Pain Management, Palliative Care, Grief, and Oncology

Comprehensive vocabulary flashcards covering pain physiology, pharmacological agents, grief models, voluntary assisted dying legislation, palliative care principles, cancer cell biology, and oncological emergencies.

Nociceptive Somatic Pain

Pain resulting from the activation of nociceptors in cutaneous structures (skin, subcutaneous tissues) or deep somatic tissues (blood vessels, muscle, bone, connective tissue), typically characterized as well-localized, constant, and achy.

Nociceptive Visceral Pain

Pain arising from the stimulation of nociceptors in internal organs and body cavity linings, characterized as poorly localized, diffuse, deep, cramping, or squeezing, often accompanied by autonomic symptoms or referred pain.

Neuropathic Pain

Pain caused by damage or disease affecting the peripheral or central nervous system structures, characterized as poorly localized, burning, shooting, fiery, shock-like, or numbness, and often exhibiting opioid resistance.

Somatoform Pain Disorder

A condition previously termed psychogenic pain, where pain is initiated, worsened, or prolonged by mental, emotional, or behavioral factors in the absence of a direct physical etiology.

Intractable Pain

Severe, persistent pain that cannot be relieved by conventional medical, surgical, or nursing measures.

Breakthrough Pain

A transitory flare or sudden exacerbation of severe pain that occurs spontaneously or in relation to a specific trigger, despite baseline analgesic control.

Transduction

The initial phase of nociception where noxious thermal, chemical, or mechanical stimuli are converted into electrical action potentials following the release of chemical mediators at peripheral nerve terminals.

Transmission

The process by which pain action potentials propagate along nerve fibers from the site of injury to the dorsal horn of the spinal cord, and ascend to the thalamus, brainstem, and cerebral cortex.

Modulation (Pain Pathway)

The physiological process by which neural signals descending from the brain damp down or amplify ascending nociceptive inputs at the spinal cord through endogenous neurochemicals like opioids, serotonin, and noradrenaline.

A-delta Fibres

Thinly myelinated, large-diameter, rapidly conducting primary afferent fibers that transmit fast, sharp, well-localized acute pain signals in response to mechanical and thermal stimuli.

C Fibres

Unmyelinated, small-diameter, slow-conducting nerve fibers that transmit diffuse, dull, aching, and persistent pain signals in response to mechanical, thermal, and chemical stimuli.

A-beta Fibres

Highly myelinated, large-diameter, fast-conducting nerve fibers with low activation thresholds that carry non-noxious tactile information such as touch and vibration, acting to inhibit pain signals.

Gate Control Theory (Melzack & Wall, 1965)

A pain theory proposing that a neural mechanism in the substantia gelatinosa of the dorsal horn acts as a dynamic gate; small-diameter fibers ($A\delta$ and $C$) open the gate, while large-diameter fibers ($A\beta$) and descending brain pathways stimulate inhibitory interneurons to close it.

Adjuvant Pain Medications

Medications whose primary therapeutic indication is not pain relief (such as anticonvulsants, antidepressants, or corticosteroids) but which provide analgesia or enhance the efficacy of primary analgesics in conditions like neuropathic pain.

Tapentadol (MORNRI)

An analgesic agent that provides synergic pain relief through two distinct mechanisms: $\mu$-opioid receptor (MOR) agonism and noradrenaline reuptake inhibition (NRI).

Capsaicin

A topical alkylamide extracted from chili peppers that binds to TRPV1 receptors on unmyelinated C fibers, leading to localized depolarization and cumulative depletion of substance P over weeks.

FLACC Scale

A pediatric behavioral pain assessment scale evaluating five categories—Face, Legs, Activity, Cry, and Consolability—scored from $0$ to $2$ each, for a total score up to $10$.

Faces Pain Scale - Revised (FPS-R)

A self-report pain assessment tool displaying six neutral-to-grimacing faces scored $0$, $2$, $4$, $6$, $8$, and $10$, measuring internal pain intensity in pediatric patients without using affective words like 'happy' or 'sad'.

Brief Pain Inventory (BPI)

A multidimensional pain questionnaire that assesses pain severity and the degree to which pain interferes with daily functions and activities using $0\text{--}10$ numeric scales.

Loss

The experience of having a person, object, role, or condition taken away or made unavailable, classified as tangible (e.g., death, employment loss) or intangible (e.g., loss of identity, security).

Grief

The complex emotional, psychological, cognitive, and physical response experienced by an individual following a significant loss.

Bereavement

The objective state of deprivation and period of mourning and adjustment that follows the death of a significant person.

Four Tasks of Mourning (Worden, 1977)

A psychological model requiring a bereaved individual to: 1) accept the reality of the loss, 2) work through the pain of grief, 3) adjust to an environment in which the deceased is missing, and 4) emotionally relocate the deceased and move forward with life.

Dual Process Model of Coping

A bereavement model proposing that healthy grieving involves an ongoing, dynamic oscillation between loss-oriented coping (grief work, intrusion) and restoration-oriented coping (attending to changes, distraction, new roles).

