Palliative Care

Question 1

cancer related causes causes of dyspnoea?

Answer 1

primary or secondary tumour causing airway obstruction, lung infiltration/lymphangitis carcinomatosis-peri-tumour oedema causing dyspnoea in these cases can be reduced with steroids
pleural effusion/pericardial
ascites
SVC obstruction
phrenic nerve palsy
chest wall pain
fatigue/weakness
immunosuppressed-infection
hypercoagulable state-PE

note also co-exisitng psychological factors e.g. fear, anxiety, distress.

Question 2

how might dyspnoea result from the treatment of Ca?

Answer 2

surgery-lobectomy or pneumonectomy
radiotherapy/chemotherapy-pneumonitis, fibrosis, immunosuppression-infection, myelosuppression-anaemia
drugs precipitating fluid retention or bronchospasm

Question 3

how is the morphine dose equivalent of codeine calculated?

Answer 3

codeine dose/10

Question 4

when converting someone on codeine to morphine, and codeine dose was inadequate to control pain fully, how much morphine should be given?

Answer 4

should be increased by at least 30% from dose equivalent
so if dose equivalent=36mg
then 36+(0.3X36)=46.8, and round up to nearest 10 or 5, so 50mg is new TDD.

Question 5

how much PO morphine prolonged-release should usually be given as starting dose for analgesia in palliative care?

Answer 5

if replacing a weaker opioid analgesic then usually 20-30mg modified release morphine BD (every 12 hrs)
with 5mg IR morphine for breakthrough pain

Question 6

preferred opioids in patients with CKD?

Answer 6

alfentanil
buprenorphine
fentanyl

Question 7

when is haloperidol a good treatment for N+V in palliative care?

Answer 7

when N+V is drug induced or due to a metabolic cause e.g. renal failure, hypercalcaemia, tumour toxins
0.5-1.5mg/12h, max=10mg/24h

levomepromazine good if morphine-induced nausea, but can sedate

Question 8

general non-pharmacological measures that can be used to treat dyspnoea in palliative care?

Answer 8

a fan
patient positioning
breathing techniques
energy conservation
PT
distraction
anxiety reduction
visualisation
CBT
goal setting
NIV

Question 9

what treatment can aid a persistent cough in palliative care?

Answer 9

sodium chloride nebulisers 5ml as needed

Question 10

treatment via continuous SC infusion for terminal secretions?

Answer 10

glycopyrronium 0.6-1.2mg/24h or hyoscine hydrobromide 0.6-2.4mg/24h

Question 11

treatment via continuous SC infusion for bowel colic in end of life?

Answer 11

hyoscine butylbromide (buscopan) 20-60mg/24hr

Question 12

treatment via continuous SC infusion for agitation in palliation?

Answer 12

midazolam 20-100mg/24h

Question 13

signs of opioid toxicity?**

Answer 13

resp depression
coma
pin point pupils
hallucinations
myoclonic jerks

Question 14

commonest side effect when opioids used for cancer pain?

Answer 14

constipation

ALWAYS CO-PRESCRIBE A LAXATIVE!