptysis
● Haematmesis /melanea

With an ulcerative bleeding wound with foul smell what would we do?
-Use medications that can stop bleeding orally or iv
Cyclonamine or Travenoic acid ?
How do we stabilize this bleed ??

Tube through the nose is not comfortable for pt so gastroscope is a better solution for them to
eat.

Bleeding wound on top of the patient head with history of Dementia

Bleeding:
Who is at risk ?
20% of cancer pts have bleeding.
Metastasis inc risk of bleeding and thrombosis
In 5 percent patient bleeding can be a cause of death especially in patient with lung cancer

Risk
Thrombocytopenia

Impaired function

7-10 days after chemo - thrombocytopenia can happen and can inc risk of bleeding.

Management :
● Treat the cause if possible
txt orally or locally
● Treat the site
 ● Stop med making the prob worse

Treat orally :
- TXA
- Etamsylate or Cyclonamine
- Desmopressin

Treat topically :
Pressure (not possible with head wounds )
Adrenaline - can close the vessels and can stop the bleeding.
Tranexamic acid
Silver nitrate - to treat any wounds because it’s antiseptic and helps in txt.

Systemic therapy:
Tranxemic acid (o)
Etamsylate or Cyclonamine
Desmopressin

Local therapy:
Radiotherapy(esp in bleed due to cancer)(1st line )
Chemotherapy
Laser
Embolization
Surgery

Severe hemorrhage as a terminal event

- Prepare /advance Care planning :

Practical-reduce risk ,
Reduce impact
green towel becoz blood in white looks worse. so we prefer darker towels.
white with blood - stressful for pts
Support patient

why morphine - when there is pt in pain. not when they are scared, when scared use
benzodiazepine.
Sedate
5mg midazolam (buccal or sc)

Spinal cord compression

Not often
In 5 percent
Esp in pt with bone metastasis cancer or spinal area
Also in case of pain due to other condition involving huge tumor near spinal area closing the
canal
Thoracic region is also mainly involved with scc
There is no position which can decrease the paIn
The level of position is still same each day the pain add on to this situation and makes it further
diff to patient make him even to stop walking

main localization - thoracic

1st symptom is pain
there is no position which can help the pt to dec the pain. level of pain is still the same. but
diagnose the ot asap and each day can make it severe. in 2-3 days, pts can stop walking.
Causes :(Slide 35)
- vertebral metastases and collapse 85%
-EXtracerebral tumor

Slide 36
- pain is the earliest
- weakness
- dec sensation over butt, thighs, perineal region
- use CT (gold standard) over vertebral - MRI more things seen in CT.

Slide 37

Diagnosis : Slide 38
In cAsE of patient with tumor of chest we dO ct scan for scc
BUt If its spinal cord Tumor we do mri for scc

Slide 39

txt :
which is best :
surgery, chemo or radio ?
not easy to mak decision.
if surgery is possible, do it. but sometimes not possible. best decision made with the team of
specialists together. if surgery not possible then radio. chemo is the worst coz the meds used
during then is difficult to go the bone and sometimes when tumor is very big, radio and surgery.
small tumors on surgery.
We should decide about surgery if Surgery is pOssible
ThE decision depends on thE team
ChemO is The worse solution as thE medication useD in chemo is more difficulT to penetrate
Into bone
So surgery and radio is 1st Line
Management
Symptomatic treatment

Corticosteroid :8mg /hr

Taper dose

Pain management :depends On the situation

Then decide whether surgery or Radiotherapy

If left untreated it dec QOL

surgery :
Post surgery rehab is imp
Rehab :
better control of the pain done by physiotherapists.

management of SCC :

SEIZURES / FITTING :
Especially in patient with tumor ass with brain
urinary
It includes nausea vomiting Headache ,fitting ,loss of consciousness ,urinary convulsion

What inc Risk

- Epilepsy
- stroke
- brain tumor
- biochemical(hyponatremia - can cause fitting )And drugs

How some meds Cause diff side effects ?

Management :
when pts with tumor which can cause fiting - use benzodiazepine(sc,iv,pr)
and educate family how to use it
CT - huge tumor
ventricle in the brain on the right side is closed by tumor and edema
2nd - no ventricle on the right closed by edema
3rd pic - a lots of metastasis

GenerAl principles-
Be aware and educated family members

S2: Opioid Rotation

Opioid rotation refers to a switch from one opioid to another in an effort to improve the
response to analgesic therapy or to reduce adverse effects. It is a common method to address
the problem of poor opioid responsiveness despite optimal dose titration.

Opioid rotation, sometimes referred to as opioid switching, has become common practice in
oncology, postsurgical care and palliative care.