NURSE Strategy

A structured communication framework to provide empathetic responses: Name the emotion, Understand the perspective, Respect the person's coping, Support the individual, and Explore concerns further.

Voluntary Assisted Dying (VAD)

A legally regulated clinical framework permitting eligible adults with an advanced, progressive, incurable condition causing intolerable suffering and an expected prognosis of under $6$ months (or $12$ months for neurodegenerative diseases) to access lethal medication.

Instructional Directive

A legally binding component of an Advance Care Directive that specifies particular medical interventions a person unconditionally consents to or refuses in future health scenarios.

Coordinating Medical Practitioner (VAD)

The medical practitioner who receives the patient's first request for voluntary assisted dying, conducts the primary eligibility assessment, applies for the state permit, and holds reporting obligations.

Anticipatory Medicines

Sublingual or injectable medications prescribed in advance and stored in the patient's home to ensure rapid symptom management during the terminal phase and avoid unnecessary hospital transfers.

Xerostomia

The subjective sensation of oral dryness resulting from reduced salivary flow, commonly induced by anticholinergics, opioids, radiation therapy, or dehydration.

Terminal Respiratory Secretions ('Death Rattle')

Audible, rattling, or gurgling sounds generated by passive movement of secretions across relaxed vocal cords in semi-conscious or dying patients with lost pharyngeal reflexes.

Neoplastic Transformation

The progressive, irreversible biological process by which a healthy cell acquires genetic mutations that bypass growth controls, giving rise to uncontrolled malignant proliferation.

Proto-oncogenes

Normal cellular genes that encode growth factors, cell-cycle regulators, and survival proteins that promote physiological cell proliferation under tight regulatory control.

Oncogenes

Mutated or dysregulated forms of proto-oncogenes that stimulate autonomous, unregulated cell division and prevent physiological apoptosis.

p53 Gene

A tumor suppressor gene acting as the 'gatekeeper' of the genome; it arrests cells at the $G_1$ checkpoint to facilitate DNA repair or triggers apoptosis if damage is irreparable.

Apoptosis

Genetically programmed, energy-dependent cell death essential for maintaining cellular homeostasis by systematically eliminating aged, damaged, or mutated cells without inflammatory reaction.

Gompertzian Tumour Growth Curve

A mathematical model describing non-linear tumor growth where initial exponential proliferation slows progressively as the tumor outgrows its nutrient and blood supply.

TNM Staging System

An internationally recognized cancer staging system classifying the size and local extent of primary tumor ($T$), regional lymph node involvement ($N$), and presence of distant metastases ($M$).

Australian Clinico-Pathological Staging (ACPS)

A classification system used in Australia for colorectal cancer staging, dividing disease from Stage A (confined to bowel wall) to Stage D (distant metastases to liver, lungs, or elsewhere).

Cell Kill Hypothesis

A pharmacological concept stating that a specific dose of cytotoxic chemotherapy kills a constant percentage (fraction), rather than a fixed number, of cancer cells.

Fractionation (Radiotherapy)

The division of a total prescribed radiation dose into multiple smaller daily fractions to maximize lethal damage to malignant cells while allowing normal healthy tissues time to repair sublethal injury.

Brachytherapy

Internal radiation therapy achieved by placing sealed radioactive seeds, ribbons, or pellets directly inside or immediately adjacent to a malignant tumor.

Chemotherapy Nadir

The point of lowest circulating blood cell counts (especially absolute neutrophil count and platelets), typically occurring around day $10$ following a chemotherapy cycle, posing the highest risk of sepsis.

Neutropenic Sepsis (Febrile Neutropenia)

An oncological emergency defined as a core body temperature $\ge 38.0^\circ\text{C}$ in the presence of an absolute neutrophil count (ANC) $< 0.5 \times 10^9\text{ cells/L}$, requiring intravenous broad-spectrum antibiotics within $1$ hour.

Malignant Spinal Cord Compression (SCC)

An oncological emergency caused by neoplastic extension or vertebral collapse impinging on the thecal sac and spinal cord, presenting with localized back pain, progressive weakness, and sensory deficits.

Tumour Lysis Syndrome (TLS)

A metabolic oncological emergency caused by massive, rapid breakdown of malignant cells, leading to hyperuricaemia, hyperkalaemia, hyperphosphataemia, and secondary hypocalcaemia.

Superior Vena Cava (SVC) Syndrome

An oncological emergency resulting from extrinsic compression or intrinsic thrombosis of the superior vena cava by thoracic neoplasms, producing facial edema, neck vein distention, and dyspnea.

