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Year 4: GERMED > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

The WHO performance status classification categorises patients as [4]

A

0: able to carry out all normal activity without restriction

1: restricted in strenuous activity but ambulatory and able to carry out light work
2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours

3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden

4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.

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2
Q

Describe how pain relief is given for palliative care [1]

A

Background of morphine given based on their 24hr requirements AND PRN dose available for breakthrough pain
- PRN dose: 1/6th to 1/10th of 24hr dose
- Consider prescribing laxative

TOM TIP: Remember that each rescue dose is 1/6 of the 24-hour background dose. This is a very common exam question and something that seniors will commonly ask to test your knowledge.

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3
Q

Whats the MoA of opioids? [1]

A

Agonist activity at opioid receptors in central and peripheral nervous system. There are three major classes of opioid receptors:
* Mu - predominately work on these
* Delta
* Kappa

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4
Q

Why may opioids cause itchiness? [1]

A

Pruritus: Opioids may induce histamine release, resulting in pruritus and other allergic-type reactions.

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5
Q

When would you not give morphine to patients? [1]

Which alternative medications could you give them? [1]

A

Poor renal function makes morphine CI:
- alternatives include: oxycodone, alfentanyl or buprenorphine.

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6
Q

What should you specificially monitor for in patients being given opioids? [3]

A

Monitor for signs of opioid toxicity
- respiratory depression
- sedation
- myoclonus

switch to alternatives or dose reduce as necessary.

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7
Q

How would you treat breathlessness? [4]

A

Non-pharmacological:
- Sit up
- Give a fan / open window

Pharmacological:
- Low dose opioids
- Benzos
- Therapeutic oxygen

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8
Q

Which medication would you give for a patient that has gastric stasis

Metoclopramide
Cyclizine
Ondansetron
Haloperidol
Levomepromazine
Hyoscine

A

Which medication would you give for a patient that has gastric stasis

Metoclopramide
Cyclizine
Ondansetron
Haloperidol
Levomepromazine
Hyoscine

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9
Q

Which medication would you give for a patient that has motion sickness

Metoclopramide
Cyclizine
Ondansetron
Haloperidol
Levomepromazine
Hyoscine

A

Which medication would you give for a patient that has motion sickness

Metoclopramide
Cyclizine
Ondansetron
Haloperidol
Levomepromazine
Hyoscine

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10
Q

For chemically-mediated symptoms (for example medications, metabolic derangemenet), aim to treat the underlying cause.

If needed, which anti-emetics could be used? [3]

A

Antiemetics that may be helpful include haloperidol, metoclopramide or levomepromazine.

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11
Q

Which medication would you give for a patient that feels sick because of raised ICP?

Metoclopramide
Cyclizine
Ondansetron
Haloperidol
Levomepromazine
Hyoscine

A

Which medication would you give for a patient that feels sick because of raised ICP?

Cyclizine
- Dexamethasone or radiotherapy may be helpful to reduce the pressure-associated symptoms.

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12
Q

Which medication should be given to patients who feel nauseous due to compression from abdominal or pelvic tumours? [1]

A

cyclizine should be used first-line.

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13
Q

Which medications can you give for agitation in end of life? [2]

A

For patients in their last days of life, haloperidol or low-dose midazolam may be prescribed

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14
Q

Which medications can be given for respiratory tract secretions in end of life care? [2]

A

An antimuscarinic such as hyoscine butylbromide or glycopyrronium bromide may be prescribed for noisy respiratory secretions.

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15
Q

“this patient is on 30mg of modified-release morphine every 12 hours; what would be the correct breakthrough dose?” [1]

A

10mg is the correct answer, as the patient is getting 60mg background morphine every 24 hours (30mg twice a day).

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16
Q

if the patient is getting 30mg in 24 hours of modified-release morphine (15mg every 12 hours), what is the rescue dose needed? [1]

A

5mg

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17
Q

Describe the three steps to the analgesics ladder

A
  • Step 1: Non-opioid medications such as paracetamol and NSAIDs
  • Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
  • Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine
18
Q

What is a key side effect of analgesic medication? [1]

A

Medical overuse headache is a common side-effect of the long-term use of analgesic medication.

