Palliative Care

Question 1

Palliative care is defined as medical care/treatment give to reduce symptoms of the disease rather than intending to cure/delay/reverse the disease itself.

True or False?

Answer 1

True

Question 2

Palliative care aims to:

• relieve symptoms
• improve QoL
• Acknowledge death & prepare patient/family/carers for it.

What ethical topics are relevant to palliative care?

Answer 2

Autonomy - PPC/ PPD

Advanced care planning - best interests, refusal of treatments, MCA, LPA, DNACPR

Question 3

What are the 4 main symptoms that are aiming to be controlled in a palliative care patient?

Answer 3

Pain
N/V
Breathlessness
Constipation

Question 4

With symptom-control, should you always treat the cause of the issue?

Answer 4

Yes - always treat REVERSBLE causes

Question 5

A 70 y/o lady with stage 4 breast cancer with long-standing spinal mets, complains of pain. How would you go about managing her?

Answer 5

History
Examination
+/- Investigation
Prescribe - WHO analgesic ladder

Question 6

Pain can be caused by 3 things in principle…

Answer 6

Illness e..g cancer
Treatment of illness e..g RT
Unrelated eg MI

Question 7

List the most appropriate drugs to treat the types of pain listed:

1. Bone pain
2. Colicky pain
3. Headache with raised ICP
4. Neuropathic pain
5. Liver capsule pain
6. Infection e.g. pneumonia

Answer 7

1. NSAIDs, RT + Pamidronate
2. Buscupan
3. Paracetamol + Dexamethasone 16mg OD
4. Gabapentin, Amitriptyline, Pregabalin, Opiates
5. NSAIDs + Dexamethasone
6. Targeted antibiotics

Question 8

List the components & standard doses/ strengths for each drug within the analegesic ladder.

Answer 8

1. NON-OPID
   - Paracetamol - 1g qds
   - NSAIDS - 400mg qds
2. WEAK OPIOD
   - Co-codamol: 8/500, 15/500, 30/500 qds
   - Codeine: 15mg, 30mg (240mg max) qds
3. STRONG OPIOD
   - *Morphine 10mg/5ml, 100mg/5ml
   - *Diamorphine
   - Oxycodone
   - Fenatyl, Buprenorphine (patches)
   - Methadone (last resort)

Question 9

What are used as adjuvants to managing pain through the analgesic ladder?

Answer 9

Pharmacological:
Neuropathic pain agents
Steroids
Buscupan
Benzodiazepines

Non-pharmalogical:
Massage
Acupuncture
Heat therapy
TENS

Question 10

Opiate prescribing is a big part of palliative care and hospital medicine.

1. What is the 1st line strong opiate of choice?
2. What strength does it come in?
3. What units should you always prescribe this drug in?

Answer 10

1. MORPHINE
2. 10mg/5ml or 100mg/5ml (some brands 5mg/5ml)
3. ALWAYS PRESCRIBE IN Mg

Question 11

A 67 y/o lady in a hospice Is in her terminal days and requires morphine prescribed for her pain management. She has a history of a stroke but a safe swallow.

Describe the standard morphine regime she will need,

Answer 11

1. 12hrly = long-acting - modified release for regular pain relief (oral).
   - MST tablets
   - Zomroph capsules

Dose: Start 20mg/5ml bd MST (converstion of co-codamol OR base on prn use)

2. 2-4hrly = short-acting - for break-though pain
   - Oromorph liquid (syringe)
   - Sevredol tablets

Dose: 1/6 of long-acting total daily dose

Question 12

A 78 y/o man with end-stage heart failure is on prn morphine 7mg. He is on 20 mg MST bd.

He is using his prn dose 8 times a day every 2 hours.

At what point do you review the prn dose and change the long-acting dose to provide better pain relief?

Answer 12

When the prn dose exceeds the total daily dose of MST

Question 13

If you want to increase the MST dose then how much do you increase it by?

Answer 13

30-50% of current MST dose

Question 14

What is the converson of oral prn dose morphine to sc morphine?

Answer 14

sc morphine = 1/2 X prn dose

Question 15

There is no max dose for opiates. However, you can write the max dose as 6 X prn.

In which cases should the morphine dose be reduced?

Answer 15

Poor renal function

Elderly (delirium)

Question 16

When is oral morphine contraindicated?

What is an alternative drug route?

Answer 16

Unsafe swallow

Patches - fentanyl, buprenorphine

Question 17

Opiate SE are adverse effects but predictable.

What are the common SE of opiates?