Opioid rotation is defined as switching from one opioid drug to another or changing an opioids
administrative route.

Changing of opioid:
● 1 to another - full rotation
● part to another part - semi rotation

80% of palliative patients stay at home.

Side effects of opioids:

● Nausea and vomiting is seen as a common side effect in around 80%/50%?
● Constipation - 80%.
● Respiratory depression is a rare side effect of opioids in palliative patients.
● With opioids and cannabinoids, we usually start low and go slow.
● Sedation is expected in around 50% especially when we change the dose to higher
especially in control release formulation and TDS*.
● Other side effects
- Acute urinary retention
- Myoclonus
- Cognitive impairment: not common.

*TDS - Transdermal patches

Why do we change?
● Patient becomes tolerant to a given opioid
● Develops hyperalgesia (increased sensitivity to pain and extreme response to pain)
● When we do not have good control of pain
● Due to side effects
● Due to patient’s clinical state such as:
- Kidney failure: it is recommended that morphine and codeine are avoided in renal
failure/dialysis patients; hydromorphone or oxycodone are used with caution and
 close monitoring; and that methadone and fentanyl/sufentanil appear to be safe
to use. Tramadol is not recommended.
Paracetamol , Fentanyl ,buprenorphine, methadone are safe for renal failure
patients (mentioned in his ppt)
Morphine , Codeine, meperidine and propoxyphene are contraindicated in
patients with advanced kidney disease.
Fentanyl , methadone ,hydromorphone ,acetaminophen and gabapentin can be
used for pain management in patient with renal failure
Tramadol is not recommended for older patient with ckd as their metabolites are
renally cleared
But tramadol , hydrocodone , oxycodone can only be used with caution ?

- Liver failure: Paracetamol is safe in patients with chronic liver disease but a
reduced dose of 2-3 g/d is recommended for long-term use.
So paracetamol is safe for patient with CLD , or Cirrhosis provided they don't
consume alcohol and it is taken at a lower dose than normal
Avoid NSAIDS in case of cirhossis
Avoid Tramadol ,morphine,codeine
Online some sites say fentanyl is ok for liver cirrhosis ??? yeah i read it too

- Fever: opioid patch is contraindicated in feverish pts.

- Other disorders that may impair pharmacokinetics or metabolism of opioid drugs.

● If oral administration is no longer feasible such as in terminally ill patients undergoing

head and neck surgery, those with gastronomies or nasogastric tubes or those with
incompatible GI symptoms like irrepressible vomiting and obstruction; during chemo
radio palliative care we cannot administer drugs orally.

Safe amount of paracetamol a day is 4g/day or 4000mg/day.

For 65 + patients - 3g
For children we can give 10-15mg//kg dose of paracetamol with ??
Max dose of paracetamol at a gfr of 30 ml /min is 3g
Q. Opioids to choice when we have renal failure?

patches

When we place under skin deposit of drug during fever we have higher dose of our drug
The rate of absorption of the medication can also be influenced by the degree of blood flow
through the skin where the patch is applied. Increased body temperature resulting from a fever,
a heating blanket, exposure to a hot, humid environment, or vasodilating anesthetics increases
peripheral blood flow to the skin attached to the patch, which subsequently increases the rate of
systemic drug absorption.
hyperalgesia - observed when we use a higher dose of opioids. But this side effect is very rare.
We need rotation to continue our route of administration.

Queen of opioids: Morphine

Second comes Fentanyl.

Selectivity of opioid activity

Methadone: specific drug used in opioid use disorder and chronic pain management .Opioid
use disorder further leads to opioid intoxication.
Due to its activity at the NMDA receptor, it may be more effective against neuropathic pain; for
the same reason, tolerance to the analgesic effects may be less than that of other opioids.
It is a synthetic opioid agonist.
Detoxification using methadone can be accomplished in less than a month, or it may be done
gradually over as long as six months.
While a single dose has a rapid effect, maximum effect can take up to five days of use.
The pain-relieving effects last about six hours after a single dose.
After long-term use, in people with normal liver function, effects last 8 to 36 hours
These frequently include dizziness, sleepiness, vomiting, and sweating , Serious risks include
opioid abuse and respiratory depression. Abnormal heart rhythms may also occur due to a
prolonged QT interval.

Onset of effects occurs 30 minutes after swallowing and peak effects are felt approximately
three hours after swallowing. At first, the half-life (the length of time for which effects are felt) of
methadone is approximately 15 hours; however, with repeated dosing, the half-life extends to
approximately 24 hours.
Methadone is in liquid form, i.e in 1 ml there is 1mg of substance. 0.1% - 1:1
When used for opioid maintenance therapy, Methadone is generally administered as an oral liquid.

