Palliative Care 20/7

Question 1

Non-pharmacological management strategies of nausea/vomiting

Answer 1

• Control odours from colostomy, wounds and fungating tumours
• Minimise sight/smell of food
• Give small snacks not large meals
• Try acupressure wrist bands

Question 2

Pharmacological management of chemical causes of nausea + vomiting e.g. opioids

Answer 2

haloperidol
- acts on D2 dopamine receptors
OR metoclopramide
- act on D2 and 5HT receptors

Question 3

Pharmacological management of gastro causes of nausea+ vomiting e.g. gastric stasis

Answer 3

metoclopramide/domperidone

- act on D2 and 5HT receptors

Question 4

Pharmacological management of non-specific/multi-factorial causes of nausea + vomiting

Answer 4

prochlorperazine/levomepromazine

- act on D2, H1 and ACh receptors

Question 5

Pharmacological management of histaminergic causes of nausea + vomiting

Answer 5

cyclizine/promethazine

- act on central and peripheral H1 receptors

Question 6

Examples of histaminergic causes of N+V

Answer 6

• obstruction
• peritoneal irritation
• vestibular causes (motion sickness)
• raised intra-cranial pressure

Question 7

Pharmacological management of radio/chemotherapy-induced nausea + vomiting

Answer 7

granisetron, ondansetron

- act on 5-HT3-receptors

Question 8

Pharmacological management of spasmodic causes of nausea + vomiting

Answer 8

hyoscine butylbromide (buscopan)

• antispasmodic that acts on ACh receptors (antimuscarinic)
• indicated for IBS, bladder cramps and period pain

Question 9

cough suppressant (antitussive) medications in palliative care

Answer 9

• codeine
• morphine (COPD/malignancy)
• glycerol (soothing barrier)

Question 10

titration options for starting morphine/strong opioid

Answer 10

1. Prescribe the dose on a four hourly as required PRN basis (this relies on the patient asking for pain relief)
2. Prescribe the dose on a regular basis every four hours (patient receives pain relief without needing to request it)
   For both methods assess the patient’s pain after 24 hours.

If effective change to BD modified relief

Question 11

breakthrough pain PRN dose

Answer 11

1/10th to 1/6th of the equivalent total daily dose of the drug is recommended

Question 12

opioid adverse effects

Answer 12

• N+V co-prescribe a suitable antiemetic, switch opioid if needed.
• Constipation co-prescribe a softening and stimulant laxative
• Cognitive impairment, drowsiness, myoclonic jerks, dysphoria and respiratory depression
• Urinary retention, may be resolved by dose reduction or opioid switch.
• Dry mouth
• Sweating
• Hallucinations

Question 13

indications for a syringe driver

Answer 13

• Patient unable to take medication orally
• Poor absorption of oral medication (N+V, oedema)
• Intestinal obstruction

Question 14

syringe driver battery charge required for 24hrs

Answer 14

35%

Question 15

signs of imminent death (palliative)

Answer 15

• increasing frailty
• difficulty swallowing (last days/hours)
• withdrawal (more sleeping, confusion in last days)
• circulatory changes (cold/pale extremities, low BP)
• breathing changes (Cheyne-Stokes breathing/rattling - last days)
• sudden event (PE/MI/stroke)

Question 16

verifying a death

Answer 16

• absence of a carotid pulse over one minute
• absence of heart sounds over one minute
• absence of respiratory movements and breath sounds over one minute
• fixed, dilated pupils (unresponsive to bright lights)
• no response to a trapezius squeeze

Question 17

sc vs oral morphine dose

Answer 17

SC dose is half of PO dose

Question 18

rattle breathing medication

Answer 18

glycopyrronium

• may reduce rattle from secretions
• not always necessary unless secretions are causing distress
• 200ug SC up to 6 hourly

Question 19

causes of delirium

Answer 19

Pain (and unable to sleep or move around)
Infection (chest, urine, skin etc)
Nutrition
Constipation (or unable to pass urine properly)
Hydration (dehydration and malnutrition)
Medication (sudden stopping or starting drugs)
Environment (being in an unfamiliar place)

Question 20

management of irreversible agitation in palliative

Answer 20

Prescribe midazolam 2.5mg SC up to 1 hourly

Question 21

opioid pain relief options in kidney disease

Answer 21

oxycodone
fentanyl
buprenorphine
alfentanil esp for syringe driver
methadone

Question 22

examples of bulk-forming laxatives

Answer 22

bran

ispaghula husk

Question 23

examples of stimulant laxatives

Answer 23

bisacodyl (dulcolax)
senna
docusate sodium (also stool softener)

Question 24

examples of stool softener laxatives

Answer 24

docusate sodium

glycerol suppository

Question 25

examples of osmotic laxatives

Answer 25

lactulose
macrogol (laxido/movicol)

Question 26

management of short-term constipation

Answer 26

bulk-forming laxative eg. ispaghula husk

- add osmotic/stimulant depending on stool

Question 27

management of opioid-induced constipation

Answer 27

osmotic and stimulant laxatives

- avoid bulk-forming

Question 28

management of faecal impaction

Answer 28

depends on stool consistency
- hard stool = oral macrogol (laxido/movicol)
- soft stool = oral stimulant
enema if unresponsive

Question 29

management of chronic constipation

Answer 29

bulk-forming laxative

- add osmotic (eg. macrogol (laxido/movicol))

Question 30

constipation in pregnancy

Answer 30

fibre supplements

• add bulk-forming laxative if required
• lactulose (osmotic) next if ineffective

Question 31

constipation in children

Answer 31

advise increased fibre, exercise and fluid intake

• macrogol (laxido/movicol)
• add stimulant if required