Palliative care E-book

Question 1

The symptoms that

often present in palliative care include:

Answer 1

• Pain
• Nausea and vomiting
• Constipation
• Anxiety
• Breathlessness
• Secretions

Question 2

According to WHO, palliative care:

Answer 2

• provides relief from pain and other distressing symptoms
• affirms life and regards dying as a normal process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual aspects of patient car
• offers a support system to help patients live as actively as possible until
death
• offers a support system to help the family cope during the patients illness
and in their own bereavement
• uses a team approach to address the needs of patients and their families,
including bereavement counselling, if indicated
• will enhance quality of life, and may also positively influence the course of
illness
• is applicable early in the course of illness, in conjunction with other therapies
that are intended to prolong life, such as chemotherapy or radiation therapy,
and includes those investigations needed to better understand and manage
distressing clinical complications.

Question 3

The Liverpool Care Pathway (LCP)

Answer 3

Developed in 1997, the LCP was designated as a model of best practice (2001) and
incorporated into the National End of Life Care Programme in 2004 (see section 2.2).
Its use was controversial; some relatives had complained that the LCP was used to
hasten the end of life of patients to relieve bed pressures within hospitals. The LCP
was not intended to be used for this purpose; its intended use had been to ensure
that during the last few days and hours of a patient’s life they received appropriate
and consistently high quality care.
In response to public concerns about the use of the LCP an independent review
panel found that among issues highlighted were the use of the LCP as a generic
protocol (“sometimes a tick box exercise”) rather than its use focused around the
individual’s care. Issues around lack of training and lack of review of the pathway
appropriate to the individual patient’s condition were also identified. The LCP has
been phased out as of July 2014.

Question 4

National End of Life Programme

Answer 4

1) “The possibility [that a person may die within the next few days or hours] is
recognised and communicated clearly, decisions made and actions taken in
accordance with the person’s needs and wishes, and these are regularly reviewed
and decisions revised accordingly.”

2) “Sensitive communication takes place between staff and the dying person, and those identified as important to them”.
3) “The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants”.

4) “The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible”.

5) “An individual plan of care, which includes food and drink, symptom control and
psychological, social and spiritual support, is agreed, co-ordinated and delivered with
compassion”

Question 5

The Gold Standards Framework (GSF)

Answer 5

• Communication
o There should be a register of patients who have end-of-life needs
within each primary care team which should be used to plan and
monitor patient care on a regular basis

• Co‐ordination
o There should be a Gold Standards Framework co-ordinator appointed
within each primary care team to ensure that the GSF is implemented
and used appropriately

• Control of symptoms
o There should be an anticipatory approach to prescribing, particularly
out of hours

• Continuity
o All professionals involved in a patient’s care should have access to all
relevant information about that patient

• Continued learning
o There should be a commitment to learning and development by all
members of the primary care team. Specialists within palliative care
should play a lead role in delivering education to other members of the team

• Carer support
o The needs of carers are as important within high quality palliative care
as those of the patients

• Care in the dying phase
o Patients in the last few days of life should receive treatment and
support based upon appropriate protocols and guidelines. All aspects of patient and family care should be considered at this time

Question 6

When considering medicines for symptom control, NICE NG31 recommends the
following are taken into account:

Answer 6

• the likely cause of the symptom
• the dying person’s preferences alongside the benefits and harms of the
medicine
• any individual or cultural views that might affect their choice
• any other medicines being taken to manage symptoms
• any risks of the medicine that could affect prescribing decisions, for example
prescribing cyclizine to manage nausea and vomiting may exacerbate heart
failure.

Question 7

For administration of meds NICE does not recommend

Answer 7

NICE

does not recommend IM injection and prefers either SC or IV injections.

Question 8

If a patient takes more than 2-3 doses of any ‘as required’ medication within a
twenty-four hour period then NICE NG31 recommends that

Answer 8

the use of a syringedriver pump is considered

Question 9

The WHO pain ladder

Answer 9

Mild pain may be controlled by
paracetamol or an NSAID, moderate pain by codeine phosphate or tramadol
hydrochloride and severe pain by morphine. Alternative strong opioids include:
transdermal buprenorphine, transdermal fentanyl, hydromorphone hydrochloride,
methadone hydrochloride, or oxycodone hydrochloride. These should be initiated by
those with experience in palliative care.

