Palliative care

Question 1

managing agitation and confusion

Answer 1

treat underlying cause

haloperidol
chlorpromazine, levomepromazine

if terminal - midazolam

Question 2

managing hiccups

Answer 2

chlorpromazine
haloperidol
gabapentic
dexamethasone if hepatic lesions

Question 3

causes of nausea and vomiting in palliative care patients

Answer 3

reduced gastric motility - due to opioids

chemical - due to hypercalcaemia, opioids, or chemotherapy

visceral/serosal - due to constipation

raised ICP - due to cerebral mets

vestibular - activation of Ach and H1 receptors in opioid use

cortical - due to anxiety, pain

Question 4

treating N/V due to reduced gastric motility

Answer 4

Pro-kinetic agents to reduce gastric dysmotility and stasis

metoclopramide, domperidone

do not use if prokinesis may negatively affect GI tract e.g., in bowel obstruction

Question 5

treating chemically mediated N/V

Answer 5

correct chemical disturbance

treat with ondansetron, haloperidol, levomepromazine

Question 6

treating N/V due to visceral/serosal causes

Answer 6

Cyclizine and levomepromazine are first-line
Anti-cholinergics such as hyoscine can be useful

Question 7

treating N/V due to raised ICP

Answer 7

cyclizine
dexamethasone

Question 8

treating N/V due to vestibular causes

Answer 8

cyclizine

Question 9

treating N/V due to cortical causes

Answer 9

short acting benzo, lorazepam
cyclizine

Question 10

starting pain treatment in palliative care

Answer 10

regular oral modified-release (MR) or oral immediate-release morphine - 20-30mg MR

oral immediate-release morphine for breakthrough pain - 5mg (oral >patches)

give laxatives

counsel re nausea and drowsiness

Question 11

SIGN guidelines

Answer 11

breakthrough dose of morphine is one-sixth the daily dose of morphine

patients who receive opioids should be prescribed a laxative

use opioids with caution if with CKD - oxycodone preferred if renal impairment

Question 12

increasing opioid doses

Answer 12

each dose increase should be by 30-50%

Question 13

other pain medication used to manage palliative pain

Answer 13

In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat metastatic bone pain.

Question 14

conversions in opioid medication

Answer 14

oral codeine/tramadol to oral morphine - divide by 10

oral morphine to oral oxycodone - divide by 1.5-2

morphine oral to SC - divide by 2

morphine oral to SC diamorphine - divide by 3

oral oxycodone to SC diamorphine - divide by 1.t

Question 15

managing excess secretions in palliative care

Answer 15

Avoiding fluid overload

hyoscine hydrobromide or hyoscine butylbromide (less sedative)

glycopyrronium bromide

Question 16

commonly used drugs in palliative care

Answer 16

nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide

respiratory secretions/bowel colic: hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.

agitation/restlessness: midazolam, haloperidol, levomepromazine

pain: diamorphine is the preferred opioid