Palliative care

Question 1

Palliative patient after withdrawing active treatment. Is agitated and restless. What is the most appropriate management?

Answer 1

subcutaneous midazolam

Midazolam is a short-acting benzodiazepine that provides sedation, anxiolysis, and amnesia. In this case, it can help to alleviate the patient’s agitation and restlessness while providing comfort during the withdrawal of active treatment. The subcutaneous route is preferred in palliative care settings as it allows for continuous administration via a syringe driver, ensuring consistent symptom control.

Question 2

Intramuscular haloperidol extrapyramidal side effects such as ?

Answer 2

dystonia or akathisia, which could worsen the patient’s symptoms.

Question 3

Oral lormetazepam

Answer 3

Lormetazepam is a long-acting benzodiazepine that can cause excessive sedation and respiratory depression in elderly patients with comorbidities such as COPD. Furthermore, oral medications may not be suitable for patients with terminal illness who have difficulty swallowing or are at risk of aspiration.

Question 4

First line anti-emetic for intracranial causes of nausea and vomiting?

Answer 4

Cyclizine

Question 5

breakthrough dose of morphine? 60 mg of modified-release oral morphine twice daily for pain management.

Answer 5

Breakthrough dose = 1/6th of daily morphine dose

The standard ‘rescue dose’ of morphine for breakthrough pain is usually 1/10th to 1/6th of the regular 24-hour dose, repeated every 2–4 hours as required (up to hourly may be needed). For a daily dose of 120 mg (as this patient has 60 mg twice daily), 1/10th is 12mg and 1/6th is 20 mg. It would be recommended that this patient has a breakthrough dose of 12 - 20mg, in which 20mg is the only option here that is correct.

Question 6

A 71-year-old woman with metastatic breast cancer comes to surgery with her husband. She is known to have bone metastases in her pelvis and ribs but her pain is not controlled with a combination of paracetamol, diclofenac and MST 30mg bd. Her husband reports she is using 10mg of oral morphine solution around 6-7 times a day for breakthrough pain. The palliative care team at the hospice tried using a bisphosphonate but this unfortunately resulted in persistent myalgia and arthralgia. What is the most appropriate next step?

Answer 6

Metastatic bone pain may respond to analgesia, bisphosphonates or radiotherapy

Dexamethasone should be considered if the metastatic spinal cord compression, but this is not a feature given the location of the lesions.

Question 7

A 78-year-old man with terminal lung cancer is reviewed by the palliative care team to assess his needs with regards to analgesia. He currently takes 30mg of slow-release morphine twice daily. Although this adequately controls his pain levels, he is increasingly finding it difficult to swallow both tablet and liquid forms of the medication. As such, the palliative team recommend that he switches to subcutaneous morphine.

What dose should he take daily?

Answer 7

Divide by two for oral to subcutaneous morphine conversion

This patient takes a total of 60mg of oral morphine throughout the day. Given that this controls his pain, the dose does not need to be increased. To switch from oral to subcutaneous morphine, the total dose should be divided by two. As such, he should be given a total of 60 / 2 = 30mg of subcutaneous morphine daily.

The other options are therefore incorrect.

Question 8

intractable hiccups. What is the most appropriate management?

Answer 8

Hiccups in palliative care - chlorpromazine or haloperidol

Question 9

Codeine phosphate

Answer 9

is an opioid analgesic used primarily for the relief of mild to moderate pain. While it can suppress cough reflex by a direct effect on the cough centre in the medulla, there’s no evidence supporting its use for hiccups.

Question 10

Diazepam

Answer 10

a benzodiazepine, is typically used for its anxiolytic, muscle relaxant, and sedative properties. Although it might theoretically help with hiccups due to its muscle-relaxing effects, there’s limited clinical evidence supporting this use. Furthermore, using diazepam could potentially cause excessive sedation or respiratory depression in a patient with advanced cancer

Question 11

Phenytoin

Answer 11

is an antiepileptic medication that stabilises neuronal membranes and decreases seizure activity. While it may have some off-label uses, there’s no established role for phenytoin in managing hiccups.

Question 12

Methadone

Answer 12

is another opioid analgesic that’s primarily used for severe pain management or opioid detoxification. It has no known efficacy in treating hiccups and could potentially cause serious adverse effects like respiratory depression or addiction.

Question 13

A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes morphine sulphate 60mg bd but it is decided to convert this to subcutaneous administration as he is frequently vomiting. What is the most appropriate dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?

Answer 13

60mg

The BNF recommend half the oral dose of morphine in this situation:

The equivalent parenteral dose of morphine (subcutaneous, intramuscular, or intravenous) is about half of the oral dose. If the patient becomes unable to swallow, generally morphine is administered as a continuous subcutaneous infusion

Question 14

A 72-year-old man has been an inpatient on the elderly care ward for the last 2 weeks. He has a new diagnosis of metastatic lung cancer. On the morning ward round, he complains that his pain is not being adequately controlled. He currently takes oral morphine sulphate 20mg four times a day along with codeine 30mg four times a day and regular ibuprofen.

What is the correct breakthrough dose of oral morphine to give this man?

Answer 14

Morphine 15mg

Breakthrough dose = 1/6th of daily morphine dose

Oral codeine to morphine (divide by 10). Therefore, oral codeine 10mg = oral morphine 1mg.

30mg x 4 = 120mg codeine. This equals 12mg morphine.

20mg x 4 = 80mg morphine.

Total morphine = 80mg + 12mg = 92mg.

The breakthrough dose of morphine is 1/6th of the total dose of morphine in 24 hours. This main takes 92mg of morphine in 24 hours. 1/6th of this is 15mg.

