OTHER PRESCRIBING

Question 1

Management of secretions e.g. death rattle?

Answer 1

Avoid fluid overload
Educate family that pt is unlikely to be troubled by secretions
Hyoscine hydrobromide or hyoscine butylbromide is first line (both same effectiveness but butylbromide may be less sedative)
Suctioning of secretions can also be done

Question 2

Management of intractable hiccups?

Answer 2

Chlorpromazine
(Haloperidol and gabapentin can be used)

Question 3

Management agitation and confusion?

Answer 3

Look for and treat any underlying causes. If not…
Haloperidol is first line
(Other options: chlorpromazine or high dose levomepromazine)

In the terminal phase of illness - midazolam

Question 4

Moa of hydroscine hydrobromide or hyoscine butylbromide?

Answer 4

Antimuscarinic - reduce bronchial secretions by acting on ACH receptors

Question 5

Why does hydroscine hydrobromide cause more drowsiness than hyoscine butylbromide?

Answer 5

As hyoscine butylbromide does not cross the blood-brain barrier and therefore does not cause drowsiness or have a central anti-emetic action

Question 6

Causes of dyspnoea at end of life?

Answer 6

Direct result of cancer e.g. tumour involving lung parenchyma, airway obstructions etc
Indirect efefcts of cancer e.g. Pleural effusions, Pericardial effusions, superior vena cava syndrome, anaemia, fibrosis, PE
Pneumonia
COPD
HF
Pneumothorax
Anxiety/fear/distress
Obesity
Fever

Question 7

What is the main mode of death in palliative care?

Answer 7

Respiratory failure and pronoun hypoxia

Question 8

In one such situation a man was dying of a combination of Neuromyelitis Optica (Devic’s disease)
and COVID-19. We reduced his oxygen to 2L via NC. He complained of breathlessness that night
so the nurse checked his saturations to find they were 77%. She therefore put him back on 15L
NRB.
Was this the right thing to do? If you think not what can you do as the doctor to safeguard against this?
Have a think about whether the above constitutes good palliative care or not.
What are the options here to manage the feeling of breathlessness caused by hypoxia?

Answer 8

This may be the right thing to do if it makes him less symptomatic and relieving suffering. However, if this is not causing any significant distress then you might consider opioids to relieve dyspnoea. Oxygen therapy can be uncomfortable and distressing and likely wont actually prolong the patients life.
You can safeguard against this with advance directives