Addiction to opioids have 4 mechanisms of action:

1. agonist of opioid
2. ketamine antagonist - Magnesium - NMDA huh?
3. SSRI and SNRI agonist

It also has potential serotonergic effects with serotonin and noradrenaline reuptake inhibition
and high affinity for serotonin receptors (5-HT2A and 5-HT2C). Methadone has been associated
with serotonin toxicity when given with other serotonergic medicines but the risk appears low.
Methadone also has highly variable hepatic clearance via CYP3A4, CYP2B6 and CYP2D6.
Most SSRIs and SNRIs inhibit one or more of these enzymes and might then precipitate
methadone toxicity. Methadone and (es)citalopram both cause QT prolongation, thus providing
yet another potential interaction.

Interaction of other opioids with antidepressants

Oxycodone: can be used in monotherapy in neuropathic pain especially in polyneuropathy post

chemo (treated with thalidomide and…….) of multiple myeloma
It is is a highly selective full agonist of the μ-opioid receptor
It is available in immediate-release and controlled-release formulations. Onset of pain relief
typically begins within fifteen minutes and lasts for up to six hours with the immediate-release
formulation
Tapentadol: similar to tramadol but similar to epi or norepinephrine
It is a centrally acting opioid analgesic whose mechanism of action involves being an agonist of the
μ-opioid receptor and as a norepinephrine reuptake inhibitor (NRI). Analgesia occurs within 32
minutes of oral administration, and lasts for 4–6 hours.
Unlike tramadol, it has only weak effects on the reuptake of serotonin and is a significantly more
potent opioid with no known active metabolites.

Buprenorphine: stronger (than morphine by 100 times) but we need a larger dose to give the
same effect as morphine and fentanyl.
Buprenorphine is an opioid used to treat opioid use disorder, acute pain, and chronic pain
It is nonselective, mixed agonist–antagonist opioid receptor modulator,acting as an unusually high
affinity weak partial agonist of the MOR, a high affinity antagonist of the KOR and DOR, and a
relatively low affinity, very weak partial agonist of the ORL-1/NOP

Q. Is it good to use oxycodone and buprenorphine in the same treatment for visceral
pain?
A. Yes, both can be used. Because we still have 40% receptibility in this area for our drug.

Naltrexone is stronger than naloxone.

Naloxone can be used sometimes as IV or orally.

Morphine:
● We compare all opioids with this.
● Three lipophilic drugs: Morphine ,buprenorphine and fentanyl and hence used as pain
patches
● Daily dose - not present, only effective dose is there.
● The rest of them are hydrophilic.

Methadone is usually the 3rd line of therapy; 2.5-3 times a day. same dose as needed. 3 times
used as needed.
Parenteral:
Initiation in Opioid Non-Tolerant Patients:
Initial dose: 2.5 mg to 10 mg IV every 8 to 12 hours
Maintenance dose: Slowly titrate to effect; more frequent administration may be required to
maintain adequate analgesia during initiation, however, extreme caution is necessary to avoid
overdosing.
Maximum doses

Tramadol : 400 mg /day(50 - 100 mg every 6 hrs ) generally but in palliative 600 mg /day
It is started at 25 mg/d and increased by 25-50 mg every 3d
For renal impairment patient it is 200mg/d
For elderly 300 mg/d

Codeine or dihydrocodeine: 340 mg a day

(Online it says 240 mg ??) and for elderly the dose is reduced yes according to NHS it should
be 240mg/day
At first, 15 to 60 milligrams (mg) every 4 hours as needed.

Ibuprofen: max dose - 3g a day. 2-3 times. Start with max dose a day
Max dose is 3200 mg divided into 3 or 4 doses.

We don't know the max dose of strong opioids.

Max dose of morphine, fentanyl and buprenorphine a day: no max doses - only effective doses

Ceiling effect - that's why tramadol has max dose - 400 ml a day; but in palliative care - 600 mg
a day.
Ceiling effect: the dose beyond which there is no additional analgesic effect. Higher doses do
not provide any additional pain relief but may increase the likelihood of side effects as well as
the cost of treatment. (OR) the phenomenon in which a drug reaches a maximum effect, so that
increasing the drug dosage does not increase its effectiveness.

Codeine - 340mg
Oxycodone - 340 mg ???
Codeine once metabolized in the liver becomes morphine.

Titration - for higher doses.

After rotation we have somnolence. We need a lower dose of drugs.

Where do we expect problems?

