Palliative Care Flashcards by Lydia Su

The indications for corticosteroid

Inflammation
Cérébral oedema, metastasis
NV
SC compression
Analgesic (nerve pain)
SOB in COPD exacerbation (reduce anxiety

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Conversion bw prednisolone and dexamethasone

6mg pred is 1 mg dexathamethasone

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Conversion bw buprenophine patch to 24h oral morphine salt

Patch duration

Buprenophine 5’ is 12mg PO morphine salt
72h / 96h/ 7d
Given morphine dose /12 then x5

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Conversion bw fentanyl patch to PO OD morphine salt

Fentanyl 12’ is 30mg morphine salt OD
25’ is 60mg 
50’ is 120mg 
Available as 72h only 
Given morphine dose/60 then x25

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Symptoms for hypercalcaemia

Dehydration 
NV
Constipation 
Confusion 
Cardiac probs
Polydipsia (thirsty)
Pruritus 
Fatigue

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Treatment for hyperca

Moa

Rehydration 
Bisphosphonates eg zoledronic acid 
If GFR< 30 ibandronic acid 
Inhibitis osteoclasts activity reduce bone resorption 
reduce ca release

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What is Corrected calcium level

55% Of calcium in the blood is bound to albumin
45% free ca to be measured
Corrected calcium level takes into account of albumin and protein level

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What is the normal range of calcium level

2.1-2.6 mmol/L

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What are the ranges for hypercalcaemia
Mild
Moderate
Severe

2.6-3
3-3.4
>3.4

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Treatment for restlessness and agitation

Induce sedation
BZ
Midazolam
AP- haloperidol, levomepromazine at high dose

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What is death rattle

Excessive chest secretion

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What are the treatment for secretion

Hyoscine butylbromide x BBB, poor BA
Hyoscine hydrobromide yesBBB
Glycopyrrodinium bromide xBBB anti muscarinic
Octreotide somatostatin analogue, reduce gi motility

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What is anticipatory medicine what is in that just in case box

medicine given to patient to use at home for emergency symptom control. AM should be based on individual patient’s condition 
Anticipatory medicine for sc use
Needle and syringes
Prescribing guidance
Rx 
PIL
Contact details for advice

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What did nice cg31 Care of the dying adult in the last day of life recommend

Recognising Last few days of life
Communicate and shared decision-making
Clinically assisted hydration
Meds for Pain,SOB,NV,anxiety,delirium,agitation,secretion
Anticipatory prescribing

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What’s the acronym IMPACT stands for in Symptom control of palliative care patient

I Identify concerns
M make an accurate assessment
P Plan your action
A act
C Continuously re-evaluate
T Talk to other HCPS

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What did nice guidelines recommend on pain relief for palliative care adult CG140

Communication
Start on strong opioid and titrate the dose-oral morphine
Use 1st line maintenance trt
Use transdermal patches if oral opioid not suitable
Use 1st line trt for BT pain in pt who can take oral opioid
Manage constipation.NV. Sedation

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What is a typical total daily starting dose of Oral morphine

20-30mg OD
10-15mg BD
5mg (1/6-1/10 OD dose)BT

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Inversion between oral morphine with: 
Tramadol/ codeine/ dijudrocodine 
IV morphine 
PO/ IV oxycodone
IV diamorphine 
IV alfentanyl 
PO hydromirphine

X10
/2
/2, /2
/3
/30
/7.5 10mg morphine is 1.3mg hydroM

Fentanyl is x times more potent than P.O. morphine?

Why is it used as 2nd line

50-100 x more potent
Greater CNS distribution
BUT Not any more effective as analgesic than morphine

Treatment for bone pain

Bisphosphonates
Zoledronic acid/ pamidronate
If GFR<30 use Ibandronic acid

Treatment for neuropathic pain

Antidepressant:  Amitriptyline50mg 
SSRI Fluoxetine
Anticonvulsants:
Sodium valproate 
carbamazepine
Gabapetin 
Ketamine - dysphoria and delirium use BZ or midazolam 
Dexamethasone

Mental capacity act 2005 -5 principles

A presumption of capacity
Individual supported to make their own decision
Unwise decisions
Best interests
Less restrictive option

Impaired Capacity to make decisions according to law

motor neurone disease -30% impaired 
Feeling a burden 
Depression and hopelessness are mutually reinforcing
Major depression 
Medication changes can impair capacity

What do u need to make any decision

Accurate info
Capacity (decision specific capacity- the capacity you have for making that decision at that time)
Voluntary- Willingness

Points covered in Assisted dying proposed legislation to UK Parliament

``` Terminally ill Clear and settled wish Mental capacity Informed of options 2 doctors Self administer ```

Why might a patient need a syringe pump

- NV - dysphagia can’t swallow tablet - pill burden - poor GI ab. Eg oleostomy/ stoma/ obstruction - profound weakness / unconsciousness

Signs of problems with syringe driver

Skin irritations Pain / leaking at injection site Precipitation in driver Discolouration of solution

How does ph affects diamorphines stability/ solubility

Diamorphine less stable, more likely to precipitate if the ph is high >6

What is the pH of injectable dexamethasone | What’s the implication and solution

Ph 7-9 Strong alkali It will precipitate our other drugs eg diamorphine Given as separate bolus inj as long t1/2

What are the sources of information for compatibility of syringe driver drugs

- BNF - compatibility tables - the synringe driver - palliative durg.com - PCF - pallcare guidrlines

What are the two benefit of anticipatory prescribing

Easy access to care and medicine when needed at home | Helpful when deterioration occurs out of hours

When deciding which anticipatory medicines to offer take into account of (NG31)

- likelihood of specific symptoms occurring - benefit and harm of rx ing or administering medicine - B&H of not rx ing - risk of sudden deteriorating for which urgent symptom control may be needed - the place of care & time it would take to obtain medicines

What are the four main symptoms that are covered in anticipatory medicine

- agitation/ restlessness - NV or agitation - ex chest secretions - pain

What are the four main medicines prescribed in anticipatory medicine in just in case box

Morphine sulfate - analgesic Midazolam - anxiolytics sedative Hyoscine butybromide - anti secretory Levomepromazine or haloperidol - antiemetic and anxiolytics

Treatment for spinal cord compression | What’s the risk

``` Emergency MRI scan 16mg dexamethasone IV/PO stat 8mg dexamethasone BD PO ongoing until MRI results Stop or wean down asap Adrenal suppression ```

What are the main symptom burden is in palliative care

``` IS PANIC Immobility SOB Pain Anorexia NV Insomnia Constipation ```

Nice guidelines on managing side effects of strong opioids

Constipation: laxatives + adherence NV: self résolve + antiemetic Sedation: self resolve (only initiation/ dose increase) + ability to drive

When does patient need opioid rotation

Inadequate analgesia despite dose titration and adjuvant CNS SE remain when dose reduced

What are the breakthrough pain alternatives to Liquid Morphine

Fentanyl lozenges / SL | ALfentanyl SL/ spray

Hydromorphone is X times more potent than P.O. morphine?

7.5 x

What class of drug is oxycodone

Kappa opioid rec agonist - dsyphoria / hallucinations-> midazolam or BZ

``` What class of drug is methadone What is it used for ```

A mixed pharmacology - Miu agonist NMDA antagonist (glutamatergic neu trans) SSRI Analgesic / opioid addiction / antidepressant

What are the characters of methodone

Long half life - risk of accumulation

In what form is methadone avalible jn

Tablet Liquid Injection Suppository