Ageing and End of Life Care

Question 1

what is involved in palliative care?

Answer 1

symptom control

communication and emotional support

Question 2

what are ACPs?

Answer 2

advanced care plans
created by GPs and shared with other professionals involved in patients care (also called KIS in Scotland)
created for everyone with life limiting illness at risk of decline

Question 3

common diagnoses of patients in palliative care?

Answer 3

cancer
organ/system failure
frailty and dementia

Question 4

how does illness trajectory differ in different groups of conditions?

Answer 4

terminal illness = steep deterioration in function until death
organ failure = fluctuating level of function over a general decrease over time until death
frailty = wavering decrease in function over time until death, slight slope

Question 5

step 1 pain management?

Answer 5

paracetamol 1g 4X daily
and/or NSAID 500mg 2X daily
an/or any other adjuvant (antidepressants, nerve block-gabapentin etc)

Question 6

step 2 pain management?

Answer 6

codeine 30-60mg 4X daily
or can use codeine with paracetamol (co-codamol 30/500) 2 tabs 4X daily
and/or adjuvant

Question 7

step 3 pain management?

Answer 7

stop codeine and switch to strong opioid - usually morphine

can use in conjunction with paracetamol/NSAID/adjuvants

Question 8

describe cancer pain?

Answer 8

constant background pain

instances of more severe breakthrough pain

Question 9

what is modified release morphine?

Answer 9

MST/zomorph
lasts for 12 hours
used for background pain

Question 10

what is immediate release morphine?

Answer 10

sevredol/oramorph
lasts for 4 hours
used on top of modified release for breakthrough pain

Question 11

how much immediate release morphine should be given?

Answer 11

1/6 of total background daily dose

e.g if patient is taking 2 15mg doses of MST (30mg total), immediate release should be 5mg

Question 12

morphine dosing?

Answer 12

modified release morphine given twice daily
immediate release morphine given as needed every 4 hours
depending on amount of “as needed” immediate release morphine needed, background morphine can be titrated up

Question 13

what are the risks of morphine?

Answer 13

opioid tolerance
toxicity
respiratory depression

Question 14

how is morphine excreted? why is his significant?

Answer 14

renally excreted

means you should check renal function if a patient becomes opioid toxic as this would cause morphine to accumulate

Question 15

how might opioid toxicity present?

Answer 15

hallucinations
myoclonus (sudden jerky movements)
drowsiness

Question 16

how is opioid resp depression managed and what is the risk of this?

Answer 16

naloxone can reverse morphine very quickly

if too much given or too quickly, can cause very severe withdrawal symptoms

Question 17

how is opioid toxicity managed?

Answer 17

dose adjustment/switch to another strong opioid

Question 18

how are opioids changed?

Answer 18

dose will change if type or route of strong opioid changes

Question 19

what strong opioid is commonly used to replace morphine?

Answer 19

oxycodone

twice as strong as morphine

Question 20

what features indicate dying?

Answer 20

worsening weakness and performance status
worsening physiological status with no reversibility
struggling to manage oral medicines (swallowing function)
lost interest in food and fluids
sleeping more, eventual unconsciousness
MUST BE NO REVERSIBLE FACTORS

Question 21

what conditions can mimic dying?

Answer 21

opioid toxicity
hypoactive delirium
sepsis
hypercalcaemia
AKI
hypoglycaemia

Question 22

are reversible factors always reversed?

Answer 22

no

not always the best thing for the patient if the deterioration has been sudden and QoL would be bad

Question 23

how is medication managed at end of life?

Answer 23

only essential medications continued (stop statins, anticoagulants etc)
oral meds converted to other route if no swallow
prescribe anticipatory medications for common problems
stop routine obvs/monitoring
take out unused cannulas

Question 24

common cause of agitation at end of life?

Answer 24

urinary retention

Question 25

what are syringe drivers?

Answer 25

continuous battery operated subcutaneous infusion of medicine
used when oral route not possible

Question 26

how is a syringe driver used?

Answer 26

sub cutaneous access via butterfly needle
up to 3 medicines can be mixed together in the syringe
infused over 24 hours
changed daily
portable

Question 27

how does subcutaneous morphine compare to oral morphine?

Answer 27

twice as strong

dose must therefore be divided by 2 if changing from oral to subcutaneous

Question 28

standard prescribing for pain/shortness of breath?

Answer 28

morphine 2mg subcutaneous every hour

Question 29

standard prescribing for distress?

Answer 29

midazolam 2mg subcutaneously every hour

Question 30

standard prescribing for nausea?

Answer 30

2.5 mg levomepromazine subcutaneously 12

Question 31

standard prescribing for secretions?

Answer 31

20mg buscopan every hour

Question 32

how is hydration and nutrition managed in the final days of life?

Answer 32

meticulous mouth care
s/cut or IV fluids generally not used as risks outweigh benefit
can trial artificial hydration if concern that patient is distressed due to thirst/dehydration

Question 33

how is death confirmed?

Answer 33

check for spontaneous movement (including resp effort)
check for reaction to voice and pain
palpate at least 2 major pulses for 1 min
inspect eyes for dryness, fixed dilated pupils, absence of corneal reflex and clouding of cornea
auscultate heart and lungs for 1 min
note if a pacemaker or other device implanted (risk during cremation)