Palliative care

Question 1

When converting oral morphine to SC, what calculation should you do?

Answer 1

Divide by 2

Question 2

When starting pain relief in palliative care, what is the initial dose of morphine for patients with no comorbidities?

Answer 2

20-30mg of modified-release morphine (MR) a day, with 5mg of immediate-release morphine for breakthrough pain.

Question 3

How would you calculate the breakthrough dose of morphine?

Answer 3

1/6th of daily morphine dose

Question 4

Which opioid is preferred in palliative patients with mild-moderate renal impairment?

Answer 4

Oxycodone

Question 5

Which opioids are preferred in palliative care patients with severe renal impairment?

Answer 5

Buprenorphine or fentanyl - as they’re not renally excreted and therefore less likely to cause toxicity.

Question 6

When increasing the dose of opioids, how much should the next dose be increased by?

Answer 6

30-50%

Question 7

What are the main side effects from opioids?

Answer 7

• Transient: nausea, drowsiness.
• Persistent: constipation.

Question 8

How would you convert from oral codeine to oral morphine?

Answer 8

Divide by 10

Question 9

What is the first line anti-emetic for raised ICP?

Answer 9

Cyclizine

Question 10

Management of agitation and confusion in palliative patients?

Answer 10

• First-line: haloperidol.
• Terminal phase of illness: midazolam.

Question 11

Metastatic bone pain may respond to…

Answer 11

Analgesia, bisphosphonates or radiotherapy

Question 12

When would dexamethasone be used?

Answer 12

Metastatic spinal cord compression or raised ICP

Question 13

List the commonly used drugs in palliative care ‘anticipatory meds’ and their indications

Answer 13

• 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.
• SOB: opioids.

Question 14

What symptoms might a patient experience towards the end of life?

Answer 14

• SOB
• Pain
• N+V
• Chest secretions
• Agitation/anxiety

Question 15

What is the role of a hospice?

Answer 15

• End of life care
• Symptom management (2 weeks)

Question 16

Why is oxycodone used in renal impairment?

Answer 16

It is metabolised by the liver, not renally excreted

Question 17

What are the common indications for a syringe driver?

Answer 17

• Persistent N+V
• Severe dysphagia

Question 18

Conversion from oral morphine to oral oxycodone

Answer 18

Divide by 2

Question 19

Fluids in hypercalcaemia

Answer 19

Sodium chloride 0.9% 4-6L over 24hrs - 250ml/hr

Question 20

Management of hypercalcaemia

Answer 20

• IV fluids
• Then bisphosphonates (pamidronate 90mg IV every 4 weeks, or zoledronic acid 4mg IV every 4 weeks)
• Other options: calcitonin, steroids in sarcoidosis

Question 21

Management of bony mets pain

Answer 21

Bisphosphonates, NSAIDs, radiotherapy

Question 22

Anorexia (decreased appetite) symptom control in palliative care

Answer 22

Dexamethasone (preferred) or prednisolone