palliative care

Question 1

what are included in the advance care planning?

Answer 1

advance statement of wishes to inform subsequent best interest judgment

advance decision to refuse treatment

appointment of lasting powers of attorney for ‘health and welfare’, ‘property and affairs’

Question 2

what are the characteristics for bone pain?

Answer 2

widespread dull ache/localized tenderness

worse on weight bearing/movement

Question 3

treatement for bone pain

Answer 3

NSAIDs (diclofenac 50mg TDS)

radiotherapy

bisphosphonates (pamidronate)

Question 4

features of visceral pain

Answer 4

dull, deep-seated

poorly localised

sometimes organ-related tenderness

sometimes spasmodic (bladder/bowel)

Question 5

treatment of visceral pain

Answer 5

constant - analgesic ladder

stretch pain (liver capsule) - NSAIDs/corticosteriods

colic pain - anticholingeric eg Hyoscine butylbromide in bowel, oxybutynin bladder

Question 6

features of raised ICP

Answer 6

dull oppressive
worst waking, coughing, sneezing

N+V

Question 7

treatment of raised ICP?

Answer 7

corticosteriods to reduce oedema (16mg Dex PO OD)

NSAIDs

paracetamol

Question 8

what are some features of neuropathic pain?

Answer 8

new area of abnormal sensation

dematome/lessdefined/band

altered sensation (numbness, hyperaesthesia)

autonomic change (pallor/sweating)

ins and needles/burning

Question 9

treatment of neuropathic pains?

Answer 9

• Antidepressants (amitriptyline 10-75mg)
• Anticonvulsants (gabapentin 100-1200mg TDS/pregablin 25-300mg BD)
• Nerve compression- corticosteroids

Question 10

what is step 1 of the analgesia ladder

Answer 10

Paracetamol: 1g QSD unless <50kg in which case you half the dose

Question 11

step 2 of the analgesia ladder

Answer 11

• Co-codamol - 8/15/30mg strengths, mostly use strongest unless frail
• Codeine
• Dihydrocodeine
• Tramadol – can give hallucinations, not used in palliative care or if on tricyclic antidepressants

Question 12

step 3 of the analgesia ladder

Answer 12

• Morphine – 1st line unless kidney failure
• Diamorphine
• Oxycodone ~ x2 morphine – better for kidney function and 2nd line after morphine if unwanted side effects occur from morphine
• Fentanyl ~ x3 morphine, does not affect kidney function
• Buprenorphine – does not affect kidney function
• Methadone – used in palliative care for pain

Question 13

what are some adjunct to the analgesia ladder?

Answer 13

• NSAIDs – good for liver capsule pain
• Antiepileptic e.g. gabapentin, pregabalin
• Tricyclic antidepressants e.g. amitriptyline
• Antidepressants/social/psychological care
• Corticosteroids e.g. dexamethasone – mainly for oedema & liver capsule pain
• TENS/acupuncture/complementary therapies

Question 14

what are the features of opioid toxicity

Answer 14

perisent nausea/vom 
drowsiness 
confusion 
myoclonic jerks
halluncinations 
respiratory depression 
pinpoint pupils 
reverse with naloxone

Question 15

what is the starting dose of MST in a pt previously on max co-codamol

Answer 15

MST 20mg + PRN of 3-4mg

Question 16

what is the amount of PRN dose of morphine should you prescribe

Answer 16

1/6 of the long-release

Question 17

what is the conversion rate of oromorph to subcut?

Answer 17

1/2

Question 18

what is the conversion rate of oromorph to subcut diamorphine?

Answer 18

1/3

Question 19

how much should you inc oromorph by daily?

Answer 19

1/3-1/5

Question 20

what are the cause of mouth problem in palliative care

Answer 20

dry mouth
reduce oral fluid
radiotherapy
drug side (antiemeitc, antidepressant, opioids)

Question 21

what are the consequence of mouth problem in palliative care

Answer 21

loss of taste 
weight loss
halitosis 
dysphagia 
infection

Question 22

management of mouthcare in palliative care

Answer 22

oral thursh

• treat with antifungal
• systemic (fluconazole 50mg OD 1 week)
• topical (nystatin 1mg QDS 1 week)

Question 23

what are some causes of anorexia in palliative care

Answer 23

thrush 
nasuea 
constipation 
depression 
pain

Question 24

management of anorexia in palliative care?

Answer 24

encourage but don’t force

dex 4mg OD but last 2-3 weeks

megestrol acetate (progesterone) 160mg OD lasts longer but fluid retention

Question 25

what are the 4 main courses of N+V

Answer 25

cerebral - raised ICP/brain mets

Vestibular - dizzy but not necessarily physically sick, cerebral mets, vestibular lesion

Gastric - gastritis, liver mets

Toxicity - drugs side effect, toxins from cancer

Question 26

management of cerebral causes of N+V

Answer 26

dex + cyclizine

Question 27

management of anticipatory N+V

Answer 27

bezno/SSRI

CBT

complementary therapy

Question 28

management of vestibular N+V

Answer 28

cyclizine

hyoscine hydro for motion sickness

Question 29

management of gastric N+V

Answer 29

metoclopramide + PPI

Question 30

management of toxic N+V

Answer 30

Haloperidol 500μm nocte
Or
Cyclizine
Or levomepromazine

Question 31

what are some example of bulk forming laxative?

Answer 31

fibrogel - not really used in palliative care medicine

Question 32

what are some example of softener laxative?

Answer 32

lactulose

docusate

Question 33

what are some example of stimulant laxative?

Answer 33

senna

dantron

Question 34

what are some examples of combination laxative

Answer 34

both are mix of stimulant and softener

1) co-dantramer (only licenced in terminal illness)
2) movicol

Question 35

first line of laxative in palliative care?

Answer 35

senna