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CCC > CCC: Palliative Care > Flashcards

CCC: Palliative Care Flashcards

1
Q

What is the duration of action of immediate release morphine? e.g. oramorph

A

20-30 mins for effect, 4 hours duration

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2
Q

What is the duration of action of modified release morphine? e.g. MST

A

12 hours duration

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3
Q

What is the duration of action of modified release morphine? e.g. MST

A

12 hours duration

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4
Q

What are the side effects of opioids?

A
  1. Constipation (common) - give laxative e.g. lactulose
  2. Nausea and vomiting (common) - relieves in days, give anti-emetics e.g. haloperidol
  3. Drowsy - relieves in 48hrs, if persistent and severe reduce dose
  4. Hallucinations (rare) - reduce dose
  5. Respiratory depression (rare) - reduce dose
  6. Dependence - withdrawal
  7. Addiction -
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5
Q

What are the side effects of opioids?

A
  1. Constipation (common) - give laxative e.g. lactulose
  2. Nausea and vomiting (common) - relieves in days, give anti-emetics e.g. haloperidol
  3. Drowsy - relieves in 48hrs, if persistent and severe reduce dose
  4. Hallucinations (rare) - reduce dose
  5. Respiratory depression (rare) - reduce dose
  6. Dependence - withdrawal
  7. Addiction (rare)
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6
Q

What are the signs of opioid toxicity?

A
  1. Severe nausea and vomiting
  2. Pin point pupils
  3. Confusion, drowsy, hallucinations
  4. Respiratory depression
  5. Myoclonic jerks
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7
Q

In which patients must you avoid morphine?

A

Chronic kidney disease

- Alfentanil, Fentanyl or Buprenorphine patches are preferred

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8
Q

In which patients must you avoid morphine? What can you use instead?

A

Chronic kidney disease

- Alfentanil, Fentanyl or Buprenorphine patches are preferred

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9
Q

In which patients must you avoid morphine? What can you use instead?

A

Chronic kidney disease

- Alfentanil, Fentanyl or Buprenorphine patches are preferred

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10
Q

How long does Fentanyl and Buprenorphine patches work?

A

72 hours duration - transdermal patch

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11
Q

What is the 2nd line strong opioid?

A

Oxycodone

  • Immediate release = Oxynorm
  • Modified release = Oxycontin
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12
Q

When would a patient require a patch rather than oral pain relief?

A

Chronic pain
Stable pain
Unable to tolerate oral - dysphagia, severe vomiting
Chronic kidney disease or renal impairment
Poor adherence/compliance

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13
Q

What is the 3rd line strong opioids?

A

Patches i.e. fentanyl, alfentanil, buprenorphine

  • last 72 hours
  • x3 as strong
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14
Q

What is the 3rd line strong opioids?

A

Patches i.e. fentanyl (x3 as strong as morphine), alfentanil, buprenorphine (x2 as strong as morphine)
- last 72 hours

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15
Q

What is the 3rd line strong opioids?

A

Patches i.e. fentanyl (divide dose of morphine by 3), alfentanil, buprenorphine (divide dose of morphine by 2)
- last 72 hours

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16
Q

What is the conversion factor for Co-codamol to oral morphine

A

Co-codamol dose / 10 = PO morphine

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17
Q

What is the conversion factor for Co-codamol to oral morphine

A

Co-codamol dose / 10 = PO morphine

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18
Q

What is the conversion factor for PO morphine to IV or SC?

A

PO morphine / 2 = IV/SC Morphine

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19
Q

What is the conversion factor for PO to SC Diamorphine?

A

PO morphine / 3 = SC Diamorphine

20
Q

What is the conversion factor for PO morphine to SC Diamorphine?

A

PO morphine / 3 = SC Diamorphine

21
Q

What is the conversion factor of PO morphine to (a) PO (b) SC Oxycodone?

A

PO morphine / 1.5-2 = PO Oxycodone

PO Oxycodone / 2 = SC Oxycodone

22
Q

What is the conversion factor of PO morphine to (a) PO (b) SC Oxycodone?

