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"

  • http://www.goldstandardsframework.org.uk

  • 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