pallative care

Question 1

how do you identify the dying phase?

Answer 1

The patient may be dying if two or more apply:
* Bed bound and/or has profound weakness
* Reducing level of consciousness
* Taking only sips of fluid
* Unable or having difficulty taking oral medication
* Deteriorating day by day

Question 2

how do you review a pallative patients regular medication?

Answer 2

Non-essential drugs should be discontinued
Essential regular oral drugs (analgesics, anti-emetics, anticonvulsants,
steroids) should be converted to alternative route if possible, usually SC, either
as stat dose or via a continuous subcutaneous infusion (CSCI) i.e. a syringe
driver
PRN medication should be prescribed for any anticipated symptoms, to be
administered subcutaneously

Question 3

what is anticipatory medication at the end of life?

Answer 3

PRN subcutaneous medication should be prescribed (proactively) for:
* pain
* agitation / restlessness
* respiratory tract secretions
* nausea / vomiting
* breathlessness

Question 4

if a patient isnt on regular analgesia and pain free what should be prescribed for pain?

Answer 4

PRN subcutaneous analgesia should be prescribed: Morphine injection 2.5mg – 5 mg PRN up to hourly SC

Question 5

what should the patient be prescribed for pain if not on any regular analgesia and in pain?

Answer 5

Morphine injection 2.5mg STAT SC

Question 6

if patient is feeling the effect of stat dose of morphine whilst in pain and no other analgesia prescribed what should be done?

Answer 6

Morphine injection 10mg SC over 24 hours via CSCI andPRN morphine as above

Question 7

when converting oral morphine to sc what do you have to remeber?

Answer 7

to include the break through doses in the total daily dosage and to divide answer by two

Question 8

what can drugs be mixed with in the syringe driver?

Answer 8

• Mix with water for injection or 0.9% sodium chloride

Question 9

how many drugs are usually mixed in a syringe driver?

Answer 9

usually 2, sometimes 3

Question 10

what happens if there is too many drugs/ incompatible?

Answer 10

may use more than 1 syringe driver

Question 11

what must you consider about the drugs when using syringe driver?

Answer 11

• Consider prescribing longer acting drugs separately as stat SC doses
  eg levomepromazine, haloperidol

Question 12

what should you prescribe if syringe driver irritating to skin?

Answer 12

consider adding dexamethasone

Question 13

can oxycodone be used in patients with renal impairment?

Answer 13

with caution

Question 14

who is alfentanil mostly used in and why?

Answer 14

• Not excreted renally therefore used in CSCI to manage opioid sensitive pain
  in patients with severe renal impairment

Question 15

why is aldentanil not practical for community use?

Answer 15

Very short half life (1-2 hours) therefore not practical to use as PRN dose in
community - low dose oxycodone injection used instead

Question 16

what is allodynia?

Answer 16

Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin

Question 17

what is hyperalgesia?

Answer 17

An increased response to a stimulus which is normally painful

Question 18

what is the strategy for the management of neuropathic pain?

Answer 18

• Avoid escalating opioid doses when pain appears refractory and poorly opioid sensitive
• Higher risk of opioid toxicity
• Consider the use of adjuvant analgesics

Question 19

how does the neuropathic pain ladder go?

Answer 19

steroid, antidepressant, anticonvulsant, NMDA antagonist, spinal anlagesia

Question 20

what are some causes of nausea and vomiting?

Answer 20

• Drugs opioids,
  chemotherapy, digoxin etc.
• Radiotherapy especially
  gut area
• Biochemical 
  hypercalcaemia, uraemia,
  sepsis
• Liver failure
• Gastric stasis
• Bowel obstruction
• Constipation
• Raised intracranial pressure
• Brain tumour/metastases
• Squashed stomach
• Anxiety, fear, conditioned,
  anticipatory

Question 21

what should be done if patient needs antiemetic but already prescribed on?

Answer 21

his should be converted to subcutaneous route and given via a syringe driver
Note: domperidone cannot be given by injection, therefore convert to alternative prokinetic e.g. metoclopramide

Question 22

what should be given if metabolic, infective or drug induced cause is likely nausea and vom?

Answer 22

Haloperidol injection
0.5-1.5mg SC hourly PRN (max 3mg SC in 24hours)

Question 23

what do you give for n/v caused by bowel distension/ obstruction, vestibular problems, raused ic pressure?

Answer 23

cyclizine SC 50mg hourly

Question 24

who should not be prescrived cyclizine and why?

Answer 24

patients in severe hf or renal failure- tachycardia
alt- haloperidol or levomepromazine

Question 25

what is gastric stasis? what may cause it?

Answer 25

• Gastric stasis – large volume vomits; hiccups; belching. Unlikely to startin
  dying phase
• Check for over-feeding first
• if PEG fed, reduce or stop feed and stop IV/SC fluids when dying
• if family feeding patient, suggest reduce intake or stop

Question 26

what should be given if patients do not respond to antiemetic?

Answer 26

a combination of antiemetics should be considered or a broader spectrum
antiemetic, such as Levomepromazine injection

Question 27

why may nausea and vomiting failed to be controlled?

Answer 27

Wrong Drug
Wrong Dose
Wrong route of administration
Plumbing problem

Question 28

what is agitation?

Answer 28

Restlessness:
Finding no rest, uneasy, agitated
Constantly in motion and fidgeting
Agitation:
Shaking, moving, unsettled can be both mental and/or physical
Terminal agitation means agitation that occurs in the last few days of life
Delirium:
Disordered state of mind with incoherent speech hallucinations / paranoia

Question 29

what can cause agitation?

Answer 29

Medication, pain, nausea,
emotional distress, anxiety, fear,
insomnia, neurological deficit

Question 30

what is usually given for agitation in the dying phase/

Answer 30

Midazolam injection
2.5 - 5mg SC PRN hourly
f agitation does not settle with increasing doses of midazolam up to 60mgs /
24hrs, consider use of:
Levomepromazine injection
6.25mg / 12.5mg SC PRN can be up to hourly

Question 31

what can be used to treat respiratory tract secretions?

Answer 31

Hyoscine hydrobromide injection or
Hyoscine butylbromide injection (non sedating)
If patient still has secretions despite hyoscine HB/BB, consider prescribing
Glycopyrronium injection

Question 32

what should a patient be given for breathlessness if not prescribed an opioid?

Answer 32

prescribe opioid injection 2.5mg-5mg SC up to hourly PRN
(prescribe the same opioid as used for analgesia)

Question 33

what should patient be given for breathlessness if on opioid?

Answer 33

prescribe midazolam 2.5mg-5mg SC
up to hourly PRN