A

PO morphine / 1.5-2 = PO Oxycodone

PO Oxycodone / 2 = SC Oxycodone

23
Q

What is the conversion factor of PO morphine to (a) fentanyl patch (b) bupornoprhine patch

A

PO morphine / 3 = Fentanyl patch

PO morphine / 2 = Buponorphine patch

24
Q

What is the break through dose for 30mg BD of MST?

A

10mg Oramorph PRN

25
Q

What is the break through dose for 30mg BD of MST?

A

10mg Oramorph PRN

26
Q

Which laxatives are stool softners?

What are the side effects?

A

Lactulose
Sodium Docusate
SE - flatulence and bloating

27
Q

Which laxatives are purely pro-kinetic? when would you not use these?

A

Senna
Dantron
Biscodyl

CI - never use in bowel obstruction or if patient has colic

28
Q

Which laxatives have mixed action? when would you use these?

A

Movicol - opioid induced constipation

Co-danthrusate

29
Q

What is the treatment for intestinal obstruction?

A
  1. NBM
  2. Ryles NGT - drain bowel of fluids
  3. IV Fluids or TPN
  4. Stop all pro-kinetic drugs including stimulant laxatives (senna, dantron, biscodyl) and anti-emetics (metoclopramide)
  5. Surgery
30
Q

What are the causes of gastric vomiting?

What is the presentation of vomiting caused by gastric causes?

What is the suitable treatments?

A

Gastric stasis or irritation
- tumour, hepatomegaly, dysmotility, large liver metastasis, ascites

Presentation: 
Large vomits with minimal nausea between 
Early satiety (fullness) 
Hiccups
Heartburn

Treatment:
1st line - Metoclopramide (10-20mg PO before meal or 30-60mg SC over 24hrs)
2nd line - Domperidone
- both are pro-kinetics and must not be used if colic or intestinal obstruction

31
Q

What are the causes of toxic vomiting?

What is the presentation of vomiting caused by toxic causes?

What is the suitable treatments?

A

Toxic

  • Drugs e.g. chemo, opioids
  • Electrolyte imbalance e.g. hypercalcaemia, uraemia
  • Infection e.g. UTI, pneumonia

Presentation:

  • Frequent, regular small vomits of possessing or wrenching
  • Continuous or intermittent nausea
Treatment: 
1st line - Haloperidol 
2nd line - Metoclopramide 
2nd line - Levomepromazine 
2nd line - Ondansetron (sickness related to chemo)
32
Q

What are the causes of vomiting due to raised ICP?

What is the presentation of vomiting due to raised ICP?

What is the suitable treatments?

A

Raised ICP
- CNS tumour, SoL, metastatic disease

Presentation: 
Early morning headache - worse on straining, coughing, lying down, bending over 
Vomiting with little nausea 
Focal neurological deficit 
Others: U/L eye dilation, papilloedema

Treatment:
1st line = Dexamethasone (8-16mg PO)
2nd line = Cyclizine (50mg TDS)

33
Q

What is the presentation of anxiety/anticipatory vomiting?

What is the suitable treatments?

A

Anxiety
Specific precipitant - breaking bad news, surgery, chemo, consultations
Psychiatric signs - rumination, derealisation, irritable, poor concentration

Treatment:
1st line = BZDs, CBT

34
Q

What is the treatment for dyspnoea in palliative care?

A
  1. Non pharmacological
    a. Breathing techniques, physiotherapy
    b. Fan onto face (helps quite a lot, better than oxygen)
  2. Pharmacological
    a. Opioids (immediate release oramorph, diamorphine, sevredol) acts as respiratory depressant
    b. BZDs (if due to anxiety)- Lorzepam (0.5-1mg sublingual) or Midazolam (0.5-1mg SC if oral not tolerated)
35
Q

What is the treatment for cough in palliative care?

A

Treat cause, but if unable to, try:

a. Saline nebs - if difficulty expectorating
b. Simple linctus - if dry, irritant cough
c. Opioids (respiratory suppressant) e.g. morphine or codeine linctus

36
Q

What advanced statements can be provided during palliative or terminal care?

