Palliative Care

Question 1

What are the four domains of palliative care?

Answer 1

Physical, psychological, spiritual, social

Question 2

Describe the Management of Pain ladder?

Answer 2

Step 1: Non opioid e.g. aspirin, paracetamol, NSAID plus or minus an adjuvant
Step 2: Weak opioid for mild to moderate pain e.g. codeine plus or minus non opioid plus or minus adjuvant
Step 3: strong opioid for moderate or severe pain plus or minus non-opioid plus or minus adjuvant

Question 3

What are adjuvants for pain medication?

Answer 3

enhance the effect
e.g. anti-depressants, anticonvulsants, local anaesthetics, steroids

Question 4

How is morphine prescribed for cancer pain?

Answer 4

slow release morphine that is taken twice daily for background pain
(prescribed as morphine sulphate M/R e.g. MST and zomorph)

then immediate release morphine for break through pain which is taken PRN and is approx 1/6 of total background dose e.g. Oramorph and sevredol

Question 5

If strong opioid side effects occur what can someone be switched to?

Answer 5

Another strong opioid e.g. morphine to oxycodone
(morphine is 1st line, oxycodone is 2nd)

Question 6

What are the safest strong opioids in renal impairment?

Answer 6

Fentanyl and alfentanil

Question 7

List 7 things you should ensure in a dying patient?

Answer 7

Ensure:
Only essential medications continued (stop statins, anticoagulants)
Essential oral medications (particularly opioids) converted to alternative route if no swallow
Anticipatory medications prescribed for common symptoms at the end of life
Don’t miss urinary retention as a cause of agitation
Stop routine obs/monitoring/take out unused cannulas
Appropriate environment and equipment in place
Offer holistic and spiritual support to family members, give regular updates

Question 8

What are syringe drivers used for?

Answer 8

Smoother delivery of medications when oral route not available

Question 9

How do you change morphine dose from oral to SCUT?

Answer 9

SCUT morphine is twice as strong as ORAL morphine

To work out SCUT dose, divide the total daily oral morphine dose by 2

Question 10

List Anticipatory/ just in case medications?

Answer 10

Pain / SOB Morphine 2mg scut hrly (or approx 1/6 background dose if already established on an opioid, use same opioid for background and PRN)

Distress Midazolam 2mg scut hrly

Nausea Levomepromazine (antagonist in CNS) 2.5mg scut twelve hrly

Secretions Buscopan 20mg scut hrly

Question 11

List confirmation of death criteria?

Answer 11

The Registered Healthcare Professional Confirming Death should observe the person for a minimum of 5 minutes and must ascertain beyond doubt each of the following:
Absence of carotid pulse over one minute
Absence of heart sounds over one minute
Absence of respiratory sounds over one minute
No response to painful stimulus (trapezium squeeze)
Fixed dilated pupils (unresponsive to bright light)

Question 12

What is the first line strong opioid?

Answer 12

Morphine

Question 13

3 common symptoms of opioid toxicity?

Answer 13

hallucinations
myoclonus
drowsiness

Question 14

Management of breathlessness in a palliative patient?

Answer 14

Assess causes, potential options:
opioids, benzodiazepines, oxygen, steroids

Question 15

Management of nausea and vomiting in palliative care?

Answer 15

Assess cause
if drug toxicity - think about causes, metoclopramide
motility disorders as it increases contractions of the stomach and intestines- metoclopramide
intracranial - cyclizine plus corticosteroid
oral/ pharyngeal irritation - treat reversible causes - cyclizine
anxiety - manage anxiety - benzodiazepines
levomepromazine for intractable nausea and vomiting - this is broad spectrum

Question 16

Management of weakness/ fatigue in palliative care?

Answer 16

mainly non pharmacologic e.g. fatigue diary, physical activity etc
if anorexia treat per guidelines of anorexia
not much evidence for other drugs

Question 17

What causes of pain in cancer do you need to consider?

Answer 17

neuropathic pain - is the cancer close to nerves
liver capsule pain
visceral pain

Question 18

What are the forms of morphine and how are they written?

Answer 18

Morphine sulfate - just written like this is the injectable form for either IV or SCUT injection

Oral morphine - morphine sulfate MR - this is oral modified release morphine which is long acting (dose twice daily needed) - brand name is MST

Oral morphine - Morphine sulfate IR - this is oral immediate release which is shorter acting for breakthrough pain - brand names e.g. oromorph and sevredol

Question 19

Do you need to do any conversion when going from IR to MR morphine?

Answer 19

no - if putting someone onto MR after seeing what they need IR you just add up what they were taking then divide it into twice daily doses

Question 20

When are procurator fiscal PMs required?

Answer 20

Suspicious deaths
Drug-related deaths (including deaths due to adverse drug reactions reportable under the Medicines and Healthcare Products Regulatory Agency Yellow Card Scheme)
Deaths in legal custody
Accidental deaths (including those resulting from falls)
Deaths resulting from an accident in the course of employment
Deaths of children from overlaying or suffocation
Deaths as a result of deliberate self harm
Any death from natural causes where the cause of death cannot be identified by a medical practitioner to the best of a doctor’s knowledge and belief (certainty is not required)
Deaths as a result of neglect / fault
Deaths where the body of a newborn is found
Deaths that may be categorised as a Sudden Unexpected Death in Infancy (SUDI)
Any death of a child who is cared for by the local authority
Deaths from notifiable / infectious diseases
Deaths under medical care (the circumstances of which are the subject of concern or complaint, or may indicate fault or negligence, or are likely to be subject to an Adverse Event Review, or may indicate that failure of a piece of equipment may have caused or contributed to the death)
Any death not falling into any of the foregoing categories where the circumstances surrounding the death may cause public anxiety.

(note relatives can also request a hospital PM if they wanted more info about the death etc but these aren’t required to be reported to the procurator fiscal and the death wouldn’t fall under this list)

Question 21

Bowel colic can be treated with?

Answer 21

hyoscine butyl bromide

Question 22

Stimulation of what centre in the brain directly causes the activation of vomiting?

This centre can be triggered by what other brain areas?

Answer 22

simulation of vomiting centre will directly cause nausea or vomiting

CTZ is triggered by drugs and metabolic issues
higher cortical centre is stimulated by emotion e.g. anxiety or fear
vestibular areas
GI tract

Question 23

Palliative treatment of bowel obstruction caused by peristaltic failure?

Answer 23

stop medications reducing peristalsis e.g. cyclizine, hyoscine, 5HT3 antagonists, amitriptyline
use pro kinetic antiemetic e.g. metoclopramide
stop if colic develops
laxatives often needed
pain management

Question 24

Palliative treatment of bowel obstruction caused by mechanical obstruction?

Answer 24

target treatment at predominant symptoms
laxatives for constipation
dexamethasone sometimes helps reverse partial obstruction
hyoscine butyl bromide can help with colic and nausea

Question 25

In palliative patients if pain not controlled ________

Answer 25

increase morphine dose by 30-50%

Question 26

How to titrate IR morphine?

Answer 26

prescribe 5mg 4x hourly and as required for breakthrough pain then add up total to get full dose for background

Question 27

Paracetamol is given as _______
Ibuprofen is given as _________
codeine is given as _____________

Answer 27

paracetamol - 1g 4x daily
ibuprofen - 400mg 3x daily
codeine - 30-60mg 4x daily

Question 28

3 examples of weak opioids

Answer 28

tramdol
codeine
dihydrocodeine

Question 29

4 examples of strong opioids?

Answer 29

morphine
oxycodone
fentanyl
buprenorphine