Palliative Care

Question 1

what is pain management for mild pain (step 1)?

Answer 1

paracetamol 1g 4x daily

and/or NSAID eg naproxen 500mg 2x daily

and/or other adjuvant

Question 2

what is pain management for moderate pain (step 2)?

Answer 2

codeine 30-60mg 4x daily

or cocodomal 50/500, 2 tablets 4x daily

and/or adjuvant

Question 3

what is pain management for severe pain (step 3)?

Answer 3

stop codeine and switch to strong opioid - usually morphine

can use in conjunction with paracetamol / NSAID

Question 4

how should morphine for background pain be administered?

Answer 4

modified release (MR)

twice daily tablet
MST or zoromorph

Question 5

how should morphine for breakthrough pain be administered?

Answer 5

immediate release (IR)

PRN tablet (sevredol) or liquid (oramorph) which is approx 1/6 of total background dose

Question 6

those on morphine do not become opioid tolerant - true or false?

Answer 6

false - they will get withdrawal if it is suddenly stopped

Question 7

what are the symptoms of opioid toxicity?

Answer 7

hallucinations
myoclonus
drowsiness

Question 8

what do patients with opioid toxicity usually respond to?

Answer 8

dose adjustment / switching to another strong opioid

Question 9

what should you check the function of when opioid toxicity occurs?

Answer 9

renal function - if it is impaired then morphine will accumulate as it is renally excreted

Question 10

what is the severe side effect of morphine which only occurs rarely when used it is correctly?

Answer 10

respiratory distress

Question 11

what can reverse morphine very quickly?

Answer 11

naloxene

Question 12

which opioid is twice as strong as morphine?

Answer 12

oxycodone

Question 13

SCUT morphine is how much stronger than oral?

Answer 13

twice - so divide dose by 2

Question 14

name 5 treatable conditions which can mimic dying?

Answer 14

opioid / drug toxicity 
sepsis 
hypercalcaemia 
AKI
hypoglycaemia

Question 15

which medications should be continued during end of life care?

Answer 15

only essential ones (stop statins and anticoagulants)

Question 16

what are syringe drivers?

Answer 16

butterfly needle with connector tubing which can mix up to 3 medications which are infused over 24 hours

Question 17

are syringe drivers portable?

Answer 17

yes - used in hospital or community

Question 18

what kind of medication is prescribed for common problems during end of life care?

Answer 18

anticipatory

Question 19

what should you keep in mind as cause of agitation during end of life care?

Answer 19

urinary retention

Question 20

what should be anticipatory prescribed for pain / SOB during end of life care?

Answer 20

morphine 2mg scut hourly

Question 21

what should be anticipatory prescribed for distress during end of life care?

Answer 21

midazolam 2mg scut hourly

Question 22

what should be anticipatory prescribed for nausea during end of life care?

Answer 22

levomepromazine 2.5mg scut twelve hourly

Question 23

what should be anticipatory prescribed for secretions during end of life care?

Answer 23

buscopan 20mg scut hourly

Question 24

since people become too weak to swallow food or water in final days of life, what is essential?

Answer 24

meticulous mouth care

Question 25

should IV fluids be used in end of life care?

Answer 25

no - burdensome for patients and high risk

can give trial of artificial hydration if patient distressed due to thirst / dehydration despite mouth care

Question 26

what 5 things should you do to verify death?

Answer 26

check for spontaneous movement inc respiratory effort

check for reaction to voice and pain

palpate at least 2 major pulses for one minute

inspect eyes for dryness, fixed dilated pupils, absence of corneal reflexes and clouding of cornea

auscultate heart and lungs for one minute

Question 27

what should you remember to note the presence of when verifying death?

Answer 27

pacemaker or other implantable device