Palliative Care

Question 1

What is step 1 for mild pain

Answer 1

Paracetamol 1g 4x daily 
AND/OR
NSAID e.g. naproxen 500mg 2x daily 
AND/OR 
Other adjuvant

Question 2

What is step 2 for moderate pain?

Answer 2

Codeine 30-60mg 4x daily or cocodomol 30/500 2 tabs 4x daily

Question 3

What is step 3 for severe pain?

Answer 3

Stop codeine and switch to strong opioid - usually morphine

Question 4

What is commonly used for neuropathic pain?

Answer 4

Gabapentin
Pregabalin
Tricyclic antidepressants such as amitriptyline

Question 5

Describe management of cancer pain

Answer 5

Gradual release for background pain

Instant release for breakthrough pain

Question 6

What are examples of drugs used for background pain

Answer 6

Modified Release BD

MST or zomorph

Question 7

What are examples of drugs that are used for breakthrough pain

Answer 7

Immediate rellease
PRN tablet - sevredol
Or liquid - oramoprh

Question 8

What dosage should breakthrough pain drugs be?

Answer 8

1/6th of 24 hour background dose

Question 9

How is the dose of morphine worked out?

Answer 9

Stop codeine if on 60mg 4x daily
Switch to morphine sulphate M/R 10-15mg BD with morphine sulpfate I/R 5mg PRN 4 hourly
Gradually titrate up background M/R morphine depending on amount of I/R PRN used

Question 10

Is there a maximum dose of morphine?

Answer 10

No

Question 11

What are common symptoms of morphine toxicity?

Answer 11

Hallucinations
Myoclonus
Drowsiness 
Confusion 
Delirium 
Pinpoint pupils
Resp depression

Question 12

Why should you think of renal impairment in morphine toxicity?

Answer 12

Morphine is renally excreted and therefore it will accumulate in the body if there is inadequate renal function

Question 13

What can be used to reverse morphine toxicity?

Answer 13

Naloxone but BEWARE and titrate 400 micrograms in 10ml of saline and give in 18 microgram doses until resp rate returns to normal

Question 14

Is oxycodone stronger or weaker than morphine?

Answer 14

Oxycodone is twice as strong and therefore if it is being conveted -
Morphine M/R 10mg BD = oxycodone M/R 5mg BD

Question 15

What are signs of a dying patient?

Answer 15

Worsening weakness and performance status
Worsening physiological status with no reversibility
Struggling to manage oral medicines
Losing interest in food and fluid
Sleeping more, eventual unconsciousness

Question 16

What are some treatable conditions that can mimic dying?

Answer 16

Opioid/ drug toxicity 
Sepsis
Hypercalcaemia
AKI
Hypoglycaemia 
Dehydration 
Delirum

Question 17

How can comfort be maintained at the end of life?

Answer 17

Only essential medications continued (stop stating and antioags)
Oral medicines converted to alt route where poss if no swallow
Anticipatory meds for common problems
Don’t miss urinary retention as a cause of agitation
Stop routine obs/ monitoring/ take out unused cannulas

Question 18

What is the smoothest delivery of medicines?

Answer 18

Continuous subcutaneous infusion using a syringe driver

Question 19

How is SC access achieved?

Answer 19

Butterfly needle with connector tubing

Question 20

How many medicines can be mixed together in a syringe driver?

Answer 20

Up to 3; opioids, antiemetics, anxiolytics, dexamethasone, antimuscarinics

Question 21

How does the dosage of SCUT morphine compare to oral morphine?

Answer 21

Twice as strong - divide total daily morphine dose by 2

Question 22

What drug is commonly used in palliative care for pain and SOB?

Answer 22

Morphine 2mg SCUT hourly

Question 23

What drug is commonly used in palliative care for distress?

Answer 23

Midazolam 2mg SCUT hourly

Question 24

What drug is commonly used in palliative care for nausea?

Answer 24

Levomepromazine SCUT 2.5 - 5 mg 12 hourly

Question 25

What drug is commonly used in palliative care for secretions?

Answer 25

Buscopan 20mg SCUT hourly

Question 26

How is hydration and nutrition managed in the final days?

Answer 26

Too weak to swallow - natural part of dying process
Meticulous mouth care essential
SCUT/IV fluids not routinely used

Question 27

How is death verified?

Answer 27

Check for spontaneous movement including resp effort
Check for reaction to voice and pain; sternal rub or supraorbital nerve
Palpate at least 2 major pulses for 2 min
Inspect eyes for dryness, fixed dilated pupils, absence of corneal reflexes and clouding of cornea
Auscultate the heart and lungs for 1 min
Note if pacemaker or other implantable device present