12.10.10 Hospice + teaching


    • 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


    • 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