19
Q

NSAIDS may be inappropriate in which patients? [5]

A

NSAIDs may be inappropriate or contraindicated in patients with:
* Asthma
* Renal impairment
* Heart disease
* Uncontrolled hypertension
* Stomach ulcers

20
Q

The key side effects of NSAIDs are: [6]

A

Gastritis with dyspepsia (indigestion)
Stomach ulcers
Exacerbation of asthma
Hypertension
Renal impairment
Coronary artery disease, heart failure and strokes (rarely)

21
Q

[] is used to reverse the effects of opioids in life-threatening overdose (usually due to respiratory depression).

A

Naloxone is used to reverse the effects of opioids in life-threatening overdose (usually due to respiratory depression).

22
Q

What are 5 key side effects of opiods? [5]

A
  • Constipation
  • Skin itching (pruritus)
  • Nausea
  • Altered mental state (sedation, cognitive impairment or confusion)
  • Respiratory depression (usually only with larger doses in opioid-naive patients)
23
Q

In general, NSAIDs are used in the management of pain.

Specific indications include:
mefenamic acid: [1]

A

In general, NSAIDs are used in the management of pain.

Specific indications include:
mefenamic acid: dysmenorrhoea

24
Q

Which drugs increase the risk of peptic ulcers if given with NSAIDS? [4]

A

SSRIs, corticosteroids, bisphosphonates; anticoagulants

25
Q

Lecture

Strong opiods:
- Normal starting dose of around []mg/day with []-[] IR PRN can go lower if frail, low BMI or other concerns

A

Normal starting dose of around 20mg/day with 2.5-5mg IR PRN can go lower if frail, low BMI or other concerns

26
Q

Describe how you would counsel to a patient about initial impact of morphine medications? [1]

A

Counsel that as the body adjusts to the dose there may be a period of drowsiness which should pass after the first day or two. As such, patients on unstable opioid prescriptions are not safe to drive and should be advised as such

27
Q

Lecture

Describe a metabolic effect of opioid prescription and how you would manage this [2]

A

Nausea and vomiting – would recommend co-prescription of an antiemetic as required – consider the context of your patient but in general, prokinetic such as metoclopramide should be first line

28
Q

Describe how you would manage an opioid dose that causes resp. depression

A
  • Sit upright
  • give oxygen
  • stop any ongoing opioid (including patch)
  • Monitor
  • IF RR < 8 and signs of compromise (e.g. low saturations) - Naloxone
29
Q

What specific GFRS indicate which pain medication is given? [2]

A

Opioids
* GFR > 30 – Morphine 2.5mg SC hourly
* GFR < 30 – Oxycodone 1.25/2.5mg SC hourly

SC ~ double potency of PO (i.e. 2.5mg SC = 5mg PO)

30
Q

3Fs of dysopnea? [3]

A

3 Fs – Focus on out breath, Fan to face and Forward leaning posture to reduce accessory muscle use

31
Q

Which medications can be used if a patient is extremely agitated? [3]

A
  • Midazolam 2.5-5mg 1hrly SC (10mg in crisis)
  • Levomepromazine 12.5-25mg 2hrly SC (higher dose than nausea)
  • Haloperidol 2.5mg 2hrly SC

midazolam usually first line

32
Q
A
33
Q

If a patient needs multiple doses of medications in 24hrs in pal. carre, what can you use to deliver the right dose? [1]

A

syringe driver

34
Q

Which is the drug class of:
- Promethazine; metoclopromide and chlorpromazine? [1]

A

Dopamine antagonists

35
Q

What is the drug class of ondansetron? [1]

A

Serontonin antagonist

36
Q
A
37
Q
A
38
Q
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39
Q
A
40
Q

What do you need to do in an examination so that you can verify death? [4]

A

Year 4: GERMED (17 decks)

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