Palliative

Question 1

A 65-year-old man is approaching the end of his life due to end stage COPD. He is being supported at home by his husband and the primary care team. He is thought to be in the last days or weeks of life. Which ‘Just in Case Medications’ would usually be prescribed?

Answer 1

Morphine, Midazolam, Hyoscine Butybromide, Levomepromazine

Question 2

A 39-year-old man is at the very end of his life with a likely prognosis of a number of days. The goals of his care are comfort and he and his family have been updated and aware of what is happening. He is not able to communicate verbally now. He has started to experience upper respiratory tract secretions and appears distressed by these.

Which medication would you prescribe for secretions?

A - Oxygen
B - Saline Nebuliser
C - Hyoscine Butylbromide
D - Antibiotics

Answer 2

C - Hyoscine Butylbromide

Question 3

A 70-year-old gentleman has a diagnosis of lung cancer and is receiving best supportive care. He is known to the palliative care team in the community. He has gradually increased breathlessness due to the malignancy and potentially reversible causes of the breathlessness have been excluded. He does not experience cough as a symptom.

Which is the best next step in management for the shortness of breath he is experiencing?

A - Intravenous Frusemide
B - Saline Nebuliser
C - Refer to a Physiotherapist for non-pharmacological breathlessness management
D - As required subcutaneous Opioids
E - As required subcutaneous Benzodiazepine

Answer 3

E - Refer to a Physiotherapist for non-pharmacological breathlessness management

Question 4

What are the different types of pain?

Answer 4

Nociceptive
Neuropathic
Mixed/complex pain

Question 5

Describe the difference between somatic and visceral pain

Answer 5

Somatic pain is sharp, localised and defined (hurts where it is) whereas visceral pain is dull, diffuse, vague and can be referred.

Question 6

Describe neuropathic pain

Answer 6

Follows nerve distribution as related to nerve damage or dysfunction

Question 7

What is neuralgia?

Answer 7

Pain in the distribution of nerves

Question 8

What is allodynia?

Answer 8

Pain from a stimulus that does not usually
provoke pain.

Question 9

What is hyperalgesia?

Answer 9

Increased response to a normally painful
stimulus.

Question 10

What is the first step in the WHO pain management ladder?

Answer 10

Paracetamol + NSAID (regular)
+/- adjuvant analgesic (pain-killers whose primary indication is for something other than pain)

Question 11

What is the second step in the WHO pain management ladder?

Answer 11

Step 1 + regular mild opioid (tramadol or codeine)

Question 12

Give examples of adjuvant analgesics

Answer 12

Gabapentin
Amitriptyline

Question 13

What type of drug is gabapentin?

Answer 13

Anti-convulsant

Question 14

What type of drug is amitriptyline?

Answer 14

Tricyclic antidepressant

Question 15

What is step three in the WHO pain management ladder?

Answer 15

Step 1 + regular strong opioid (morphine, fentanyl, diamorphine)

Question 16

How do you convert oral morphine to S/C morphine (syringe driver)?

Answer 16

Divide the 24 hour oral dose of morphine by 2

Question 17

How do you calculate dosage for breakthrough pain?

Answer 17

1/6th of total morphine in 24 hours (PRN)

Question 18

How do you calculate MST dosage?

Answer 18

Oramorph 5mg prn 4 hourly
Once pain controlled, assess total dose
morphine over 24 hours and convert to twice daily MST

Question 19

What should you prescribe alongside opioids?

Answer 19

Laxative and anti-emetic

Question 20

Which anti-emetics are commonly used alongside opioids for N+V?

Answer 20

Metoclopramide
Levomepromazine

Question 21

What drug is prescribed for distress?

Answer 21

Midazolam

Question 22

What class of drug is levomepromazine?

Answer 22

Anti-emetic

Question 23

What drug is prescribed for respiratory secretions?

Answer 23

Buscopan

Question 24

What is the management of SVC obstruction?

Answer 24

• High dose corticosteroids (dexamethasone or prednisolone - consider gastric protection)
• Smoking cessation
• Hand-held fan
• Maintain activity levels

Question 25

Management of breathlessness in pallative patients

Answer 25

1. Opioids
2. Corticosteroids
3. Benzodiazepine
4. Oxygen
5. Inhaled therapy

Question 26

What type of drug is midazolam?

Answer 26

Benzodiazepine

Question 27

Name some benzodiazepines

Answer 27

Midazolam
Lorazepam
Diazepam

Question 28

What is a clear sign of superior vena cava (SVC) obstruction?

Answer 28

Swollen face and visible veins are suggestive of Superior Vena Cava Obstruction (SVCO) which causes a reduction in blood flow from the head, neck and upper extremities to the heart.

Question 29

What are the symptoms of venous hypertension?

Answer 29

breathlessness
visual changes
dizziness
headache – worse on stooping
swelling of face, neck and arms

Question 30

What are the signs of venous hypertension?

Answer 30

conjunctival and peri-orbital oedema
papilloedema – late
dilated neck veins – non-pulsatile
dilated collateral veins – arms and anterior chest wall
oedema of hands and arms
stridor
cyanosis
increased respiratory rate

Question 31

What needs to be monitored alongside steroids?

Answer 31

Blood glucose