Palliative Care and Pain Management

Question 1

Give 5 situations in which a patient could be described as approaching the end of life

Answer 1

patient whose death is imminent,
patient with advanced incurable condition/s,
patients at risk of dying from a sudden acute crisis of their condition,
patients with life-threatening acute conditions caused by sudden catastrophic events
patients with general fraility and co-existing conditions that mean they are expected to die within 12 months

Question 2

How would you define ‘a patient who is approaching the end of their life’?

Answer 2

likely to die within 12 months

Question 3

List 5 long-term conditions other than cancer which may result in palliative care needs

Answer 3

cardiovascular disease,
AIDs,
kidney failure,
dementia,
multiple sclerosis

Question 4

List some common symptoms in patients with advanced illness

Answer 4

Loss of appetite, reduced food and fluid intake
Weight loss
Fatigue
Pain
Low mood
Incontinence
Insomnia

Question 5

Give some common changes that are seen in a patient’s final days

Answer 5

Loss of appetite
Changes to breathing
Changes to skin
Needing more sleep / Restlessness
Losing control of bladder or bowels

Question 6

How can agitation and confusion be managed in palliative care?

Answer 6

Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication.

If specific treatments fail then the following may be tried:
first choice: haloperidol
other options: chlorpromazine, levomepromazine

Question 7

How is agitation / restlessness in the terminal phase best managed?

Answer 7

midazolam

Question 8

How can hiccups be managed in palliative care?

Answer 8

chlorpromazine is licensed for the treatment of intractable hiccups
haloperidol, gabapentin are also used
dexamethasone is also used, particularly if there are hepatic lesions

Question 9

What are the six broad nausea and vomiting syndromes in palliative care?

Answer 9

Reduced gastric motility
May be opioid related

Chemically mediated
Secondary to hypercalcaemia, opioids, or chemotherapy

Visceral/serosal
Due to constipation/ oral candidiasis

Raised intra-cranial pressure
Usually in context of cerebral metastases

Vestibular
Related to activation of acetylcholine and histamine (H1) receptors
Most frequently in palliative care is opioid related
Can be motion related, or due to base of skull tumours

Cortical
May be due to anxiety, pain, fear and/or anticipatory nausea

Question 10

how can N+V due to reduced gastric mobility be managed?

Answer 10

Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis

first-line medications include metoclopramide and domperidone

metoclopramide should not be used when pro-kinesis may negatively affect the GI tract, particularly in complete bowel obstruction, perforation, or immediately following gastric surgery

Question 11

how can chemically mediated N+V be managed?

Answer 11

the chemical disturbance should be corrected first

Key treatment options include ondansetron, haloperidol and levomepromazine

Question 12

How can visceral/serosal causes of N+V be managed?

Answer 12

Cyclizine and levomepromazine are first-line
Anti-cholinergics such as hyoscine can be useful

Question 13

How can N+V due to raised ICP be managed?

Answer 13

cyclizine for nausea and vomiting due to intracranial disease
Dexamethasone can also be used
Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours

Question 14

How can vestibular causes of N+V be managed?

Answer 14

cyclizine is first-line
Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine

Question 15

How can cortical causes of N+V be managed?

Answer 15

If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful

If benzodiazepines are not ideal, BMJ best practice recommends use of cyclizine

Question 16

What is the preferred route of administration for antiemetics in palliative care?

Answer 16

oral anti-emetics should be used if possible

Situations where use of oral medications may not be possible include if the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis

If the oral route is not possible the parenteral route of administration is preferred
The intravenous route can be use if intravenous access is already established

Question 17

Headache caused by raised intracranial pressure due to brain cancer (or metastases) can be palliated with what?

Answer 17

dexamethasone

Question 18

What is the first line for pain relief in palliative care?

Answer 18

regular oral modified-release (MR) or oral immediate-release morphine, with oral immediate-release morphine for breakthrough pain

if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required

Question 19

What should be considered on initiation of pain relief in palliative care?

Answer 19

laxatives should be prescribed for all patients initiating strong opioids

patients should be advised that nausea and drowsiness are often transient

Question 20

What is the breakthrough dose of morphine?

Answer 20

one-sixth the daily dose of morphine

Question 21

What is preferred to morphine in palliative patients with renal impairment?

Answer 21

mild-moderate renal impairment = oxycodone
more severe renal impairment = alfentanil, buprenorphine and fentanyl

Question 22

How should you increase opioid dose?

Answer 22

the next dose should be increased by 30-50%

Question 23

In addition to strong opioids, bisphosphonates and radiotherapy, what may be used for bone pain?

Answer 23

denosumab

Question 24

Which opioid side effect often persists?

Answer 24

constipation

Question 25

How do you convert from oral codeine to oral morphine?

Answer 25

Divide by 10

Question 26

How do you convert from Oral tramadol to Oral morphine?

Answer 26

Divide by 10

Question 27

What is the equivalent strength of the 2 common transdermal opioid prescriptions?

Answer 27

a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily

a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

Question 28

Give some features of opioid toxicity

Answer 28

reduced conscious level, slow respiratory rate, myoclonic jerks, and pinpoint pupils

Question 29

What is the conservative mx of secretions?

Answer 29

Avoiding fluid overload - particularly stopping IV or subcutaneous fluids

Educating the family that the patient is likely not troubled by secretions

Question 30

What is the medical mx of secretions?

Answer 30

hyoscine hydrobromide or hyoscine butylbromide is generally used first-line

glycopyrronium bromide may also be used

Question 31

When should syringe drivers be considered in palliative care?

Answer 31

when a patient is unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma

Question 32

What are the 2 main types of syringe driver used in the UK?

Answer 32

Graseby MS16A (blue): the delivery rate is given in mm per hour
Graseby MS26 (green): the delivery rate is given in mm per 24 hours

Question 33

Which drugs can be given via syringe driver for excess secretions and bowel colic?

Answer 33

hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide

Question 34

Which drugs can be given via syringe driver for agitation/restlessness?

Answer 34

midazolam, haloperidol, levomepromazine

Question 35

Which is the preferred opioid for delivery via syringe driver?

Answer 35

diamorphine

Question 36

cyclizine is incompatible with a number of drugs including:

Answer 36

clonidine, dexamethasone, hyoscine butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, sodium chloride 0.9%

Question 37

What are the 3 steps to the WHO analgesic stepladder?

Answer 37

Step 1: Non-opioid medications such as paracetamol and NSAIDs
Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine

Question 38

What are the key side effects of NSAIDs?

Answer 38

Gastritis with dyspepsia (indigestion)
Stomach ulcers
Exacerbation of asthma
Hypertension
Renal impairment
Coronary artery disease, heart failure and strokes (rarely)

Question 39

What are the key side effects of opioids?

Answer 39

Constipation
Nausea
Skin itching (pruritus)
Altered mental state (sedation, cognitive impairment or confusion)
Respiratory depression (usually only with larger doses in opioid-naive patients)

naloxone used to reverse resp depression

Question 40

Adequate analgesia in the post-operative period is vital to encourage the patient to:

Answer 40

Mobilise
Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
Have an adequate oral intake