Answer 17

Constipation- prescribe laxative (senna)

N/V - prescribe anti-emetic (1/3, goes in ~3days)

Drowsiness (goes in ~3 days, no driving)

Dry mouth

Question 18

Opiate toxicity is when too much of the drug is given (reduced renal function, rug error, interactions, weight changes, narrow TI)

What are the signs of toxicity, in order?

Answer 18

Delirium, sedation
Vivid dreams
Pin-point pupils (get smaller as get older)
Hallucinations - esp visual
Myoclonus - jerky movements
Respiratory depression - uncommon

Question 19

What is the treatment for respiratory depression?

Answer 19

Naloxone

for any opiate toxicity - blocks & reverses effects of it

Question 20

A 80 y/o lady with lung cancer and brain mets has chronic N/V from constipation and raised ICP.

If you didn’t know the cause of the N/V then how would you manage it?

Answer 20

History
Examination
Investigations: FBC (infection), U&Es (dehydration, electrolyte ab), Ca-adjusted, LFTs (mets)

Question 21

N/V has different mechanisms of action.

What are the 4 main domains that can cause N/V

Answer 21

Gastric
Brain
Toxicity
Vestibular/Ear - GP

Question 22

For brain causes of N/V:

1. What causes it?
2. What anti-emetics/ treatment would you give?

Answer 22

• Raised ICP “early morning vomiting). — Give Cyclizine, paracetamol, steroids
• Anxiety —- Benzodiazepine

Question 23

For Gastric causes of N/V

1. What are they?
2. What anti-emetic would you give?
3. describe the features of the antiemetic

Answer 23

Reduced stomach volume –> more vomiting
Bowel obstruction e..g constipation, cancer, ascites, intra-abdo D, organomeagly. gastrostasis, gastritis

METOCLOPROMIDE= Dopamine antagonist, crosses BBB, oral/parenteral. PRO-KINETIC

DOMPERIDONE = dopamine antagonist, doesn’t cross BBB so okay in PD

Question 24

Metoclopramide is a pro-kinetic anti-emetic so promotes gastric emptying.

When is it contraindicated?

Answer 24

Bowel obstruction

Young females (<30yrs?)

Question 25

Chronic nausea is often stemming from toxicity causes of N/V 1. What are they? 2. What anti-emetic would you give?

Answer 25

Chemo/RT, opiates, dehydration, antibiotics, infection/sepsis, digoxin, ab blood tests: hypercalcaemia, hyponatraemia, uraemia from CKD/AKI HALOPERIDOL - oral/parenteral ONDANSETRON - serotoinin antagonist, esp for chemo. oral/IV

Question 26

There are vestibular/ear causes of N/V mostly seen in GP. 1. What can cause this? 2. What anti-emetic is given?

Answer 26

BPPV, Meniere's, Labrinthyitis... Prochlroperazine (1st generation anti-psychotic)

Question 27

A 78 y/o lady in the hospice has tried Cyclizine, Haloperidol and Ondansetron for her N/V. She cant use Metoclopramide as she has bowel obstruction from constipation. None of them have worked to make her feel better What is the last resort anti-emetic?

Answer 27

Levomepromazine | 3rd line, old anti-psychotic, not in hospitals

Question 28

Which route of anti-emetic is the best to deliver the medication?

Answer 28

Parenteral (IV/SC/IM) | May not keep don't the oral medication!

Question 29

Constipation is a everyday presentation in palliative care. What are the common causes in this setting?

