(Medication in) Palliative care

Question 1

Potential issues with routes of administration
Oral
Subcutaneous
Intramuscular
Sublingual/Buccal
Transdermal
Inhalation

Answer 1

Oral – primary route, use if available and appropriate.
Subcutaneous – preferred parenteral route
Intramuscular –painful. Difficult in cachectic patients.
Sublingual/Buccal – not useful if patient has a dry mouth.
 Transdermal – limitations; dose titration can be difficult .
 Inhalation – patient co-ordination can be an issue in the final stages.

Question 2

3 recenprtors involved in vomining (peripherally and in vom centre)

Answer 2

Vomiting centre (all feed into here)- ACh, H2. 5HT2
GI tract (stasis, obstruction, irritation)- D2, 5HT3
Vestibular input (motion sickness) - Ach, H1)
Higher centre (anxiety/ raised ICP) - H1
Cemoreceptor trigger zone ( biochemical e.g. drugs) - D2, 5HT3

Question 3

Give 3 treatable causes of nausea/vom

Answer 3

Drug side-effects, constipation, severe pain, anxiety, infection, cough, hypercalcaemia, raised intracranial pressure, and bowel obstruction.

Question 4

Give 4 non-pharma management strategies

Answer 4

• Control odours from colostomy, wounds and fungating tumours
• Minimise sight/smell of food
• Give small snacks not large meals
• Acupressure wrist bands

Question 5

N&V - Drug group Butyrophenone antipsychotics
example
mode of action
use
S/E(4)
Dose

Answer 5

example - Haloperidol
mode of action - Dopamine (D2 receptors) in chemo-receptor trigger zone
use - chemical causes of nausea (e.g. opioids)
S/E - EPSE, sedation, QT-prolongation,
depression
Dose - 500mcg - 1.5mg/24hr Continuous subcutaneous infusions (CSCI) or PO/SC at ight +/ 4hrly PRN (max 5mg/24hrs)

Question 6

What common palliative care med causes nausea

Answer 6

opioids

Question 7

N&V - Drug group Butyrophenone antipsychotics
example
mode of action
use
S/E(4)
Dose

Question 8

what anti-emetic is used in nausea and vomiting caused by intracranial tumours

Answer 8

dexamethasone

(reduces ICP)

Question 9

Metoclopramide and domperidone are pro-kinetic anti-emetics ( so useful in gastric dysmotility/stasis). What is the appropriate anti-emetic in refractory (tx resistant) vestibular causes of nausea and vomiting?

Answer 9

olanzapine

Question 10

Metoclopramide and domperidone are pro-kinetic anti-emetics ( so useful in gastric dysmotility/stasis). What is the appropriate anti-emetic in chemically-mediated causes of nausea and vomiting (e.g. chemo) ?

Answer 10

ondansetron

Question 11

name 2 anti-muscarinic medications which should not be co-prescribed with metoclopramide/ domperidone

Answer 11

cyclizine, hyoscine

Question 12

completing confirmation of death
a) what staff should be informed
b) when should the death certificate NOT be issues

Answer 12

• Inform relevant nursing staff of confirmation of death (If not present, nursing staff should inform next of kin )
• Coroner referral?
• If yes – do not issue death certificate & discuss with patient’s consultant

Question 13

certification of death
1a = the disease/ condition that lead directly to death. what “ conditions” would NOT be acceptable as a sole 1a

Answer 13

• “Failures” as a sole 1a (e.g. heart/kidney/liver/respiratory failure). (EXCEPT: congestive cardiac failure) .
• Asphyxia
• Asthenia
• Cachexia
• Cardiac arrest
• Coma
• Exhaustion
• Old age/frailty ( EXCEPT: in patients >80 years old).

Question 14

certification of death, Ia .
How would you fill in 2 primary causes of death

Answer 14

• enter them both on the same line, then in in brackets state they are joint causes of death

Question 15

who set the list for when a death should be referred to the coroner

Answer 15

Set by the Notification of Deaths Regulations (2019)

Question 16

what deaths should be referred to the coroner

Answer 16

remember 3

• Cause of death is unknown.
• Death may be suicide
• Identity of deceased is unknown
• Sudden/ unexpected death
  o Includes all deaths <24hrs after Adx
• Deceased person had not seen a doctor within 14 days before e their death
• Death considered suspicious, unnatural or violent
  o Poisoning/ otherwise benign substance
  o Exposure/ contact with toxic substance
  o Medicinal product
  o Violence/trauma/ injury (inc. self harm)
• Death due to an accident or (self-)neglect
• Death is/ could be due to their prior employment ( e.g. industrial disease/ injury)
• Death may be due to an abortion
• Death during an operation/ before recovery from anaesthetic
• Death during or shortly after police custody / detention
• There was no attending registered medical practitioner/ other registered practitioner to sign a medical certificate cause of death
• The attending medical practitioner is not available within a reasonable time of the persons death to sign the certificate

Question 17

how to refer deceased to coroner

Answer 17

talk to hospital bereavement team on how to contact coroner’s office

Coroners are often lawyers and occasionally doctors, or dual-qualified.