A

Advanced statement for best interests decision
Advanced statement for refusal of treatment
Appointment of LPA for health and welfare and property and affairs

37
Q

What signs may indicate a patient requires end of life care?

A 
Step-wise deterioration in physical function 
Change in breathing pattern 
Loss of appetite for food 
Cannot tolerate oral medication 
Profoundly weak 
Bed bound most days 
Death rattle 
Terminal restlessness 
Limited attention span 
Drowsy, confused or disorientated
38
Q

A terminal care patient is suffering from a dry mouth, how will you manage this?

A

Good mouth care - frequent sips of cold unsweetened drinks, ice pops, vaseline (lips), pilocarpine (salivary stimulant)

Do not give fluids - fluids increase peripheral and pulmonary oedema, making it harder to breathe. The benefits of withdrawing fluids are reduced vomiting, incontinence and preventing painful venepuncture

39
Q

What are the 4 common medications given at end of life care and how are they given?

A

Analgesia
Anti-emetics
Anti-secretory
Anxiolytics

Via Syringe Driver

40
Q

How would you manage a patient with terminal restlessness in terminal care?

A

Look for any reversible causes of pain or discomfort

1st line = Midazolam (2.5-5mg SC or 10-60mg infusion/24hrs) - a short/fast acting sedative anxiolytic, anti-convulsant, muscle relaxant

2nd line = Levomepromazine or Haloperidol

41
Q

what is a ‘death rattle’ and how would you manage it?

A

Death rattle - noise a terminally ill patient makes when they are too weak to expectorate their secretions

Reposition the patient

1st line = Hyoscine butyl bromide aka Buscopan
2nd line = Hyoscine hydrobromide (may cause paradoxical agitation)

42
Q

What are the indications for a syringe driver?

A 
Palliative or Terminal care patients 
Unable to swallow medication due to reduced LoC 
Dysphagia 
Persistant nausea and vomiting 
Malabsorption of drugs 
Intestinal obstruction
43
Q

What is the most common syringe driver used?

A

McKinley T34

44
Q

Talk through the process of a syringe driver?

A

Administers anxiolytics, anti-secretory, analgesia, anti-emetics

Butterfly needle inserted subcutaneously into chest, abdomen, upper arm or thigh
Covered with transparent dressing
Rotate SC needle site
If precipitation - may indicate drugs are incompatible

45
Q

List the analgesia, anti-emetics, anti-secretory and anxiolytic agents pescribed in a syringe driver?

A

Analgesia:

  • MST (5mg starting dose)
  • Diamorphine (5mg starting dose)

Anti-emetic:

  • Metoclopramide (30-60mg)- 1st line gastric, 2nd line toxic must not use in intestinal obstruction or colic
  • Haloperidol (3-10mg) - 1st line toxic, also A/P, may cause EPSE
  • Levomepromazine (6.5-100mg) - 2nd line toxic, also sedative, A/P, causes skin irritation
  • Cyclizine (100-150mg) - Cerebellar, causes skin irritation

Anti-secretory

  • Hyoscine butylbromide (100-150mg) - 1st line, also anti-spasmodic
  • Hyoscine hydrobromide (400mcg - 2.4mg) - 2nd line, also anti-spasmodic, also causes paradoxical agitation

Anxiolytics
- Midazolam (10-60mg) - also sedative, anti-convulsant

46
Q

What are the 11 reasons to make a referral to HM coroner?

A

Any death which meets the following:

  1. Unknown cause
  2. Suspicious circumstances
  3. Violence or negligence
  4. Un-natural causes
  5. At work or due to occupational hazard
  6. In custody or prison
  7. Within < 24hrs admission to hospital
  8. Not seen during last illness by doctor
  9. Seen but not in last 14 d
  10. During operation or before waking up from GA
  11. Sudden and unexpected
47
Q

After death what are the key things to do?

A

Inform GP within 24 hours
Administer death ceritificate - aim for 24 hours
Out of hours handover form completed

CCC (7 decks)

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