Palliative Care

Question 1

What is palliative care?

Answer 1

Palliative care – care that is not aimed at curing someone of an illness but of making them comfortable and live as long as possible with as high a quality of life as possible. It involves physical, mental, social and spiritual care and may involve the family as well.

In palliative care active treatment is still undertaken if the underlying cause is reversible e.g. PE, constipation etc.

Question 2

How should pain be assessed?

Answer 2

It’s always important to assess pain properly using SQITARS and the 1-10 rating.

Question 3

Does regular PRN use of analgesia mean daily doses need to be increased?

Answer 3

When evaluating PRN use check it’s not just being given for when care is given – this is fine to do but doesn’t mean the overall dose needs increasing.

Question 4

What is nociceptive pain?

Answer 4

Nociceptive pain = normal nervous system identifying lesion or insult causing tissue damage. Can be somatic or visceral. Described as sharp, throbbing and ache.

Question 5

What is neuropathic pain?

Answer 5

Neuropathic pain = malfunctioning nervous system or damage to nerve structure. Described as stabbing, shooting, burning, numbness and stinging.

Question 6

Describe the WHO analgesic ladder?

Answer 6

1) Non-Opioids
Paracetamol
Ibuprofen, diclofenac or naproxen (PPI needed)

1) Opioids for mild-moderate pain
Codeine phosphate/Dihydrocodeine
Tramadol
Co-codamol

1)	Opioid for moderate-severe pain 
Morphine
Diamorphine 
Oxycodone or Buprenorphine (moderate renal impairment)
Alfentanil (severe renal impairment)
Fentanyl (severe renal impairment)

Question 7

Should you stop step 1 WHO ladder analgesia when starting stages 2 and 3?

Answer 7

Paracetamol and NSAIDs can be opioid sparring and should be alongside steps 2 and 3

Question 8

What drugs need prescribing alongside opiates?

Answer 8

Prescribe PRN laxatives and anti-emetics with strong opioids

Question 9

What adjuvants can be prescribed alongside analgesia?

Answer 9

Other Adjuvants include amitriptyline, pregabalin, gabapentin, corticosteroids, benzodiazepines, bisphosphonates and nerve blocks.

Question 10

Which drugs are good for nerve pain and what are their side effects?

Answer 10

Amitriptyline (confusion, hypotension), pregabalin and gabapentin (sedation, tremor, confusion, dizziness) are good for neuropathic pain

Question 11

What are the 4 most important rules for pain relief prescribing?

Answer 11

Pain relief should be given my mouth
Regularly (by the clock)
Follow the ladder (by the ladder)
Be individually titrated

Question 12

What dose of morphine should you start on in an opioid naive patient?

Answer 12

In an opioid naïve patient, you should start with a very low dose of morphine usually 5mg every 4 hours (IR) plus 5mg PRN for breakthrough pain maximum hourly. Increase dose by 30-50% until pain is controlled.

Question 13

If someone is taking too much PRN often how should you alter their daily dose?

Answer 13

Once controlled add up all daily doses and PRNs used and give modified/slow release (SR) over 2 doses during the day. PRN dose should be a 6th of this given hourly maximum and up to 6 times a day.

Always prescribe a PRN IR dose of morphine, preferably oral but can be SC

Question 14

Give some examples of IR and SR morphine

Answer 14

IR morphine = Oromorph – liquid, Sevredol – tablets

SR morphine = Zomorph – capsules

Question 15

If oral analgesics are contraindicated what should be given?

Answer 15

Fentanyl patches are first line for those who oral analgesics are contraindicated

Question 16

What is the opioid ratio of codeine/tramadol to morphine and morphine to SC morphine?

Answer 16

Codeine/Tramadol: Morphine is 10:1

Oral morphine: SC morphine 2:1

Question 17

As opioids are controlled drugs what must you do when prescribing TTOs?

Answer 17

Opioids are controlled drugs so when prescribing for TTOs you have to write them out fully.
Write prescription as normal then exactly what the pharmacist should supply
NAME FORM and STRENGTH
Supply NUMBER (written both ways) then dose of tablets/bottles/patches

e.g. Oral Morphine (SR) Zomorph 20mg BD 
Supply 28 (twenty eight) 20mg tablets

Question 18

If prescribing liquid/patch/syringe driver analgesia how do you write the total dose?

Answer 18

Make sure to supply whole bottles
Patches usually last 3 days (but take 12 hours to start working properly) and are dosed in mcg/hour
If giving by syringe driver then write SCSD

Question 19

What are the side effects of opioids?

Answer 19

Constipation, nausea and vomiting (usually just transient), drowsiness (in first 5 days) and dry mouth. If difficulty tolerating or toxicity, then switch to oxycodone.

Question 20

What are the features of opioid toxicity

Answer 20

Sedation, respiratory depression, visual hallucinations, myoclonic jerks, pinpoint pupils and delirium. Causes are usually recreational use, stepping up dose too quickly or renal impairment.

Important to diagnose early so Naloxone can be avoided. Check O2 sats and give oxygen as needed, reduce opioid dose and hydrate well. Naloxone should only be used in severe respiratory depression as it can lead to pain crisis and fatal acute withdrawal.

Question 21

What causes nausea due to reduced gastric motility and how should it be treated?

Answer 21

Reduced gastric motility – can be opioid related.

Due to serotonin and dopamine receptors

Metoclopramide
Domperidone

Question 22

What causes chemically mediated nausea and how should it be treated?

