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12.10.10 Hospice + teaching

Prognosis
  • Double removal
    • Reality: 25 days
    • Optimistic doctor thinks 75 days
    • Doctor tells patient 90 days


Three cardinal clinical skills

  • Diagnostics
  • Therapeutics
  • Prognostication 


Pain types

  • Nociceptive
    • Opiods
  • Neuropathic
    • (Opioids) but not really
    • Amitriptyline (1st line)
    • Gabapentin
    • Clonazepam


Gold Standards Framework

  • "Enabling a gold standard of care for all people nearing the end of life"
  • 3 triggers indicating approaching death:
    • The Surprise Question
      • ‘Would you be surprised if this patient were to die in the next few months, weeks, days’?
    • General indicators of decline
      • Deterioration, increasing need or choice for no further active care
    • Specific clinical indicators related to certain conditions
  • Trajectories:
    • Rapid
    • Erratic
    • Slow

Notes

  • Midazolam is 1st line for terminal agitation
  • Haloperidol has double effect
    • Antipsychotic
    • Antiemetic
  • "Ceiling of care"
    • Need to know the prognosis, so you know how much intervention is appropriate
    • e.g. Treat neutropaenic sepsis, but not necessarily chest infection in terminal AIDS
  • Total pain
    • Physical, but also psychological, social, spiritual
  • Tapentadol
    • Centrally acting analgesi with opioid and non-opioid activity
    • Dual mode of action
      • Agonist of the μ-opioid receptor
      • Norepinephrine reuptake inhibitor
    • Potency between tramadol and morphine
  • Steroids can => Proximal myopathy
  • Referred pain to the back from upper GI disturbance is via the COELIAC PLEXUS
  • Pinpoint pupils are common when pain is managed with opioids
    • DON'T give naloxone unless RR < 8
  • Oral oxycodone is twice as strong as oral morphine
  • Domperidone doesn't cross BBB => Good antiemetic choice in Parkinson's
  • Ondansetron => Constipation
  • Need to contact coroner to certify death if you haven't seen the patient in >1 week
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