Hypercalcaemia of Malignancy

A severe metabolic complication in cancer patients (serum calcium exceeding normal range of $2.2\text{--}2.7\,\text{mmol/L}$) due to tumor-secreted PTHrP or osteolytic bone metastases, causing renal, gastrointestinal, and neurological dysfunction.

progeny

genetic descendent of normal cells that have undergone neoplastic transformation

cancer cells can

transgress barriers, intravastate and extravaste

Monoclonal Antibodies

Lab create immune proteins engineered to target specific antigens or cancer cells

well differentiated

tumour cells reproduce these features well

poorly differentiated

tumour cells reproduce these features poorly and its difficult to tell where cell originated from

undifferentiated

cannnot tell - no maturation - limits treatment

doubling time

time tumour takes to double its size

solid tumour

usually palpable at approx 30 doublings

death

from cancer occurs around 40 doublings

cancer staging allows

• prognostic information

• informs clinicians of the benefit of treatment

• risk of recurrence

• criteria for entering clinical trials

metastatic cascade (1-8)

1. tumour initiation

2. progression

3. proliferation

4. angiogenesis

5. invasion/ intravasion

6. extravasion

7. colony formation

8. evasion of host defences

staging systems

• location of tumour

• type of cells such as germ cells or adenocarcinomas

• measurement of tumour cells

• metastatic spread to other sites

Cancer staging T

T(tumour) - size and extent of primary tumour

Cancer staging (N)

N(Nodes)- number of nearby lumoth nodes that contain cancer/cells

Cancer staging (M)

M (Metatasis) - spread to other sites and organs

Aetology of how cancer develops

DNA damage disrupts normal cell communication and regulatory controls (P53) the affected cell may transform into an autonomous cancer cell which grows and divides independently of normal signals. Once transformed the cancer cell divides to produce daughter cells that also carry same DNA changes, This leads to exponential growth creating population of cells characterised by uncontrolled proliferation and spread.

characteristics of cancer cells

• loose contact with neighbouring cells and community purpose

• are adaptable and self serving

• consume more resources than normal cells

• live longer and produce more offspring

• uncontrolled proliferation

• uncontrolled spread

Diagnostic investigations

• CT scans

• MRI

• PET scan

• Bone scan

• Biopsies

Staging I

Stage I cancer is localised, small tumour

Staging II

Larger or deeper tumour may involve local tissue (require surgery and adjuvant therapy)

Stage III

regional spread to lymph nodes localled advanced disease

Stage IV

disant metastasis present - palliative care often considered

Systemic therapy for Cancer

treatments such as chemotherapy, immunotherapy and targeted or hormone therapy sued to treat cancer cells throughout the body

Local treamtments

Surgery or radiotherpay may be used to remove or control specific tumours that can cause pain or impair organ functions

Survival defintion

proportion of cancer patients who are alive at a certain time after diagnosis usually 5 years

Clinical distress def

specific term used when this emotional suffering reaches a level that interferrs with a persons ability of cope, function, maintain relationships that require psychosocial intervention

Clinical distress related to

• disease status

• treatment tolerance

• symptom tolerance

• quality of life

risk factors for heightened emotinal distress

• being very young or very old

• being female

• being single, widowed or divorced

• cognitive impairment

• recurrent disease

• previous mental health conditions

• being socially isolated

• cultural or language barriers

palliative care defintion WHO 2020

Is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

what palliative care can provide

• integrates psychosocial and spiritual aspects of patinet care

• uses a team approach to adress needs to patient and their family

• provides multidisciplinary care

• enhance quality of life

• educates family and communoty

• not confined to end stage of care

Palliative care team

• pharmacist

• palliative care nurse

• social worker

• Bereavement counsellor

• volunteers

• General practitioners

• Acute hospital health professionals

National palliaitve care strategy 2022-2025

• growing the health care, aged care and community care workforce

• innovate models of care

• increase accessibility

National Palliative care standards 1-9

1. Assessment of needs

2. development of care plann

3. caring for carers

4. providing care

5. transition between and within services

6. Grief support

7. Service culture

8. quality improvement

9. staff qualification and training

Symptom assessment Nurisng

• talk in reassuring manner

• ask if its a new symptom

• level of comfort or distress caused by symptom

• every four hours

• when change of condition is noticed

• after medication and treatment

Commmon symptoms

• anorezia

• dyspnoea

• nausea and vomiting

• restlessness

• confusion

• fatigue

• depression

Dyspnoea

breathlessness - may require oxygen, cool air, humidifiers

Constipation causes

• medication

• lack of exercise/movement

• low fibre diet

• reduced fluid intake

Constipation managemnet

• increase fluid

• increase exercise

• increase fibre in diet

• stool softeners

Pruititis (itchy skin) management

• antihistamines

• loose fitting clothing such as cottton

• increase fluid intake

• 
  

Observation Chart for management palliative care

Comfort observation and symptom assessment chart

multidisciplinary care meeting

regular meeting of all health practitioners involved in the treatment and care of cancer patient.

Nursing role

• patient advocacy

• monitoring and assessment

• education

• emotional support

• co-ordination and communication

anemia

low red blood cell count = low haemoglobin which means less oxygen is being carried around the body and pt can become fatigued

leucopenia

low white blood