Question 10

Bone metastases

Answer 10

Bone metastases can cause significant pain. In addition to analgesia, radiotherapy,
bisphosphonates, and radioactive isotopes of strontium chloride may be used.

Question 11

Palliative care treatment with opioids

Answer 11

NICE CG140 recommends (for patients without renal or hepatic issues) a starting
total daily dose of 20-30mg morphine as either oral immediate release or oral
sustained release depending on patient’s preference. NICE CG140 also
recommends 5mg oral immediate-release morphine for breakthrough (rescue) doses
during the titration period.
The dose should then be adjusted upwards until there is a balance between pain
control and side effects.

Question 12

‘Once their pain is controlled, patients started on

Answer 12

‘Once their pain is controlled, patients started on 4-hourly immediate-release
morphine can be transferred to the same total 24-hour dose of morphine given as
the modified-release preparation for 12-hourly or 24-hourly administration. The first
dose of the modified-release preparation is given with, or within 4 hours of, the last
dose of the immediate-release preparation. For preparations suitable for 12-hourly or
24-hourly administration see modified-release preparations under morphine.
Increments should be made to the dose, not to the frequency of administration. The
patient must be monitored closely for efficacy and side-effects, particularly
constipation, and nausea and vomiting. A suitable laxative should be prescribed
routinely.’

Question 13

should be avoided for breakthrough pain

Answer 13

NICE CG140 states that fast-acting

fentanyl should be avoided for breakthrough pain.

Question 14

patients who cannot tolerate morphine.

Answer 14

The BNF recommends oxycodone

Question 15

Transdermal patches are ‘not

suitable for

Answer 15

acute pain or in patients whose analgesic requirements are changing
rapidly because the long time to steady state prevents rapid titration of the dose

Question 16

Indications for use of syringe pumps

Answer 16

Persistent nausea, vomiting, dysphagia, severe weakness or unconsciousness
leading to patients who can’t swallow medication;

Patients unable to absorb oral medications;

Patients unwilling or unable to take medicines by mouth;

Malignant bowel obstruction where surgery is inappropriate;

Head and neck lesions or surgery

Question 17

Advantages for use of syringe pumps

Answer 17

Increased comfort as repeated
injections are not required

Control of multiple symptoms with a
combination of drugs

Round-the-clock comfort because
plasma drug concentrations are
maintained without peaks and troughs, giving constant therapeutic drug levels over a 24-hour period

Mobility maintained because the device is lightweight and can be worn in a holster under or over clothes

Generally needs to be loaded only once every 24 hours

Question 18

Disadvantages for use of syringe pumps

Answer 18

Staff training

Possible inflammation and pain at
the infusion site and potential source
of infection

In emaciated patients or those on
long-term infusions skin-site
availability may become a problem

Lack of reliable compatibility data for
some mixtures of medications

Question 19

Certain medications are contra-indicated for use in subcutaneous infusion

Answer 19

chlorpromazine hydrochloride, prochlorperazine, diazepam due to skin reactions.

Question 20

The following medications can cause skin reactions at the injection site to a lesser
extent and are not necessarily contraindicated:

Answer 20

• cyclizine

* levomepromazine.

Question 21

Breathlessness

Answer 21

Breathlessness at rest in palliative care patients may have several causes.
Reversible causes include cardiac failure, COPD, infection, pleural effusion.
Other causes include anxiety, airway obstruction and excessive respiratory
secretions.

Question 22

It is important to treat any underlying cause of breathlessness:

Answer 22

• Antibiotics for infections
• Diuretics for cardiac failure or pleural effusion
• Nebulised 0.9% NaCl (+ ipratropium if still wheezy) for COPD
• Benzodiazepines for anxiety if prognosis is less than 2-4 weeks e.g. diazepam 2-
10mg PO at night and prn or lorazepam 0.5-1mg PO bd and prn. Midazolam can
also be used.
• SSRIs for anxiety if prognosis is greater than 2-4 weeks
• Dexamethasone for bronchospasm or partial obstruction
• Palliative radiotherapy for obstruction

Low dose morphine (2.5-5 mg every four hours prn, carefully titrated to
response) can also be very useful for breathlessness.