In our equIanalgesic dose
ratio - 0.25-12- we do not know how many times oxycodone is stronger than morphine.

Morphine and oxycodone

We change to morphine and codeine
MF why 60mg - becoz avg dose of MF in PC is 60mg orally a day. Idk what you mean?

Generally we use immediately releasing morphine in liquid or tablet form

In the EU this is in the form of sevredol - Immediately releasing morphine IRMF 20mg. It has 60
to 120 mins duration of action. Start of action in 30 mins. Use tab after 12 hrs - there's a stable
level of drug in plasma. Online it says one tablet every 4-6hrs?

How long do we wait for the action of paracetamol?

In 30 mins and lasts from 4 to 6hrs.

control release, slow release

Initiation dose of morphine - 2.5 mg of morphine and then you inc - every 4 hrs if good condition
of kidney and liver. Online it says 10-20mg if oral solution and if parenteral then for opioid naive
pts we start at 2.5mg IV.

We use 2 groups of patient

● Opioid naive - we start at 2.5 -5 mg every 4hrs + 1/6th daily dose

Q. How many times can we use morphine in a day - 0.5% ml - 5mg; So in 1ml we have
5mg mf?
So basically we never know how many times we can immediately release morphine. So give a
dose as per if the patient wants or not .

During titration, we never know. So we give them mf again if they need it and then the next day,
we calculate and give the same full dose as the previous day.

● non opioid naive patient 5 -10 mg /6hrs + 1/6th extra dose daily

pt received tramadol - ???

How many times a day do we use half of sevredol? One tablet every four hours. Increase in
pain or tolerance to morphine will require increased dosage of sevredol.
How many tImes a day do we use the rapid onset of opioids?
4 times and 4 extra doses - When we have stable pain we accept 4 incIdence and 4 extra doses
to control pain.

Oxycodone:
Doses seen in market 5,10,20,40, 70 mg; but we prefer control release tabs.
We need 40 mg in 2 portions.
20 mg twice a day ie every 12 hrs + half of sevredol as needed.

Accordeon - another name of oxycodone.

We start from 10mg. If we need 15, 1.5 tabs twice a day.

10% of patients have end of dose failure - when we use control release tablets -
80% pts have good control after swallowing. but 10% after 8-10 hrs they feel pain. so they need
to use 3? times a day instead of 2? times a day. –not clear about this idk what is this?

Equianalgesic Dose
Recalculation of doses

oxycodone and Naloxone in control release dose is always in 2:1 ratio.

oxy :nal - 20mg+10mg
used twice a day.

OIC -Opioid induced Constipation

OBD - Opioid induced bowel dysfunction

Fentanyl
● Patches are always transparent. Best areas to place medicated patches include: Chest,
back and arm (over the diaphragm). Wait for a patch to act: 12 to 24 hrs. 25microg/h
patch every 72 hours (3d).
● 100 times stronger than morphine.
● 600micrograms - 24hrs ???
● Transdermal fentanyl is avoided in opioid naive patients.

Q. How many hours does the action of patch last once we remove a patch from the body?
A. Another 24 hrs. We have a deposit under the skin of the medication which gets slowly
released into the circulation so its effect will continue even once we remove the patch.

Buprenorphine
● 0.8mg = 800microg
● skin color, bigger
● Patch of buprenorphine :skin color

Patient during titration:

Drugs used include morphine ,oxycodone – opioid naive patient

soft titration - ???

Analgesic ladder pic :

We have no max dose of morphine ,oxy etc due to the ceiling effect
no max dose for the last 2 drugs in the pic. and 1st step of analgesic ladder. ???

● Max dose on morphine in the 2nd step is 30 mg/d.

● And oxy is 20 mg/d
● Codeine and dihydrocodeine 240mg? 240 or 340?

How do I work through the ladder ?

So we can start with the first step where we give NSAIDS , paracetamol etc , then if the pain is
still strong we can move onto the 2nd step with weak opioids while continuing non opioids.

But Reduce dose once we find the 2nd is effective ?? not sure abt this

But if the pain still doesn't subside we can move onto the 3rd step where we can continue
non-opioid drugs. we can reduce the dd of strong opioids to 20-30%.
But we cannot use weak and strong opiod for the same therapy.

In the 3rd step we can't use 2nd step drugs because they work with the same mechanism.
However, we are free to combine drugs from the first step with the second, or with the third.

