Palliative Care

Question 1

Name three major problems that patients in palliative care experience

Answer 1

Constipation
Pain
Nausea and vomiting

Question 2

What are the non pharmacological and pharmacological management options of breathlessness in a patient in palliative care?

Answer 2

Non pharmacological: reassurance, relaxation techniques, breathing retraining

Pharmacological: 5-10mg MR oramorph (twice daily)
prescribe concurrent laxative/anti emetic

Benzodiazepines: use only in breathlessness associated with acute panic attacks/anxiety or if patient is imminently dying (500mg lorazepam)

Oxygen therapy

Question 3

What are the reversible causes of constipation in palliative patients?

Answer 3

hypercalcaemia
fluid depletion
side effects of medications

Question 4

What is the pharmacological management of constipation?

Answer 4

1) increase fluids, fruit juices
is stool hard or soft?
hard stool = 1) softener = sodium docusate
soft stool = 1) stimulant = senna

if this hasn’t worked, combine docusate + senna and PR exam

if on PR exam, if;
stool is soft and impacted = bisocodyl
stool is hard and impacted = glycerin suppositories
no stool = high phosphate enema

Question 5

give examples of stimulant laxatives, their mechanism of action and the dosing

Answer 5

senna and bisocodyl
reduces bowel transit time - stimulant
15-30mg at night

Question 6

give examples of osmotic laxatives, their mechanism of action and the dosing

Answer 6

macrogols = movicol
lactulose

retain water in gut lumen which encourages peristalsis

1-3 sachets daily

Question 7

what are the S.E. of lactulose?

Answer 7

bloating
flatulence
abdominal pain

Question 8

what are the different laxative enemas you can use?

Answer 8

arachis oil
microlax
phosphate

all are softener enemas

Question 9

what are the reversible causes of nausea and vomiting in palliative care?

Answer 9

constipation
hypercalcaemia
medication side effects

Question 10

what is the non pharmacological management of nausea and vomiting in palliative care?

Answer 10

provide a calm environment away from where food is prepared
make sure the meals are small and palatable
offer cool, fizzy drinks
consider parenteral hydration
complementary therapies: relaxation techniques

Question 11

if nausea and vomiting is caused by medication, what anti-emetics would you give?

Answer 11

1) haloperidol
2) levomepromazine

(you can tell it is caused by medication as the nausea will be unrelenting, not relieved by vomiting)

Question 12

if nausea and vomiting is caused by gastric stasis, what anti-emetics would you give?

Answer 12

metoclopramide or domperidone

Question 13

if nausea and vomiting is caused by chemotherapy or radiotherapy, what anti-emetics would you give?

Answer 13

acute: ondansetron
delayed: levomepromazine

Question 14

if nausea and vomiting is caused by organ damage, what anti-emetic should you give?

Answer 14

cyclizine

Question 15

if nausea and vomiting is caused by raised intracranial pressure, what anti-emetic should you give?

Answer 15

cyclizine

Question 16

in postoperative nausea and vomiting, what anti emetic should you give?

Answer 16

ondansetron

Question 17

what are the antihistamine anti-emetics, their mechanism of action, and side effects?

Answer 17

cyclizine and promethazine

block H1 receptors in the vomiting centre in the medulla. have antimuscarinic properties too.
best for ‘higher neurological’ issues such as meniere’s and vertigo.

SE: sedation, dry mouth, blurred vision, hypotension

an example dose: cyclizine 50mg 8 hourly

Question 18

what is the antimuscarinic anti-emetic?

Answer 18

hyoscine hydrobromide

used in motion sickness

Question 19

what are the dopamine receptor antagonist anti-emetics and their side effects?

Answer 19

chlorpromazine, metoclopramide, domperidone

act at the chemoreceptor trigger zone blocking dopamine receptors

SE: hyperprolactinaemia, EPS = dystonia, parkinsonism, akathisia, neuroleptic malignant syndrome

Question 20

what are the 5HT3 receptor antagonist anti-emetics, their mechanism of action and side effects?

Answer 20

ondansetron

blocks the 5HT3 receptors in the CTZ and gut

side effects: constipation, headache, flushing, QT interval prolongation

Question 21

what are the commonest causes of malignant ascites? what is the treatment of ascites?

Answer 21

primary tumours of breast, colon, ovary, stomach, pancreas, bronchus

treatment: paracentesis or spironolactone