Oxygen is widely used but studies show it brings no additional benefit
compared with medical air. However patients often like the sensation, so
should be encouraged to use portable or handheld fans. Guidelines suggest
that oxygen should be restricted to patients with severe hypoxia or those who
report significant relief from the use of oxygen. However patients should be
encouraged to try non-drug and opioids before using oxygen

Question 23

NICE NG31 recommends considering managing breathlessness with:

Answer 23

• an opioid or
• a benzodiazepine or
• a combination of an opioid and benzodiazepine

Question 24

causes of nausea and vomiting

Answer 24

• Drugs (opioid analgesics, chemotherapy)
• Tumours
• Increased intracranial pressure
• Radiotherapy
• Hepatomegaly
• Peptic ulceration
• Biochemical causes e.g. hypercalcaemia
• Psychological causes
• Gastrointestinal motility disorder
• Ileus or bowel obstruction

Question 25

The most commonly used anti‐emetic agents in palliative care include:

Answer 25

• Cyclizine
• Dexamethasone
• Domperidone
• Haloperidol
• Levomepromazine
• Metoclopramide
• Octreotide

Question 26

Constipation in palliative care, as in other patients, has many possible causes.
These include:

Answer 26

• Drugs
• Opioid analgesics, anticholinergics (e.g. TCAs), chemotherapy, antiemetics (e.g. cyclizine), diuretics
• Metabolic disturbances
• Neurological disorders
• e.g. spinal cord compression
• Tumours
• Decreased fluid intake
• Age
• Reduced mobility
• Lack of privacy

Question 27

The treatment aims in constipation are:

Answer 27

• A comfortable passage of stool
• Re‐establish comfortable bowel habits
• Relieve discomfort and/or pain
• Avoid laxative dependence
• Prevent GI symptoms

Question 28

The preferred combination of laxatives in palliative care is

Answer 28

a stimulant (e.g. senna)
with a stool softener (e.g. docusate). Macrogols are commonly prescribed as these
are often preferred by patients but these are expensive at higher doses.

Question 29

licensed for opioid-induced constipation

Answer 29

Methylnaltrexone

Question 30

not suitable for opioid induced constipation

Answer 30

Bulk‐forming laxatives as the patient
often cannot maintain a sufficient fluid intake for them to be effective and bowel
obstruction may occur as a consequence.

Question 31

new class of laxative licensed for the management of opioid-induced
constipation (OIC)

Answer 31

Naloxegol

The drug is a form of pegylated naloxegol (attached to a
molecule of polyethylene glycol) which selectively antagonises peripheral opioid
receptors to relieve constipation. It may be a useful addition to the existing treatment
options available in palliative care, however it is still quite new and is expensive.

Question 32

The excessive secretions can be relieved

Answer 32

by hyoscine hydrobromide (400‐600 mcg
subcutaneously every 4 to 8 hours) or glycopyrronium (200 mcg sub‐cut or IM every
4 hours). NICE NG31 also recommends the use of hyoscine butylbromide or
atropine.

These medications are all anti-cholinergics, so will potentially exhibit the classic side
effects of dry mouth, urinary retention, delirium, agitation and sedation. Patients
should be monitored frequently for side effects and the drug stopped and an
alternative prescribed. Glycopyrronium bromide does not cross the blood brain
barrier so will be less likely to cause central effects. Smaller quantities of the drug
hyoscine butylbromide crosses the blood brain barrier than hyoscine hydrobromide
so side effects are likely to be less.

Question 33

Anticipatory prescribing can be defined as:

Answer 33

“The proactive prescribing of medicines that are commonly required to control
symptoms in the last days of life.”