In patient over 65 /dementia

oxycodone and buprenorphine patches preferred when considering nephro/neurotoxicity
patch with talc and gel - fentanyl?
now only matrix patches - glue and drug and this kind can be cut.
WheRe there is Glue and drug and we can cut such patches —- not sure what this is

Buprenorphine 35 microgram/h for every 72 (96) h (3-3.5-4 d) Mentioned in his ppt is it for
patch? )
30mircrog per hr for bupre

For opioid naive patients:

We start with 1/4th of Patch, However they cause some neurotoxicity.

Pts with renal failure :

● paracetamol - eGFR 30ml/m - dd 3mg and then reduce
● nsaids - NOT good for these pts because of risk of hemodialysis due to renal failure.
● We prefer lipophilic drugs -fentanyl and buprenorphine in patches

Chronic kidney disease

We titrate to lower dose ?to get good control of pain

methadone - specific for CKD you mean?
high half life of morphine 2.5 - 3 hours but action is 4 hrs.

Half life of methadone is 120 hrs??

OIBD :
Early in eu it was oxycodone +naloxone
now we prefer the drugs from the group PAMORA (Peripherally Acting Mu Opioid Receptor
Antagonists) like naldemedine 1 tab/1d 0.2mg (oral)

naldemedine - for constipation after weak and strong opioid

once daily and continue therapy with opiod with the drug that the pt received now,

Immunosuppression
In patient with anticancer therapy

buprenorphine + oxycodone - do not cause immunosuppression and can be used.

The 2nd drug of choice is tramadol.

Methadone cause 50-50 immunosuppression

Avoid morphine and fentanyl to prevent immunosuppression
In patient with breathlessness :
morphine and adjuvants like (benzos and steroids )

initiation dose and we wait for effect and when effect start and give drug every 4 hrs

BZD :To treat pts with breathlessness along with anxiety.

swallow
lorazepam -Can be used when the patient is in a better condition
We get action in 10 mins
for faster action - we use - lorazepam?
In hospice with Risk oF swallow patient we use midazolam

Visceral pain
Metamizole is non opioid analgesic (It belongs to NSAIDS)
It is banned in many places due to its ability reduce WBC and cause agranulocytosis
Usually for colic pain as its spasmolytic and not prefered in daily use
whose max dose is . 4000 mg/d
Its oral form is started at 500 mg every 3-4 times a day and max is 4000 mg /d and injection
dose is 250 -500 mg 3 times a day to a max daily dose of 2g /d

extra component of analgesia - coanalgesics for neuropathic pain

Visceral Pain
1st choice - oxycodone - good for neuropathic, inflammatory, visceral pain, and rheumatic
diseases, cancer and non-cancer pain also good choice,
oxycodone and mf - 1st line for cancer pain? or non-cancer ???

Oxycodone In women is better to control pain

Tapentadol is best for every pain esp for those with neuropathic component

Tapentadol can be sold in its prolonged release form as Palexia retard - It is an opiod
analgesic, mu agonist which inhibits reuptake of norepinephrine
Its initially 50 mg/twice a day ,then the dose may be increased by 50 mg every 3 d
Max dose is 500 mg/d

But for patch - buprenorphine is the best

Cause they have an additional way of action , It is a partial agonist at mu receptor and weak
kappa antagonist and delta agonist
Use the 1/4th patch every 4 d

Methadone is also good but not 1st line of therapy

tramadol + paracetamol - hybrid drug
4 ways of action
tramadol - agonist
tramadol (centrally-acting opiate) plus paracetamol (acetaminophen; nonopiate, non salicylate
analgesic)

Trazodone is antidepressants used at night and after that we have natural regulation of
circadian rhythm

Zolpidem is better than trazodone (another type of tramadol)

If patient can't swallow

tramadol po to sc - 1:1
bioavailability of tramadol - 90%. avg 70%.
same dose when changing from oral to subcut.
period between doses - 8,6,4 hrs

Morphine po to sc - 2:1 or 3:1

period between doses - 4/6 hrs??
reduction at least 50% daily dose, maybe even 70%.
Bioavailability is 30% max 40%

Oxycodone po to sc ~ 2:1
at least 50%
period - 4/6 hrs.

