Palliative care Flashcards
When should routes other than oral be considered for morphine for pain relief?
If the patient has dysphagia, gastric stasis, intractable N+V, impaired consciousness
What are some side effects of opioids?
Constipation, N+V (usually improves after 5 days), drowsiness (often temporary), dry mouth, respiratory depression (rare if prescribed correctly).
What should be co-prescribed when prescribing an opioid?
A laxative
Consider adding an anti-emetic.
What are some signs suggestive of opioid toxicity?
Persistent N+V, persistent drowsiness, confusion, visual hallucinations, myoclonic jerks, respiratory depression, coma.
How do you convert oral codeine dose to equivalent oral morphine dose?
Divide total daily codeine dose (max. is 240mg) by 10
=24mg. NICE recommends starting dose of 20mg, slightly lower if renal failure
What PRN dose of oral morphine should be prescribed for breakthrough pain?
Total daily dose or MR morphine (starting dose - 40mg) divided by 6 (=6.666mg so prescribe 5-10mg).
How many times can a prn dose of morphine be given in a day?
Maximum 6 doses in 24 hours.
Can be given hourly if needed but should not exceed 6 doses in 24 hours
When should oxycodone be considered for pain relief?
If the patient has renal failure or can’t tolerate the side effects of morphine.
What are the 4 main mechanisms that stimulate the vomiting centre in the brain thereby producing nausea and vomiting?
Gastric stasis/irritation
Toxic causes (e.g. chemotherapy, palliative drugs)
Cerebral causes (e.g. raised ICP, anxiety, indeterminate)
Vestibular causes
Which antiemetic is best suited for the management of nausea and vomiting due to gastric reasons?
Metaclopramide
What are the important side effects to be aware of for metaclopramide?
EPSE/Parkinsonian side effects.
QT prolongation
What drug should be considered if a patient is unable to tolerate the side effects of metaclopramide?
Domperidone - as this only works peripherally. However, domperidone can only be given orally.
When should pro-kinetics (e.g. metaclopramide, domperidone) be avoided in the management of N+V?
When there’s bowel obstruction - use haloperidol instead
What are the first and second line antiemetics suited for the management of nausea and vomiting due to toxic causes?
1st line - Haloperidol
2nd line - ondansetron (often given with chemo)
Which antiemetic is best suited for the management of nausea and vomiting due to raised ICP?
Dexamethasone 8-16mg po plus Cyclizine 50mg tds
Which antiemetic is best suited for the management of nausea and vomiting due to anxiety?
Benzodiazepines may help
Which antiemetic is best suited for the management of nausea and vomiting due to vestibular causes?
Consider cyclizine, hyoscine or cinnarazine
What type of laxative are lactulose, docusate, poloxamer and Mg salts?
Stool softeners
What type of laxative are Senna, bisacodyl and picosulphate?
Stimulants
What type of laxative is movicol?
Combination stool softener and stimulant. Predominantly softening action.
What are key S/E of the combination laxative co-danthramer to be aware of?
Stains urine red, may cause perianal rash
What are some signs that a patient is dying/close to death?
Irreversible life-threatening illness, step-wise change in functioning, day-to-day change, bed bound/profound weakness, reduced consciousness, unable to take meds/food, no easily reversible cause such opioid toxicity/renal failure/hypercalcaemia/infection
What 4 anticipatory drugs should be prescribed for end of life patients?
Analgesia (e.g. diamorphine sc for SD)
Antiemetic (e.g. haloperidol)
Anxiolytic (e.g. midazolam)
Anti-secretory (e.g. hyoscine butylbromide)
All can be put in a syringe driver - diluent should be water for injection
