Palliative Care Flashcards
What is an advanced care plan and who creates it?
A document indicating a patients wishes for treatment/care they will receive as their illness worsens and they near the end of their life
Created and updated by the GP, can be shared with other healthcare professionals involved
What is an advanced care plan also known as in Scotland?
Key Information Summary (KIS)
Who should have a KIS?
Any patient identified to have a life limiting illness who are at risk of decline
What is the first step in pain management (mild pain)?
Paracetamol 1g 4x daily
+/- NSAID e.g. naproxen 500mg 2x daily
+/- other adjuvant
What is the second step in pain management (moderate pain)?
Opioid for mild/moderate pain e.g. codeine
+/- adjuvant
Which dose of codeine should be prescribed?
30-60mg 4x daily OR
co-codamol 30/500 2 tabs 4x daily
What is the third step in pain management (severe pain)?
Stop codeine and switch to strong opioid –> usually morphine
Use in conjunction with paracetamol/NSAIDs/other adjuvant
Describe the principles of prescribing morphine for pain in palliative medicine?
Background pain:
- modified release (MR), twice daily tablet
- MST or zomorph
Breakthrough pain:
- immediate release (IR)
- tablet (sevredol) or liquid (oromorph)
- as required (PRN)
How do you work out the dose of morphine for breakthrough pain?
1/6 of total daily background dose
Describe how you would initiate a patient on morphine if they are currently take codeine at max dose (60mg 4x daily):
Stop codeine
Start morphine sulphate MR 10-15mg twice daily
+ morphine sulphate IR 5mg PRN
Titrate up background morphine depending on amount of breakthrough used
What is the maximum morphine dose?
No ‘max dose’ as such –> monitor pain and side effects
What are the symptoms of opioid toxicity?
Hallucinations
Myoclonus
Drowsiness
If someone is showing symptoms of opioid toxicity what should you do?
Dose adjustment or switch to another strong opioid
–> senior advice
If severe (respiratory depression) –> naloxone
Why should you check renal function if a patient is opioid toxic?
A reduction in renal function may have caused the toxicity
–> morphine is excreted by the kidneys so a reduction in function would cause morphine to accumulate
What should you change if a patient develops morphine toxicity due to worsening renal function?
Switch to oxycodone
How does the dose of oxycodone compare to morphine?
Oxycodone is twice as strong as morphine
What is the equivalent dose of oxycodone if a patient is on morphine MR 10mg 2x daily?
Oxycodone MR 5mg 2x daily
What is the other name for CSCI (continuous subcutaneous infusions) used in palliative care?
Syringe drivers
When are syringe drivers used and how do they work?
SC infusion once oral intake not possible
Butterfly needle with connector tubing
Up to 3 medicines in syringe
Infusion over 24 hours, changed daily
How do you work out the dose of morphine to put in the syringe driver?
SC morphine 2 x as strong as oral morphine
—> divide TOTAL daily oral morphine by 2 to work out SC infusion dose
SC breakthrough approx 1/6 of regular daily dose
Which drugs should you consider for anticipatory prescribing/just in case box and what for?
Morphine 2mg SC –> pain
Midazolam 2mg SC –> distress
Levomepromazine –> nausea
Buscopan –> secretions
When a person is dying and they stop taking fluids, which part of their care is vital?
Meticulous mouth care (dehydration)
How long should be spent on an examination to verify death?
At least 5 minutes
Describe the examination done to verify death
Check patient identification
Check for verbal response
Check for pain response (sternal rub/supraorbital pressure)
Check pupils are fixed and dilated
Palpate two major pulses for at least 1 minute
Auscultate for cardiac output + respiratory effort for 1 minute
Check for pacemaker
Document clearly in notes
Who registers a death and how long do they have to do it?
Death certificate given to family for them to register
Within 8 days of death in Scotland