We need to know everything from today 😭😭

S3: Breaking Bad News
PC pts with advanced cancer :
- not all info needed
- find what info the ot would like to get

- has it's own development dynamics and often takes many days or even months
- never lie to the pt by giving them false hope
- no need to tell the whole truth
- avoid brutal ir mindles openness
- truth is like med and should be doses individually according to pt’s sensitivity
- most pts prefer to get to know the truth rather in sensitive way than with brutal words if
they are not ready
PAtieNts suicidal thoughts can arise when the breAking bad News WAs done improperly

communication rules :
● adapt content of your message to current health condition and cognitive abilities of a pt
○ encourage to openness in a verbal and non-verbal way
○ opening statements
○ appreciciation
○ clarification
○ paraphrase - rephrasing in your words
○ dereflection - inorming how do i understand pt’s words and behavior
○ summarsing

● Opening statement (always make sure you get more ans from patient)

● Avoid making the patient aware of what you actually feel and avoid blaming him/her

unfavorable behaviors :
- analyzing pt’s past
- lying to pt
- judging
- using of persuasion
- downplaying, teaching and forcing

most common mistakes :

● unfavorable attitude
● withdrawing from the convo
● hastening the convo
● wearing a mask of a professional
● limited contact
● only medical conact
● closed Qs

the causes of difficulties un BBN :

- lack of abilities in communication
- high level of fear
- defense mechanisms
- unconsciously
- ignorance
- pressure of pt’s family
- outside factors (lack of time or proper place for convo)
- pt’s attitude
WHat are docs afraid of
Not SUrE abt the patient Reaction - fear, anger
Giving tOo Much info
DiD they undErstand
Not being able to answer to all their questions - will we be able to handle it?

projection -
Eg: the pt is not mentally prepared to handle the course of his disease

ways of depersonalisation of pt :
- talking abt pt in he/she form in his/her presence
- asking about his/her opinion and nots taking t into consideration in the saem time
- blocking negotiations
- Routine care

encouraging to open up :
- don't be afraid of silence
- be empathic
- ask open Qs
- ask about psychosocial issues - to see the pt as a whole human being - with his cons
and pros, and attitude and everything
- sit near pts
- explain if you understand correctly the patients gestures, comments and voice changes

Immop model of concept of consciousness by glasses and strauss

- model of closed consciousness:
- patient believes the family and doctor because he had hope
- If the fam is in talk with doc a.n.d they're not telling patient and he is being lied to
by fam and doc
BUT if still things take a turn For worse but he is being told he Is doing good

- “ of suspicion:
- Pt feels betrayed and lonely by his family and doctor and her tried to get
information from books or net,

- “ of pretending:
- pt also was talking the doc and he and the family the truth but they have no
communication between the mand they are pretending that tdk the truth. having a
mask that everything is alright.

Patient also talk with doc so he and his family also knows but they pretend to not know abt the
situation
ItIt'like they have a fake mask and can't show real emotions
 - “ of open consciousness
- sharing emotions are twice less scary.
- Open conversation: Best modal. Every knows same truth. With the possibility to
support and be together sharing emotions

LEgal aspects of breaking bad news :

- every pt has constitutional right to get but also to protect info about his/her condition
- every pt has right to get know every single aspect of his/her health and disease including
every examination and results of tests
- informing pt’s family should be agreeing with pt.

1st Model means doc broke the law

As he didn't discuss with the patient abt his condition

But there Are exceptions to this like if they don't have the mental capacity to understand or if
they have a mental disease like acute depression (we can consult with psychiatrist ), medium
dementia, children
We can be very careful

If the child has cancer asks the doc if he has

about children with cancer and specific scnearios.

results of not respecting the pt’s will :

- worsening of stress
- lost of trust
- higher level of far
- making confessions impossible
- robbing of pt’s time (we can't take their time away by not telling them if they r gonna die
))

if pt disagrres with telling family and the family asks the doc about ut, the dr will have to say that
he is not allowed to give the info about the pt.

ways of getting info :

- in the hospital :
-

Stages Of dying by ElIsabeth kubkler ross :

- shock
when they get the result for the 1st time. He doesnt feel anything
He feels empty
- denial
We use projection as a defence mechanism
Patients may require a bigger defence mechanism than we do
They might start to find reasons for not having disease
Imma good person to have cancer
- anger
Vvimp
Very hard to deal with like how do we talk to him when he gets upset so quick
People can be AB C personality
A at risk of heart problem always screaming and stressed out .
B - oppo
C - hard pts , inner anger
- bagaining
We tried to txt you, and it didnt work. i can't txt you anymore becoz of metastasis and you’l get a
reference to hospice. tries to avoid death. bargaining with doctor and with god
there has to be smth to cure me and etc
- depression
when he sees nothing works
1st type is just a stage we don't need to be worried
He is just sad and scared upon getting the news
But when he starts thinking of suicide ,isolating diagnose as clinical depression and txt with
antidepressants and coanalgesics
- acceptance
Not everyone reaches this stage and here they ll prep to die
Where they write abt wrong doings, seeks forgiveness, right their wrongs, write their will
Completing their bucket list, preparing for funerals, choosing their clothes in the coffin, choosing
their way - burned or cremated.

