Palliative care Flashcards
Analgesia should be ‘done’ by what three things?
By the ladder, by the clock, by the mouth (if poss)
How many times stronger than morphine is oxycodone?
2x
How many times stronger than morphine is fentanyl?
3x
Which two opioids are suitable for end stage renal failure?
Fentanyl or bupranorphine
What does a co-codamol dose of 30/500 mean?
30mg codeine, 500mg paracetamol
Why might you give co-codamol on the analgesic ladder?
It keeps ‘step 1’ paracetamol going as well as step 2, but combined in a tablet
SEs morphine
Constipation
N+V
Drowsy/clouded consciousness
Dry mouth
Itching
Reduced perception of breathlessness
Symptoms opioid toxicity
delirium
vivid dreams
visual hallucinations
myoclonus
decreased resp rate
pinpoint pupils
Immediate release morphine takes how long to work and lasts for how long?
within 30mins
Lasts 2-4hrs
Examples of IR morphine?
Oramorph
Sevredol
Modified release morphine lasts for how long
12 (or 24) hours
Examples modified release morphie
MST
Zomorph
Morphgesic
If a patient is on co-codamol 30/500 two tablets QDS and you want to add some morphine for breakthrough pain how much morphine would you prescribe?
30 x 2 x 4 = 240mg
240mg codeine = 24mg morphine
1/6 daily dose for breakthrough so 24/6 = 4
Prescribe 5mg (no more than 6-8 doses in 24hr)
What is the breakthrough morphine dose compared to MR dose?
1/6 daily total
How do you increase someone who is on MR and IR morphine?
Increase the MR to the current total daily dose, including IR (but only 1/3-1/2 increase is safe).
MR given BD
Is oramorph prescribed in mg or ml?
mg because it comes in 10mg/5ml and 100mg/5ml
What specific signs are there that you should reverse the opioid?
RR <8 and not rousable- reverse with naloxone
The SC dose of morphine is ____ the oral dose
half
Four causes of nausea and vomiting?
Cerebral
Toxicity (mainly nausea)
GI (mainly vomiting)
Ear
Two cerebral causes of nausea?
SOL
Anxiety/perception
Rx for cerebral nausea
SOL- Dex or cyclizine
Anxiety/perception- benzo/SSRI
Rx for chemo nausea
Ondansetron
Graniestron
Rx for the rest of the toxicity causes of nausea
Haloperidol
Which antipsychotics help with nausea?
Levomepromazine and olanzapine (but typical so SEs)
Can you give metaclopromide and cyclizine?
No they counteract each other
What are the four types of laxative?
Bulking agent
Softener
Stimulant
Combination
Fybogel is what sort of laxative?
Bulking agent
Senna is what sort of laxative?
Stimulant
Docusate is what sort of laxative?
Softener
Movicol is what sort of laxative?
Combination
Condranthamer is what sort of laxative?
Combination
How do you know whether to give oral or enema laxative?
If can feel hard stool in rectum- enema. Oral will cause overflow.
What can an advanced care plan say regarding treatment?
It can refuse in specific circumstances, can’t demand
Decisions to refuse treatment are legally binding if valid and appliable
Why do people make ACPs?
In case they lose capacity in future
What is the Gold Standards Framework?
Approach to optimising EoL care
What are three steps in the GSF?
Identify EoL patients
Assess current and future clinical and personal needs
Plan (MDT)
What should be discussed with a patient about their last days? (6)
Medication review
Symptom control
Family needs
Nursing needs
Psycho-spiritual needs
Preferred place of death and goals of care
What are 4 essential medications to continue at EoL
the anticipatories
analgesic, antiemitic, anxiolytic, anti-secretory
Are antidepressants essential to continue at EoL?
No
Are laxatives essential to continue at EoL?
No
Are anticoagulants essential to continue at EoL?
No
Are LT Abx essential to continue at EoL?
No
Are corticosteroids essential to continue at EoL?
Maybe- consider stopping
Are diuretics essential to continue at EoL?
No
Are hypoglycaemics essential to continue at EoL?
Consider stopping
Are anticonvulsants essential to continue at EoL?
Consider stopping
How should children be involved in death?
Involve them, be honest and factual (age appropriate).
Recognise that they grieve and share sadness
Create a new routine
How is death confirmed?
Absence of central pulse or heart sounds.
After 5 mins of cardio-resp arrest (e.g. listen to HS for 2 mins and Resp sounds 3 min), confirm absence of
- Pupillary light reflexes
- Corneal reflexes
- Motor response to supra-orbital pressure
May also include asystole on ECG, absence of pulsatile flow on intra arterial pressure monitor or absence of contraction on echo.
When is time of death?
After it has been confirmed
What might the body be examined for after death?
Pacemaker, bruises, pressure sores
When should you not issue death certificate
Coroner needed
Who must do the death certificate
A doctor who attended the person during their last illness. Must have seen them within 14 days. Provide within 24hrs
How should the date be written on a death cert?
Write the numbers out in letters e.g. twenty
Can you put ‘old age’ on a death certificate?
No
What is section II of cause of death
Other significant conditions contributing to the death but not related to the disease causing it
Is the mode of dying e.g. resp arrest put on the death certificate?
No
Can you use abbreviations e.g. CKD on death cert?
No
When is referral to coroner needed
No doctor attended during last illness, or not in the last 14 days
Cause of death unknown (post mortem required)
If death occured:
- during operation or before anaesthetic ended
- industrial poisoning or at work
- sudden or unexpected (including <24h in hosp)
- unnatural (medical mistake)
- violence of neglect
- other suspicious cause
- in prison, custody or other state detention
If post mortem reveals the death was not unnatural what happens?
Pink form issued to registrar
Death can be registered
Body released for cremation or burial
What happens to the MCCD (medical certification of cause of death) or coroner’s certificate?
Given to registrar of births and deaths within 5 days
Death certificate issued to family
What can be used in patients who require an opioid but cannot tolerate morphine?
Oxycodone hydrochloride
What laxative should be given with opioids?
Co-danthramer (softener + peristalsis)
Or lactulose with senna
Do patients taking an opioid require an anti-emetic?
Maybe for the first few days but then ok
What should be discussed when talking to a pt about escalation plan and ceiling of care?
Other Rx
ward vs ICU
CPR?
Nutrition and hydration
Interventions
Medication and symptom management
Preferred place of death
What is ‘fast track’ in palliative care?
Unlocks funding for care at home if short time left to live
Give examples of the anticipatories
Analgesic- morphine
Antiemitic- haloperidol 1.5-3mg
Anxiolytic- midazolam 2.5-5mg
Antisecretory- hyoscine butylbromide 10-20mg
Can you give diazepam, chlorpromazine or prochlorperazine SC?
No
Can you mix the usual anticipatories?
Yes, but nb drugs do exist that need a separate syringe driver e.g. dex, diclofenac, ketorolac