Answer 29

``` Not E/D - poor hydration/ fibre Immobility Opiate use Hypercalcaemia Bowel pathology ```

Question 30

An 80 y/o man with metastatic prostate cancer and constipation from opiate use has been using laxatives for 3 days and they haven't produced a bowel movement. What laxative has he been using as 1st line for opiate SE? How will you manage him?

Answer 30

Senna Do PR then move to suppositories --> enemas (do this after 3 days of no bowel movements when started laxative)

Question 31

There are 4 types of laxatives. State the 4 types Give examples in each category and the indication/dose

Answer 31

1. SOFTENER - Lactulose 15ml bd, bloating - Docusate - nasty taste, rarely used 2. STIMULANT - Senna - 1st line in opiod-indiced, avoid in colic/bowel ob 3. COMBINATION - Movicol = Laxido. 1 sachet in 125mls liquid - Co-dranthramer - turns urine red 4. BULK-FORMING (fibre) - Fybogel (rarely used, not for constipation due to medcal cause, bd)

Question 32

How often should you review the constipation? Constipation can lead to ____________ __________

Answer 32

Review every 2 days Urinary retention (not other way round)

Question 33

Laxatives and supposites, enemas work in whole of large colon. True or False?

Answer 33

False Laxatives work in large colon Suppositories, enemas work in rectum to expel hard poo

Question 34

Breathless can be a natural part of dying. What else can cause breathlessness in a palliative setting?

Answer 34

Respiratory pathology New pathology - PE, Pulmonary oedema, MI, pneumonia, COPD exacerbation, SVCO, congestive HF, anaemia, pleural effusion ... Anxiety*

Question 35

A 69 y/o lady in the hospice has been breathless for the last 3 days. You do a history, examination and investigations to rule out acute causes. You diagnosis the breathlessness as anxiety. How would you manage this?

Answer 35

Talk about fears | Lorazepam

Question 36

How would you manage medical causes of breathlessness?

Answer 36

1. Treat underlying cause 2. Morphine 3. Oxygen Non-pharmacological: sit upright, fan

Question 37

Within end of life care there is a Gold standards framework (GSF). What does it aim to do?

Answer 37

RECOGNISE those at the end of their life to put them on a register, assess their care needs/ wishes/ advanced planning/ proceedings. There's a meeting once a month in GP to review these patients

Question 38

You are in the GP and want to approach the topic of end of life care in a patient with end-stage COPD with a MRC of 4. What key areas will you discuss?

Answer 38

1. ICE, current understanding on situation, goals 2. Ceiling of care - exacerbations 3. Anticipatory meds, all meds review 4. Advanced care planning - Advance statement of wishes, Advanced directive to refuse Rx, LPA 5. Will/ finances 6. Family - commitments, care, communication 7. Spiritual care 8. Funeral planning 9. Preferred place of care/ death 10. Organ donation 11. DNACPR

Question 39

What resource can you sign-post a patient to after a conversation about end of life?

Answer 39

dyingmatters.org

Question 40

DNACPR -Consider if it would be effective or chances of success in the first place?  - If not, don’t have to offer Rx of DNACPR (patients can’t demand Rx) BUT MUST EXPLAIN THAT TO PATIENT AND/OR RELATIVE AND REASONS. - Can review it +/- change it DNACPR only applies to that condition that may lead to cardio-respiratory arrest. True or False?

Answer 40

True DNACPR DOESNT MEAN DO NOT TREAT (Patients keep sheet and carry round with them)

Question 41

It is important to recognise when death is imminent. How would the patient present?

Answer 41

Profund weakness Too weak to swallow meds Loss of interest in E/D Drowsy, disorientated, limited attention --> Terminal agitiation

Question 42

How would you manage the medications of a person in their last days of life?

Answer 42

Have meds for symptomrelief only Prescribe anticipatory meds in syringe driver: 4As: Analgesia, Anti-emetic, Anxiolotic, Antisecretory

Question 43

What medications are prescribed in the anticipatory medications as prn? Use syringe driver if unsafe swallow

Answer 43

4A's: - Analgesia - Morphine - Anti-emetic - Haloperidol or Levomepromazine - Anxiolotic - Midazolam - Anti-secretory - Hyoscine Butylbromide (mg) or Hydrobromide (mcg, BBB)

Question 44

Syringe drivers are battery-powered portable devise that deliver continuous SC infusion of medications over time. What are the indications for the use of a syringe driver?

Answer 44

Unsafe swallow Persistent N/V Bowel obstruction Malabsorption of drugs

Question 45

How would you find out which drugs are compatible for the syringe driver?

Answer 45

BNF - Palliative care section

Question 46

After a patient dies, you must anticipate their religious practices, inform GP within 24hrs, write a death certificate or refer to coroner and provide indo/support for families. Who can write a death certificate?

Answer 46

Doctor who's seen patient in last 14 days

Question 47

Outline the process for certifying death

Answer 47

1. Check patient details, DNACPR in-situ? 2. Check responsiveness - AVPU 3. Check Pupillary reflex 4. Check carotid pulse 5. Listen to heart sounds - 2 mins 6. Document - time of certification, explain findings at each stage. On cert: Section 1 = cause of death. Section 1b = secondary condition leading to death. Section 2 = comorbidites

Question 48

How many Dr's do you need to fill out a cremation form?

Answer 48

2

Question 49

List the situations when you would need to refer the patient to a coroner. (found in death cert book)

Answer 49

``` Occupational D - Mesothelioma Unknown cause Violent/ unnatural/ accident Prisoner/ under MHA Child Death during surgery If havn't seen Dr within last 14 days (hence why GPs do home visits every 2 weeks in terminally ill palliative) ```

Question 50

List non-essentials medications that can be stopped in the last days of someone's life.

Answer 50

``` Risk factor modifying drugs: - anti-HTN, statins, diabetic meds (unless type 1) Antidepressants Laxatives Anticoagulatns Longterm Abx Vitaines Diuretics Antirrythmics. ```