But most pt get stuck in denial and depression

Onnnn every stageeeee paientsss haaavee hoooopeeeeee jhopeeee

Hope is imp
Big hope: Hope to live from the bottom of their Heart and u can't give Him
and love.

Small hopes :hope to live for until their sons next bday, that it could be a sunny day, that you’ll
feel better in the evening.
Shorter durAtion
Doing small things that gives joy
We shld try to give this hope a lot

Problematic pts :
- pt in fear
whats he afraid of ?
Everyone is afraid to die and prepped to be not scared
- with depression
pt can also make us feel hopelessness, dk what to do, or what to say and we’ll feel like wdk
what to say or do for him.
- with low self-esteem
pay close attention support and appreciate Him a lot
- angry pt
- pt with denial mechanism
2 situation
1st is denial being so strong they refuse treatment
2nd - nonone wants to txt him and can only do symptomatci txt
- patient who doesn’t want to cooperate or even talk

fear of death and dealing with that convo - to be dicsussed in tuto

Role of families
- positive role
- Supporting the patient
- Recognising and satisfying the patients needs
- AccurAte reading of patients message
- being a part of nursing
- InForming the medical staff about changes in his condition accurately

negative role :
- denying the pt’s feelings
- lyin g to the pt
- Too many PeOple visiting tires patient
- make the pt feel guilty becoz of his/her disease
- Communication block
- Overprotection
- refusing of nursing the pt
- Undeserving complaints and demands of medical staff
- aggressive behaviour

Spikes protocol vvimp

- gathering info from the pt

- transmitting the medical info
- providing support to the pt
- Eliciting patients collaboration in developing a strategy for treatment in the future

STEPS of spikes protocol:

1. setting up interview
2. Assessing the patients perception of condition
 3. Obtaining patients invitation
4. Giving Knowledge and info to the patient
5. Addressing patients emotion with empathic response
6. Strategy and summarize
We shld ask if they have anyone to support them
if you do step 4 at first, there is the 1st step of dying - shock.
what worries you the most.

T1: w/ Nowakowska
Karnofsky score - 100 to 10.
Too long, so ecog score more uses coz its from 0-5 and is easier to remember.

NRS scale is from 0 to 10.

60 Yr old with lung cancer during chemo:
Complains of chest pain, in NRS 8-9
Chest infiltrated by tumor
h/o : C with heart valve failure. ICD and taking meds - ice inhibitors, BB, stating, ASA and
diuretic.
BP - 15kg/m2,

Start with lowest of analgesic ladder ie medicines like paracetamol, NSAIDS. We have tumor
that infiltrate the chest so NSAID is more preferred. There might be inflammatory or metastases
to the bone, so NSAIDS used. Paracetamol can be used but it's non-inflammatory. Won't be
much effective comparatively but it's still used.

Second and third step analgesic ladder meds cannot be used together because they work the
same way. But first step meds can be combined with second or with third alone.
3rd drugs can be used together.

Using high doses of opioids will lead to respiratory depression. Hence we begin with small
doses.

With morphine we prefer to start with titration with immediately infused morphine.

Mf every 4 hrs -2.5mg

If there is extra pain, 2.5 mg every 4 hrs + 2.5 again if needed.

But taking meds every 4hrs is not comfortable so we can use slow acting or controlled release
which is normally used twice a day.

In the case above - receptor and neuropathic pain.

Morphine control only receptor pain.
So use oxycodone, buprenorphine or tramadol is used in this case.

In case of low BP of this pt,

Beta blockers dose cannot be decreased all at once. There is no edema So we can stop
Diuretic first.

Two kinds of opioid patches - Buprenorphine and fentanyl.

Position:
Chest - over the diaphragm, under the clavicle - to work correctly it needs to be put under -
Subcutaneous tissue that needs to be placed with buprenorphine is FAT

For back : Between vertebral column and scapula

Patch changed in :
72 hrs
96 hrs for bupre

Can even go swimming with it 🏊‍♀️

Not in sauna because the heat will dilate the vessels so the dose should be higher.
Same in the case of fever, and hot shower.

Case 2 :
92 year old lady with breast cancer. With big dirty bleeding open sore wound.
Had stroke 12pro ago, afib and takes oral anticoagulants.
Lives by herself.
(Pic of wound)

Patient takes oral anticoagulants but doesn’t agree to switch to heparin.

What meds to use when we cannot use oral anticoagulants and patient doesn’t allow the usage
of heparin? Acetylsalicylic acid.

Chadsvasc score if it’s more than 3 points then we have another risk of stroke. Sne has score 3.

Has Bled score - 3

>=3 means need to continue oral anticoagulants.

