Palliative care

Question 1

Steps of WHO analgesic ladder

Answer 1

1. paracetamol
2. codeine
3. strong opioid - morphine
   +- adjuvants

Question 2

side effects of codeine

Answer 2

constipation

Question 3

signs of opioid toxicity

Answer 3

confusion 
hallucinations 
vivid dreams 
myoclonus 
sleepiness / sedation
pinpoint pupils 
respiratory depression

Question 4

potential causes of delirium in a cancer patient

Answer 4

PE 
constipation 
dehydration 
infection 
hypercalcaemia 
opioid toxicity 
brain metastases 
lymphangitis carcinomatosis

Question 5

what should you do if a patient is toxic on opioids

Answer 5

review / reduce opioid
IV fluids
renal and hepatic function
opioid switch - oxycodone

Question 6

non-pharmacological management of breathlessness

Answer 6

PT - pacing, position, posture, handheld fan, pattern of breathing
OT - assess previous function levels, goal setting and priorities
CT - massage, relaxation techniques, mindfulness

Question 7

pharmacological management of breathlessness

Answer 7

low dose oral opioid - oramorph
lorazepam - more to relieve anxiety
long term oxygen

Question 8

how should you approach someone who is at end of life

Answer 8

anticipatory medications 
DNACPR discussion 
communication about needs, family... 
chaplaincy 
financial support 
visiting...

Question 9

codeine to morphine conversion

Answer 9

divide by 10

Question 10

oral oxycodone is twice as strong/weak as oral morphine

Answer 10

oxycodone is twice as strong

10mg PO morphine = 5mg PO oxycodone

Question 11

oxycodone is excreted renally/hepatically

Answer 11

oxycodone has hepatic excretion

therefore used in patient with renal failure

Question 12

morphine is excreted renally/hepatically

Answer 12

morphine has renal excretion

Question 13

what can be given to suppress cough

Answer 13

opioids specifically, methadone
(also codeine)
but this can make the patient sleepy

Question 14

if a patient is having haemoptysis, what should you do with regards to medications
e.g. from lung Ca

Answer 14

check medications - anticoagulants
consider tranexamic acid, patient would already be hypercoaguable from Ca and so tranexamic acid might make them clot more

Question 15

what type of pain can ketamine be used to treat

and what must you monitor

Answer 15

neuropathic pain

BP

Question 16

actions of levomepromazine

Answer 16

anti-emetic

helps to relieve agitation

Question 17

what kind of neuropathic pain might a cholangiocarcinoma cause

Answer 17

coeliac plexus neuropathy

Question 18

reversible factors that can mimic death

Answer 18

drug toxicity 
electrolyte imbalances 
hypoglycaemia 
delirium (and its causes)
encephalopathy

Question 19

checklist for death verification

Answer 19

1. no response to voice
2. no response to painful stimuli
3. absence of carotid pulse 1min
4. absence of heart sounds 2 min
5. absence of breath sounds 2 min
6. fixed dilated pupils