Answer 22

Chemically mediated

Secondary to hypercalcaemia, opioids or chemoterhapy

Ondansetron, haloperidol and levomepromazine

Question 23

What causes visceral/serosal mediated nausea and how should it be treated? (this includes raised ICP)

Answer 23

Visceral/serosal

Constipation or oral candidiasis

Cyclizine and levomepromazine
Anticholinergics can be useful

Raised ICP
Cyclizine
Dexamethasone
(radiotherapy for cranial tumours)

Question 24

What causes vestibular mediated nausea and how should it be treated?

Answer 24

Vestibular

Activation of acetylcholine and histamine receptors, can be opioids related, motion related or base of skull fracture

Cyclizine

If refractory – metoclopramide, prochloperazine or atypical antipsychotics

Question 25

What causes cortical mediated nausea and how should it be treated?

Answer 25

Cortical
Anxiety, pain, anticipatory due to GABA and histamine receptors

Anticipatory – lorazepam
Cyclizine if benzos aren’t ideal
Ondansetron and metoclopramide can be trialed

Question 26

What are the benefits and problems with levomepromazine as an antiemetic?

Answer 26

Levomepromazine – broad spectrum affecting all receptors but may cause sedation.

Question 27

What route should be used for anti emetics?

Answer 27

Consider route as oral absorption may be poor – SC for first 24 hours
If first anti-emetic doesn’t work combine with another with different mechanism

Question 28

What causes constipation in palliative patients?

Answer 28

Causes: Opioids, Hypercalcaemia, Dehydration and Intrabdominal obstruction.

Question 29

Name the anti-constipation meds classes and examples of each?

Answer 29

Stimulants – Senna
Faecal softener – Sodium docusate
Osmotic laxatives – Macrogol/Movicol, Lactulose and Laxido
Bulking agents – Fybogel
Rectal Treatment – glycerol suppositories and phosphate enemas

Question 30

How should breathlessness be assessed and managed in palliative patients?

Answer 30

First must look for reversible causes: PE, infection, effusion, CCF, COPD, anaemia, arrythmia or SVC obstruction. Reversible causes can be treated as normal.

If non-reversible or intractable then management is different.
Use gravity to aid breathing 
Remain calm and confident 
Airflow across face from fan or window
Oxygen if hypoxic

Question 31

How can breathlessness be managed pharmacologically?

Answer 31

Pharmacological management
Trial low dose opioid, if opioid naïve then start at around 2.5mg IR every 4 hours. Benzodiazepines may help if anxiety related to breathlessness – trial Lorazepam or midazolam.

Question 32

How can oral problems be managed - especially dry mouth?

Answer 32

Generally important to give good mouthcare and stay well hydrated.

Consider side effects of drugs which may be influencing any symptoms.

Sugar free chewing gum, normal saline mouth washes and soft toothbrush. Avoid products containing alcohol as they will sting. Salivary stimulants (better than substitutes) can be helpful such as pilocarpine eye drops on the floor of the mouth QDS.

Question 33

How should oral candidiasis be managed in pallaitive patients?

Answer 33

Candidiasis – topical miconazole oral fluconazole but check interactions e.g. warfarin.
Herpes simplex – oral ganciclovir or aciclovir.

Question 34

What advice can you give patients suffering from insomnia?

Answer 34

Most important points are sleep hygiene 
Don’t drink too much before going to bed
Dark quiet room 
Avoid screens 
Don’t look at the clock if you wake up

Question 35

What pharmacological management can be given for insomnia?

Answer 35

Zopiclone or benzodiazepines can be used to re-establish normal sleep wake cycles but should not be used indefinitely.

Question 36

What causes pruritis in palliative patients?

Answer 36

Causes: systemic disease (renal failure, hepatitis and polycthaemia), cancer related (cholestasis, lymphoma, leukaemia, hepatoma, myeloma and paraneoplastic), primary skin disease and drug reactions.

Question 37

How can pruritis be managed in palliative patients?

Answer 37

Management
Treat underlying causes where possible.
If opioid, then consider antihistamine or opioid switch.
Topical emollients and as a soap substitute

Question 38

How should agitation and confusion be managed in palliative patients?

Answer 38

Check for underlying reversible causes first: infection, delirium, hypercalcaemia, or medication.

Question 39

If required how can agitation and confusion be managed pharamacolgically?

Answer 39

First choice treatment is Haloperidol, Chlorpromazine or Levomepromazine
In the terminal phases of illness then SC midazolam is indicated.

Question 40

What drug class do cyclizine, metoclopramide, domperidone, haloperidol, prochloperazine, ondansetron and hyoscine butylbromide

Answer 40

Antihistamines Cyclizine

Dopamine antagonists Metoclopramide
Domperidone
Haloperidol
Prochloperazine

Serotonin antagonists Ondansetron

Anticholinergics Hyoscine butylmromide

Question 41

Describe the WHO performance status

Answer 41

• 0: Fully active, no restrictions on activities. A performance status of 0 means no restrictions in the sense that someone is able to do everything they were able to do prior to their diagnosis.
• 1: Unable to do strenuous activities, but able to carry out light housework and sedentary activities. This status basically means you can’t do heavy work but can do anything else.
• 2: Able to walk and manage self-care, but unable to work. Out of bed more than 50% of waking hours. In this category, people are usually unable to carry on any work activities, including light office work.
• 3: Confined to bed or a chair more than 50 percent of waking hours. Capable of limited self-care.
• 4: Completely disabled. Totally confined to a bed or chair. Unable to do any self-care.
• 5: Death