Has bleeding wounds - might be befoz of the oral ac.

Aspirin- used in this case. Can be used a prophylaxis of another stroke.
But the lady died of breast cancer.

Case 3 :
60yr old man during chemo for small cell lung cancer complains of burning pain and numbness.
He can't use spoon becoz of this pain.

For neuropathic pain - coanalgesics?, tramadol, buprenorphine, Ssri, sNRi,

lignocaine,methadone

Burning pain - nerves destroyed

Case 4 :
66 Yr old with ovaris carcinoma disease.
Zubrod 1, prepared dinner for son and walked for a walk two weeks ago. In short time, she gets
worse. With breathlessness, not in good mental health.
Says illogical things according to son.

Taken yo pulmo hospital. Gasomtry -

pco245 mm
Po2n45 mm pH 7
Angiography CT- rt Pulmonary artery was closed by PE.

Suspect metastasis to lung due to breathlessness, and brain due to difficult of speech and
unconsciousness.
Suspect pulmonary embolism. She should be sent to hospital because symptoms took over her
in a short period of time.

noacs
Heparin subcut 1st line.
In the beginning 10mg BID. 60 mg.??
After 3 mlnth - smaller doses- 75%of the whole dose.
120mg after the 30 days will be 70-90 mg OD.
3 mths is the shortest time.
Prescribe aspirin only if there is no threat for death and for prophylaxis.

Case 5:
70yr old women during chemo because of lung cancer.
She complains of 2 days of fever.
When she got to hospital her analysis was:
Wbc - 1.000/ul, Neut 0.45/ul, plt 40.000 without Symptomatic thrombocytopenia.
Gasometrey - ph 7.34, pco2 44mm, po2 40 mm. Bp 60/40 but in good mental health.

Ventilate the patient

Antipyretics
Wait to give platelets till symptoms start.
Blood transfusion
WBC - shows infection
Normal 4000-10000 range

After chemo or radio therapy, all blood cells are dec. If inf happen during this, it'll be dangerous
for the pt. Also inc the WBC - inc growth factors.

She received oxygen therapy, and RBC transfusion.

she still had hypoxemia, suspect Pulmonary embolism. In this situation, giving her platelets
would lead to death.

In angiography ct, the embolism in the bifurcation in the trunk pulmonary artery.

Case 6 :
61yr old women suffering from right hand pain for half an year.
She visited many specialists. And no help. Shes got this tumor that destroyed the bone and
hypercalcemia.
Pain in NRS 9-10
Calcium is high around 12mg/dLe
NSAIDS is enough but if the pain is too high, we can,give other opioids.
Ketoprofine was given here in this case.
IV saline, bisphosphonate - each 4 weeks given again.

Case 6
PE on the chest, vessels seen.
Huge tumor that closed the superior vena Cava.

Low BMI pts are nit suitable for opioid patches.

On the knee, NSAIDS can be put here.

CT pic :
Ascites pic :
Paracentesis - done on the left side after fluid motion test.

Case
88 Yr old, ecog 1.
Has HT and only took only 1 med.
Surgery can be done on him because he has only high BP and single medicine.

T2: w/ Labus-Centek
Fear of death Should be divided into
Smaller parts to deal with the whole overwhelming scenario.

Pieces of the pizza : what are they afraid of :

● What comes after
● Unsolved problems
● Family
● The time when they die
● Pain
● Financial
● Loneliness
● Feeling Guilty
● Unfulfilled dreams
● Process of dying
● Condemnation
● Regrets

Dying in agony - physical changes:

● Drooping of face
● Eyes going deeper into skull
● Pale shin
● Nose is longer than thin
● Less movements movements or none at all
● LOsS of contact
● Unconscious disorders?
● The patient is calmer
● Stops eating, drinking
● Breathing becomes slower
● Cold hand and feet
● Blue nails
We observe Cheyne stokes breathing at the LaSt moments with pauses in between and finally
the last pause might be forever
● Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical
episodes of apnea and hyperventilation.
We can give med via patches under skin

How to treat the fear of death, if they feel like they're gonna suffocate :
Only for acceptance stage pts -
Medications are a help
We can talk with him and tell him what changes he can observe
That it's calm and smooth
It's not suffocation and it's own way

We shld only tell this to a patient in the stage of acceptance and not in a denial Phase

we shld only answer the questions

It's imp for fam to be with dying person to see how calm of a process it is

Trauma in palliative care patient

Bleeding out of pulmonary organs (very rare)
leading to unconsciousness.
Breathlessness

People who believe is God will be more at rest in death than atheist to tend to look backward