GEM - palliative care educational module

Palliative care

• studies of patients and their carers have repeatedly shown that many terminally ill patients prefer the option of a death at home. Helping patients die with dignity and with minimal distress has been one of the most fundamental aspects of medicine, and over the past 50 years specialist palliative care services have increasingly worked with general practice to develop more advanced knowledge and skill than ever before. Most GPs testify to this being one of the more difficult, but most satisfying, parts of their job (1)

Analgesia in palliative care:

It is important for the primary care clinican to be aware of the various options for analgesia in palliative care management.

Important areas of the palliative care knowledge case include:

• awareness of the "pain ladder"
  • GPN reference
• what are used on step 1 of the pain ladder?
  • GPN reference
• strong opioids, such as morphine, are used for moderate to severe pain. It is important the primary care clinician has knowledge regarding the relative potencies of different forms of opioid analgesia. If a person was taking the maximal dose of tramadol per day (400mg per day) then what dose of morphine would be approximately equivalent to the dose of tramadol?
  • morphine total dose of 40 mg per day
  • morphine total dose of 100mg per day
  • morphine total dose of 150 mg per day
  • GPN reference
• how do you calculate doses of analgesia for breakthrough pain?
  • GPN reference
• how do you calculate morphine to fentanyl equivalence?
  • GPN reference
• what cautions should considered in terms of the effectiveness of analgesia when using a fentanyl patch?
  • GPN reference
• if there is a sudden "failure" in analgesia then this may signify a development such as pathological fracture. What other conditions should be considered?
  • GPN reference
• use of syringe drivers is an area of palliative care where the primary care clinician may become involved. Some key areas of knowledge include:
  • drugs used with syringe drivers and their respective indications
    • GPN reference
  • indications for a syringe driver
    • GPN reference

Agitation/Anxiety in palliative care

If a patient becomes agitated and restlessness then the primary care clinician must be aware of potential causes for the agitation/restlessness and a management strategy

• GPN reference

Other important areas of knowledge include:

Use of Antiemetics in the palliative care setting

• consider the management of nausea in various scenarios:
  • drug induced/biochemical cause
  • evidence of gastric stasis
  • if GI involvement/cerebral turmour
  • GPnotebook reference
• antiemetics section on GPnotebook GPN reference

Management of respiratory secretions in palliative care:

• what is the mechanism of action that is common to agents used in the syringe driver to manage this problem?
• what is the advantage of the use of hyoscine butylbromide over hyoscine hydrobromide in this situation?
• GPN reference

Use of Laxatives in the palliative care setting GPN reference

Awareness of palliative care emergencies

• what are the clinical features of superior vena caval obstruction?
  • GPN reference
• a review of the clinical features of spinal cord obstruction
  • GPN reference
• which cancers might cause bony mets?
  • GPN reference
• a review of the clinical features of hypercalcaemia
  • GPN reference

Sickness certification

• A form DS 1500 should be issued if requested by a patient (or their representative) if you consider that the patient may be suffering from a potentially terminal illness. The DS 1500 should be handed to the patient or their representative and not sent directly to the DWP. A fee is payable by the DWP for the completion of this form, which is supplied in booklets by the Department on written application. The DS 1500 asks for factual information and does not require you to give a prognosis
  • terminal illness is defined in Social Security legislation as: 'a progressive disease where death as a consequence of that disease can reasonably be expected within 12 months' T/F
  • if a patient is claiming Incapacity Benefit then a person who is terminally ill and incapable of work can get the highest rate of benefit after 28 weeks instead of 52 weeks sickness T/F
  • GPN reference

Other useful reference on GPN

• palliative care section on GPN

Reference:

1. Royal College of General Practitioners. Curriculum Statement 12 Care of people with Cancer and Palliative Care.