End of Life Care

Question 1

Cancer pain usually has ______ pain with ________

Answer 1

background pain with intense bursts of pain

Question 2

Describe how you prescribe opioids for cancer pain?

Answer 2

Background pain: slow release morphine that lasts 12 hours taken twice daily prescribed as morphine sulphate M/R e.g. MST or Zomorph

Breakthrough pain: immediate release morphine that lasts 4 hours taken PRN, it is approx 1/6 of total background dose prescribed as morphine sulphate I/R e.g. oramorph or sevredol

Question 3

Describe how you would move to morphine from a weaker opioid (ie go from step 2 to step 3 on WHO pain ladder)?

Answer 3

Stop codeine or weak opioid

Switch to morphine sulphate M/R 15mg twice daily with morphine sulphate I/R PRN four hourly
Gradually titrate up background M/R morphine dose depending on the amount of PRN I/R morphine used and how effective it is
There is no maximum dose but monitor pain to make sure morphine is helping and there is no unwanted side effects.

Question 4

Not all pain responds to __________ and it is important to remember

Answer 4

Not all pain response to opioids and you may need to consider alternative analgesia if not helping

Question 5

3 common symptoms of opioid toxicity?

Answer 5

hallucinations
myoclonus
drowsiness

Question 6

What does opioid toxicity usually respond to?

Answer 6

dose adjustment or switching to a different strong opioid

Question 7

What should you check if someone suffers from opioid toxicity?

Answer 7

Should check renal function as morphine is renally excreted
if someone has poor renal function they are more likely to get toxicity because the morphine will build up in body as kidneys are bad at excreting it

Question 8

Describe resp depression and opioid toxicity?

Answer 8

Respiratory depression is a severe side effect of morphine and occurs rarely when used correctly, naloxone can reverse morphine very quickly, use small doses e.g. 80mg IV bolus every 2 mins to avoid pain reversal (don’t want to reverse opioid completely because they will be in high amounts of pain)

Question 9

What is the first line strong opioid?

Answer 9

Morphine

Question 10

What is the common second line opioid?

Answer 10

Oxycodone

Question 11

What two opioids are safe in severe renal impairment?

Answer 11

fentanyl and alfentanil

Question 12

List some signs of dying?

Answer 12

• Worsening weakness and performance status- usually bed bound
• Progressive fatigue, sleeping for longer periods with eventual unconsciousness
• Losing interest in fluid and food, eventual loss of swallow and unable to take oral meds
• Changes in breathing pattern with apnoeic spells

Question 13

List some treatable conditions that can mimic dying?

Answer 13

• Opioid/ drug toxicity
• Sepsis/ infection
• Hypercalcaemia
• AKI
• Hypoglycaemia

Question 14

Once you have identified someone who is dying what should you ensure?

Answer 14

• Only essential medications continued (stop statins, anticoagulants)
• Essential oral medications (particularly opioids) converted to alternative route if no swallow (if they not swallowing then could go into withdrawal and be in bad pain whilst dying)
• Anticipatory medications prescribed for common symptoms at the end of life
• Don’t miss urinary retention as a cause of agitation
• Stop routine obs/ monitoring/ take out unused cannulas
• Appropriate environment and equipment in place
• Offer holistic and spiritual support to family members, give regular updates

Question 15

Explain what syringe drivers are and when used?

Answer 15

Used when someone is dying because SCUT is smoothest delivery method
Up to 3 meds in syringe infused over 24 hours

Question 16

List anticipatory medicines for dying and what symptoms they are for?

Answer 16

Pain/ SOB > morphine 2mg subcut hrly if opioid naïve (or approx. 1/6 of background dose if already established on an opioid, use same opoiod for background and PRN)
Distress> midazolam 2mg scut hrly
Nausea > levomepromazine 2.5 mg scut twelve hrly
Secretions > buscopan 20mg scut hrly

Question 17

Is it normal for people to become too weak to swallow food or water in final days of life?

Answer 17

yes

natural part of dying process

Question 18

Are fluids usually used in someone who is dying?

Answer 18

No can be burdensome for patients and risks generally outweigh benefits
Can give a trial of artificial hydration if concerns that patient is distressed due to symptoms of thirst/ dehydration despite mouth care

Question 19

Explain the criteria needed to confirm a death?

Answer 19

Observe person for at least 5 minutes and must ascertain beyond doubt each of the following:

• Absence of carotid pulse over one minute
• Absence of heart sounds over one minute
• Absence of respiratory sounds over one minute
• No response to painful stimulus (trapezius squeeze)
• Fixed dilated pupils (unresponsive to bright light)