Question 34

Linda Johnstone, in her 2017 article, states that there are four stages to anticipatory
prescribing:

Answer 34

1. Initiating the conversation with the patient and their family
2. Writing the prescription
3. Dispensing the medicines
4. Administering the medicines to the patient

Stage 4 is usually conducted by nurses, however stage 1-3 could be conducted by a
pharmacist (stages 1-2 as an independent prescriber specialising in palliative care)

Question 35

NICE NG31 also recommends that the following should be taken into account for stages to anticipatory
prescribing:

Answer 35

• the likelihood of specific symptoms occurring
• the benefits and harms of prescribing or administering medicines
• the benefits and harms of not prescribing or administering medicines
• the possible risk of the person suddenly deteriorating (for example,
catastrophic haemorrhage or seizures) for which urgent symptom control may
be needed
• the place of care and the time it would take to obtain medicines.

Question 36

Noisy Respiratory Secretions

1st & 2nd line

Answer 36

Hyoscine is usually used first line.

Glycopyrronium bromide is usually second line.

MHRA/CHM advice: Hyoscine butylbromide (Buscopan®) injection: risk of serious adverse effects in patients with underlying cardiac disease

Question 37

Anorexia may be helped by

Answer 37

prednisolone or dexamethasone.

Question 38

Bowel colic and excessive respiratory secretions may be reduced by

Answer 38

a subcutaneous injection of hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide

These antimuscarinics are generally given every 4 hours when required, but hourly use is occasionally necessary, particularly in excessive respiratory secretions. If symptoms persist, they can be given regularly via a continuous infusion device. Care is required to avoid the discomfort of dry mouth.

Question 39

Capillary bleeding can be treated with

Answer 39

tranexamic acid by mouth; treatment is usually discontinued one week after the bleeding has stopped, or, if necessary, it can be continued at a reduced dose.

Vitamin K may be useful for the treatment and prevention of bleeding associated with prolonged clotting in liver disease.

Question 40

dry mouth associated with candidiasis can be treated by

Answer 40

oral preparations of nystatin or miconazole, alternatively, fluconazole can be given by mouth

Question 41

Dysphagia can be treated with

Answer 41

A corticosteroid such as dexamethasone may help, temporarily, if there is an obstruction due to tumour.

Question 42

Dyspnoea can be treated

Answer 42

Breathlessness at rest may be relieved by regular oral morphine in carefully titrated doses. Diazepam may be helpful for dyspnoea associated with anxiety. A corticosteroid, such as dexamethasone, may also be helpful if there is bronchospasm or partial obstruction

Question 43

Fungating tumours can be treated by

Answer 43

Regular dressing and antibacterial drugs; systemic treatment with metronidazole is often required to reduce malodour but topical metronidazole is also used.

Question 44

The pain of bowel colic may be reduced by

Answer 44

loperamide hydrochloride.

Question 45

Insomnia can be treated with

Answer 45

Benzodiazepines, such as temazepam, may be useful.

Question 46

ntractable cough may be relieved by moist inhalations or by regular administration of

Answer 46

oral morphine

Question 47

The pain of muscle spasm can be helped by

Answer 47

a muscle relaxant such as diazepam or baclofen.

Question 48

Headache due to raised intracranial pressure often responds to a

Answer 48

a high dose of a corticosteroid, such as dexamethasone and should be given before 6 p.m. to reduce the risk of insomnia.

Question 49

Restlessness and confusion may require treatment with an

Answer 49

antipsychotic, e.g. haloperidol or levomepromazine, by mouth or by subcutaneous injection, both repeated every 2 hours if required.

Question 50

Bowel colic and excessive respiratory secretions treatment

Answer 50

Hyoscine hydrobromide effectively reduces respiratory secretions and bowel colic and is sedative (but occasionally causes paradoxical agitation).

Hyoscine butylbromide is used for bowel colic and for excessive respiratory secretions, and is less sedative than hyoscine hydrobromide.

Glycopyrronium bromide may also be used to treat bowel colic or excessive respiratory secretions.

Question 51

Confusion and restlessness

Answer 51

Haloperidol has little sedative effect.

Levomepromazine has a sedative effect.

Midazolam is a sedative and an antiepileptic that may be used in addition to an antipsychotic drug in a very restless patient. Midazolam is also used for myoclonus.

Question 52

first‑line pharmacological treatment for nausea and vomitting

Answer 52

hyoscine butylbromide

• consider octreotide if the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide.