Palliative Flashcards
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?
Morphine, Midazolam, Hyoscine Butybromide, Levomepromazine
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
C - Hyoscine Butylbromide
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
E - Refer to a Physiotherapist for non-pharmacological breathlessness management
What are the different types of pain?
Nociceptive
Neuropathic
Mixed/complex pain
Describe the difference between somatic and visceral pain
Somatic pain is sharp, localised and defined (hurts where it is) whereas visceral pain is dull, diffuse, vague and can be referred.
Describe neuropathic pain
Follows nerve distribution as related to nerve damage or dysfunction
What is neuralgia?
Pain in the distribution of nerves
What is allodynia?
Pain from a stimulus that does not usually
provoke pain.
What is hyperalgesia?
Increased response to a normally painful
stimulus.
What is the first step in the WHO pain management ladder?
Paracetamol + NSAID (regular)
+/- adjuvant analgesic (pain-killers whose primary indication is for something other than pain)
What is the second step in the WHO pain management ladder?
Step 1 + regular mild opioid (tramadol or codeine)
Give examples of adjuvant analgesics
Gabapentin
Amitriptyline
What type of drug is gabapentin?
Anti-convulsant
What type of drug is amitriptyline?
Tricyclic antidepressant
What is step three in the WHO pain management ladder?
Step 1 + regular strong opioid (morphine, fentanyl, diamorphine)
How do you convert oral morphine to S/C morphine (syringe driver)?
Divide the 24 hour oral dose of morphine by 2
How do you calculate dosage for breakthrough pain?
1/6th of total morphine in 24 hours (PRN)
How do you calculate MST dosage?
Oramorph 5mg prn 4 hourly
Once pain controlled, assess total dose
morphine over 24 hours and convert to twice daily MST
What should you prescribe alongside opioids?
Laxative and anti-emetic
Which anti-emetics are commonly used alongside opioids for N+V?
Metoclopramide
Levomepromazine
What drug is prescribed for distress?
Midazolam
What class of drug is levomepromazine?
Anti-emetic
What drug is prescribed for respiratory secretions?
Buscopan
What is the management of SVC obstruction?
- High dose corticosteroids (dexamethasone or prednisolone - consider gastric protection)
- Smoking cessation
- Hand-held fan
- Maintain activity levels
Management of breathlessness in pallative patients
- Opioids
- Corticosteroids
- Benzodiazepine
- Oxygen
- Inhaled therapy
What type of drug is midazolam?
Benzodiazepine
Name some benzodiazepines
Midazolam
Lorazepam
Diazepam
What is a clear sign of superior vena cava (SVC) obstruction?
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.
What are the symptoms of venous hypertension?
breathlessness
visual changes
dizziness
headache – worse on stooping
swelling of face, neck and arms
What are the signs of venous hypertension?
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
What needs to be monitored alongside steroids?
Blood glucose
