Palliative Care 2

Question 1

how do you work out a breakthrough dose?

Answer 1

take a patients total daily dose of morphine/oxycodone and divide it by 6

breakthrough dose usually lasts four hours. in hospital, write it up as being two hourly max.

Question 2

what should you do when starting opioid treatment?

Answer 2

offer patients PO MR morphine with an immediate release breakthrough dose
use 20-30mg MR morphine and 5mg immediate release morphine
laxatives should be co-prescribed

Question 3

outline the different oral opioid conversions

Answer 3

oral codeine to oral morphine (divide by 10)
oral tramadol to oral morphine (divide by 5)
oral morphine to oral oxycodone (divide by 2)
oral morphine to oral hydromorphine (divide by 7)

IV morphine is 3 times stronger than PO

Question 4

what are the guidelines for prescribing pain relief in people with renal impairment?

Answer 4

the metabolites of opioids build up in renal failure therefore be careful

alfentanil, buprenorphine and fentanyl are preferred

Question 5

what are the guidelines surrounding the use of transdermal opioid patches?

Answer 5

transdermal opioids are used when a patient has stable pain or cannot have oral morphine

transdermal fentanyl is 100-150x more potent than morphine

transdermal 12mg fentanyl patch = 45mg oral morphine daily

patches are worn for 72 hours and take 12-24 hours to start working and reach a steady state

Question 6

how do you convert a dose of oral morphine to a continuous subcutaneous infusion?

Answer 6

divide the daily dose of oral morphine by 3 to get the 24hour CSCI of morphine

Question 7

where delirium and psychotic features are predominant, how do you treat agitation and restlessness?

Answer 7

haloperidol 1.5-10mg PO/SC stat.

may need a repeat dose at 30mins

Question 8

where anguish and anxiety features are predominant, how do you treat agitation and restlessness?

Answer 8

midazolam 2.5-5mg SC/IM

may have a paradoxical effect and worsen symptoms early so frequent review is essential

Question 9

what are the signs and symptoms of malignant spinal cord compression?

Answer 9

increasing neck or back pain
pain worse in bed and with cough or strain
weakness of extremities
loss of sensory, light touch, vibration or proprioception
incontinence/urinary retention

Question 10

what is the management of malignant spinal cord compression?

Answer 10

dexamethasone 8mg stat (give 16mg in total in a day)
analgesia and bisphosphonates if not resolving
radiation or decompressive surgery

Question 11

what can be used to treat metastatic bone pain?

Answer 11

strong opioids, bisphosphonates and radiotherapy

denosumab

Question 12

what is the management of hiccups in palliative care?

Answer 12

chlorpromazine for intractable hiccups

haloperidol and gabapentin can also be used

Question 13

what are the causes of SVCO?

Answer 13

lung cancer (most commonly right sided lung tumours), lymphoma
intraluminal thrombus

Question 14

what are the signs of SVCO?

Answer 14

early: periorbital oedema, facial swelling, cough, SOB
late: cyanosis, headache, altered mental status, raised JVP

Question 15

what are the investigations and treatment of SVCO?

Answer 15

investigations: clinical examination, CXR, CT or MRI
examination: radiotherapy and chemotherapy if tumour, dexamethasone, lytic therapy if thrombosis, treatment of cause

Question 16

in what cancers is hypercalcaemia most commonly seen?

Answer 16

multiple myeloma, breast, squamous cell carcinomas, lymphomas, leukaemias

tumour secretion of PTH is the most common

Question 17

what is the management of hypercalcaemia?

Answer 17

rehydration with 0.9% sodium chloride
IV bisphosphonate: zoledronic acid 4mg IV

recheck calcium if symptoms have not improved
maximal response for bisphosphonates seen after 4-11 days

Question 18

what is an advanced statement?

Answer 18

expression of wishes and priorities for care
not legally binding
can be verbal, written informally or formal

Question 19

what are the features of advanced care plans?

Answer 19

not clinical documents

personal choices being voiced and documented. need to occur while the patient has capacity

Question 20

what is an advanced decision?

Answer 20

can enable a patient to refuse medical treatments
legally binding

an example is a DNACPR

must be correctly documented, signed and witnessed

Question 21

what is a lasting power of attorney?

Answer 21

legally binding
can involve a solicitor
nominates an attorney to make decisions on your behalf

Question 22

what is an emergency health care plan?

Answer 22

a detailed and individualised treatment plan for emergencies

it is guidance and not legally binding

Question 23

what non pharmacological support can you give to patients at the end of life?

Answer 23

day hospice: nutrition advice, anxiety management, breathlessness care
complementary therapies
medication reviews
respite for family

Question 24

what medications are used to treat secretions at end of life?

Answer 24

hyoscine hydrobromide
hyoscine butylbromide
glycopyrronium bromide

Question 25

what are the long acting and short acting versions of oxycodone?

Answer 25

longtec (lasts for 12h) (used to be oxycontin)

shorttec (lasts for 4h) (used to be oxynorm)