Question 15

n elderly woman with metastatic breast cancer is discharged from the hospital to continue palliative care at home. She was started on oral morphine to be taken as 10mg four times daily, to manage pain from her bony metastases. This dose was working well in managing her pain.

The patient’s condition deteriorates and she is no longer able to take the medication by mouth, due to swallowing issues. Her GP advises for the morphine to be converted to a subcutaneous injection to be administered by the district nurses.

What is the required dose of subcutaneous morphine for this patient?

Answer 15

Divide by two for oral to subcutaneous morphine conversion

The correct answer is to give subcutaneous morphine 5mg four times daily.

The dose of subcutaneous morphine is equivalent to twice the same dose of oral morphine, i.e. 1mg of subcutaneous morphine is equivalent to 2mg of oral morphine.

In this case, 5mg of SC morphine four times daily is equivalent to giving 10mg of oral morphine four times daily. As the patient’s pain is reportedly well controlled on the current dose, there is no indication to change the dose of analgesia at present.

Question 16

A 65-year-old female with metastatic breast cancer is reviewed in clinic. Her husband reports that she is increasingly confused and occasionally appears to talk to relatives that are not in the room. She undergoes investigations for reversible causes, of which none are found. If conservative measures fail and she continues to be confused/agitated, what is the most appropriate management?

Answer 16

Oral haloperidol is the most appropriate treatment here. If the patient was in the terminal phase and agitated then subcutaneous midazolam would be indicated

Question 17

You are asked to review an 85-year-old man who was admitted 5 days ago with community acquired pneumonia. He has a past medical history of type 2 diabetes mellitus, angina, chronic obstructive pulmonary disease (COPD) and spinal stenosis.

Unfortunately, despite optimal ward-based treatment including IV co-amoxiclav, the patient has continued to deteriorate. He current scores 11 on the Glasgow coma scale. His pupils are 3mm bilaterally and reactive to light. He has been unable to take his morning medications which include morphine sulphate modified release (Zomorph) 30mg twice daily, oramorph 10mg as required, and metoclopramide 10mg three times a day. In the past 24 hours, he has used 4 doses of PRN oramorph.

He is reviewed on the consultant ward round and the decision is made that he should be for end of life care. He is currently comfortable, with no evidence of hallucinations, pruritis or myoclonus. The nurse asks you to convert his medications to a syringe driver.

What will you prescribe?

Answer 17

Metoclopramide 30mg s/c + morphine 50mg s/c

Divide by two for oral to subcutaneous morphine conversion

This question is asking you to convert oral morphine to subcutaneous morphine for use in a syringe driver - also known as a continuous subcutaneous infusion (CSCI).

The first step to calculate doses for use in a CSCI is to calculate the total 24-hour usage of the drug. We are told this patient is taking both zomorph (modified release morphine), and oramorph (immediate release) - we need to include both of these medications in our calculation.

The patient is taking 30mg zomorph twice daily = 60mg/24 hours.
He has also taken 4 doses of 10mg oramorph = 40mg/24 hours.

This gives us a total of 60mg + 40mg = 100mg/24 hours of oral morphine. In order to convert this to subcutaneous morphine, we must divide by two. Therefore the amount of morphine needed in the CSCI is 100mg/2 = 50mg/24 hours.

The patient is comfortable, with no evidence of opioid toxicity, and so there is no indication to change to oxycodone at the moment.

Question 18

A 77-year-old man is receiving palliative care after having been diagnosed with glioblastoma. His pain is well controlled on regular paracetamol. However, he is complaining of feeling nauseous.

What would be the most appropriate first-line anti-emetic to prescribe for this patient?

Answer 18

Cyclizine is a good first line anti-emetic for intracranial causes of nausea and vomiting

Question 19

Domperidone antagonises

Answer 19

the inhibitory effect of dopamine, resulting in stimulation of gastric muscle contraction. It is a good anti-emetic to use for gastro-intestinal pain in palliative care.

Question 20

Metoclopramide

Answer 20

is used for the symptomatic relief of acute migraine, chemotherapy or radiotherapy-induced nausea and vomiting. It is a prokinetic agent which is unlikely to provide relief from nausea related to increased intracranial pressure.

Question 21

Ondansetron

Answer 21

is indicated for the prevention and treatment of nausea and vomiting related to chemotherapy. It is a selective 5-hydroxytryptamine (5-HT3) antagonist.

If steroids are used in palliative care, dexamethasone is usually chosen as the first line. Steroids have multiple indications in this setting including treatment of nausea, anorexia, spinal cord compression and liver capsule pain. Dexamethasone may have a role in treating this patient’s nausea if the intracranial pressure is raised and could be considered in addition to cyclizine. Cyclizine should be used as a first-line option if the nausea is thought to be due to raised intracranial pressure.

Question 22

Which one of the following opioids is it most appropriate to use given his impaired renal function?

Answer 22

Buprenorphine

Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.

Question 23

A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?

Answer 23

10 mg

Breakthrough dose = 1/6th of daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg

Question 24

A 65-year-old man with metastatic squamous cell lung cancer is admitted to the Acute Medical Unit for the management of hypercalcaemia. He is currently taking slow-release morphine sulphate (MST) 90mg bd to control his pain along with regular naproxen and paracetamol. During his admission, he complains of pain in his right arm which is the site of a known skeletal metastasis.

What is the most appropriate medication to prescribe for his break-through pain?

Answer 24

Oral morphine solution 30mg

This patient is describing break-through pain. Whilst bisphosphonates have a role in bone metastases they are not suitable for acute pain. A suitable break-through dose is therefore 1/6th of the total daily morphine dose i.e. 1/6th of 180mg = 30mg.