Ageing and End of Life Care

Question 1

What is palliative care about?

Answer 1

Doing everything possible to support someone’s quality of life in the context of an incurable illness

Question 2

What communication should take place in palliative care?

Answer 2

Proactive communication = recording and sharing discussions is essential

Question 3

What are electronic advance care plans?

Answer 3

Created by GPs and shared with other professionals involved in patient care = called a Key Information Summary in Scotland

Question 4

What patients should have a key information summary?

Answer 4

All patients identified with a life limiting illness who are at risk of decline

Question 5

When is palliative care offered?

Answer 5

At any time from diagnosis = some patients have prognosis of many months or years

Question 6

Where is most palliative care provided?

Answer 6

By hospitals, nursing homes and community teams = only tiny percentage die in hospice

Question 7

Why do specialist palliative care teams exist?

Answer 7

Some patients with complex needs require additional support by teams with specialist experience in providing palliative care

Question 8

What are some examples of specialist palliative care services?

Answer 8

Hospices, community palliative care teams and hospital palliative care teams

Question 9

What is step 1 for pain management?

Answer 9

Mild pain = paracetamol 1g 4x daily +/- NSAID +/- other adjuvant

Question 10

What is step 2 for pain management?

Answer 10

Moderate pain = codeine 30-60mg 4x daily or cocodomol 4x daily +/- neoadjuvant

Question 11

What is step 3 for pain management?

Answer 11

Severe pain = stop codeine and switch to strong opioid (usually morphine) +/- paracetamol/NSAIDs/adjuvants

Question 12

How is morphine given for background pain?

Answer 12

Modified release = 2x daily tablet

Question 13

How is morphine given for breakthrough pain?

Answer 13

Immediate release = PRN tablet or liquid (oramorph)

Question 14

What is the maximum dose of morphine?

Answer 14

No maximum dose but monitor pain to make sure morphine is helping and that there are no unwanted side effects

Question 15

What patients are likely to suffer withdrawal if their morphine is stopped?

Answer 15

Those established on morphine = opioid tolerant

Question 16

What are the symptoms of morphine toxicity?

Answer 16

Hallucinations, myoclonus, drowsiness

Question 17

Why must renal function be considered in a patient with morphine toxicity?

Answer 17

Morphine undergoes renal excretion = if renal function impaired then morphine will accumulate

Question 18

What is a severe side effect of morphine toxicity?

Answer 18

Respiratory depression

Question 19

What is used to reverse morphine toxicity?

Answer 19

Naloxone

Question 20

What are some signs that someone is dying?

Answer 20

Worsening weakness and performance status
Worsening physiological status with no reversibility
Struggling to manage oral medicines
Losing interest in food and fluid
Sleeping more, eventual unconsciousness

Question 21

What are some conditions that mimic dying?

Answer 21

Opioid/drug toxicity, sepsis, hypercalcaemia, AKI, hypoglycaemia

Question 22

How is comfort maintained when someone is dying?

Answer 22

Only essential medications continued
Oral medications converted to alternative route where possible if no swallow
Anticipatory medications given for common problems

Question 23

What is the benefit of syringe drivers?

Answer 23

Smoothest delivery of medicines = gives subcutaneous infusion

Question 24

What are some features of syringe drivers?

Answer 24

Access via butterfly needle with connector tubing
Up to 3 medicines can be mixed in syringe
Infused over 24 hrs and changed daily

Question 25

Is subcutaneous morphine the same strength as oral morphine?

Answer 25

No = subcutaneous morphine is twice as strong as oral morphine

Question 26

How is the dose of subcutaneous morphine needed calculated?

Answer 26

Divide total daily oral morphine dose by 2

Question 27

What are some examples of anticipatory prescribing?

Answer 27

Pain or SOB = morphine 2mg subcutaneous hourly Distress = midazolam 2mg subcutaneous hourly Nausea = levomepromazine 2.5mg subcutaneous 12hr Secretions = buscopan 20mg subcutaneously hourly

Question 28

What are Just in Case boxes?

Answer 28

Used for subcutaneous symptom control at home to prevent delays in symptom relief

Question 29

Why is mouth care important in the final days of life?

Answer 29

People become too weak to swallow food or water = keep mouth moist as symptomatic relief

Question 30

Are subcutaneous/IV fluids given when a patient can no longer swallow in the final days of life?

Answer 30

Not routinely = risks generally outweigh benefits | Can give artificial hydration if concerned about distress due to symptoms of thirst despite mouthcare

Question 31

Who can verify expected deaths?

Answer 31

Will usually be "Nurse can Verify"

Question 32

How do you verify a death?

Answer 32

Check for spontaneous movement 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 reflexes and clouding of cornea Auscultate heart and lungs for 1 min

Question 33

What must be recorded when verify a death?

Answer 33

Date and time of death | Presence of pacemaker or other implantable devices

Question 34

What must be remembered when filling in a death certificate?

Answer 34

Check cause of death with senior and that reporting of death to procurator fiscal isn't needed

Question 35

What information is made available to families once a relative has died?

Answer 35

Information packs = registering the death and getting a funeral director as key steps

Question 36

How audits the accuracy of death certificates?

Answer 36

Death certification review services