Palliative Care Past Paper Questions Flashcards
A 72-year-old man with a background of metastatic colorectal cancer and chronic kidney disease has been admitted unwell with rectal pain not controlled with analgesia. He is being treated for sepsis and an acute kidney injury from a local tumour perforation and is not fit for surgery or percutaneous drainage. Despite aggressive treatment with intravenous antibiotics and intravenous fluids for three days he continues to deteriorate. Following discussions with the patient, his family, and his parent team, the decision is made to keep him comfortable, to discontinue antibiotics and intravenous fluids, and to make provisions for end-of-life care.
His current analgesic medications are paracetamol 1g four times daily, morphine sulfate modified release (long-acting) 90mg twice daily, and morphine sulfate immediate release oral liquid (short acting) 30mg as required, 4-hourly. He has used 4x30mg doses of oral morphine in 24hrs.
His eGFR is 22mL/min/1.73m2. The patient has asked you if it is possible to minimise his oral medications as he struggles to swallow multiple tablets and if it is possible to convert some of them to a syringe driver.
Which of the following analgesic regimes would be most suitable for this patient?
75mg oxycodone/24hrs subcutaneously via a syringe driver with 7.5-12.5mg subcutaneous oxycodone as required 4-hourly for breakthrough pain
35mg oxycodone/24hrs and 4g/24hrs paracetamol subcutaneously via a syringe driver with 4-6mg subcutaneous oxycodone as required 4-hourly for breakthrough pain
150mg oxycodone/24hrs subcutaneously via a syringe driver with 15-25mg subcutaneous oxycodone as required, 4-hourly for breakthrough pain
210mg morphine sulfate/24hrs subcutaneously via a syringe driver with 20-35mg subcutaneous morphine sulfate as required 4-hourly for breakthrough pain
10mg alfentanil/24hrs and 4g/24hrs paracetamol subcutaneously via a syringe driver with 7.5-12.5mg subcutaneous oxycodone as required 4-hourly for breakthrough pain
75mg oxycodone/24hrs subcutaneously via a syringe driver with 7.5-12.5mg subcutaneous oxycodone as required 4-hourly for breakthrough pain
This patient is on 90mg twice daily of morphine sulfate modified release and has used 4 doses of 30mg morphine immediate release, equating to a total of 300mg oral morphine sulfate in24hrs.
Morphine sulfate accumulates in renal failure with eGFR <45mL/min/1.73m2 and so the choice of opioid should be changed to one with less renal excretion.
In patient such as this one, with eGFR 10-30mL/min/1.73m2, the most common choice is oxycodone.
To convert between opioids, always convert to the 24hr dose of oral morphine from the current opioid regime and then convert to the new drug of choice.
If you are unsure, always look up conversions online or in your local trust guidance. The following table shows dose equivalents of 10mg oral morphine
*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. If in doubt, always opt for the lower dose and titrate up.
This patient is on 300mg/24hrs oral morphine equating to 75mg subcutaneous oxycodone/24hrs. Breakthrough analgesia dose is calculated 1/10th-1/6th the 24hr dose. This equates to 7.5mg-12.5mg subcutaneous oxycodone as required.
Paracetamol is not available as a subcutaneous injection and so must be given orally or IV. Often when patients approach the end of their life intravenous medications are stopped or converted to other routes to avoid repetitive cannulations
An 87-year-old male is admitted to hospital from a nursing home with aspiration pneumonia. He clinically deteriorates, and after discussion with his family, the decision is made to palliate and control his symptoms. His family are concerned he is becoming increasingly agitated due to his respiratory secretions. What medication might be of benefit here?
Haloperidol
Nebulised salbutamol
High flow nasal oxygen
Morphine
Glycopyrronium
Glycopyrronium
Glycopyrronium is a medication from the muscarinic anticholinergic group. It is often used for respiratory tract secretions in palliative care patients who can no longer manage their own secretions due to impaired cough reflex
A 75 year old woman with metastatic mesothelioma was admitted with progressive shortness of breath and ongoing uncontrolled pleuritic chest pain. After full investigation, the pain is found likely to be secondary to her mesothelioma which has extensive pleural, diaphragmatic, and pericardial metastases. Her eGFR is 85mL/min/1.73m2 and her liver function tests are all within normal range.
She currently takes 900mg gabapentin three times daily, 1g paracetamol four times daily, 80mg modified standard release morphine sulfate (long acting) twice daily, and 75mg amitriptyline at night. She is currently requiring all of her allowed as required oral morphine immediate release doses and is asking for her next dose frequently before it is due to ongoing pain.
You decide to increase her modified standard release morphine sulfate dose to 90mg twice daily. Please calculate the most appropriate breakthrough oral morphine sulfate immediate release dose for this new regime.
5-10mg oral morphine sulfate immediate release as required, 4-hourly
40-50mg oral morphine sulfate immediate release as required, 4-hourly
10-15mg oral morphine sulfate immediate release as required, 4-hourly
20-30mg oral morphine sulfate immediate release as required, 4-hourly
30-40mg oral morphine sulfate immediate release as required, 4-hourly
20-30mg oral morphine sulfate immediate release as required, 4-hourly
Breakthrough dose of morphine in adults with cancer is calculated by dividing the 24-hour dose of oral morphine by 6. Usually a range is required and so the range should be approximately 1/10th-1/6th of the 24-hour total morphine dose.
The principal is the same for all opioids, although it is best practice to convert the full 24 hour dose of opioids to the corresponding oral morphine dose, and then convert back to the desired drug and route. This is of use when the long-acting drug is different to the breakthrough drug e.g. oral oxycodone breakthrough with a buprenorphine patch.
The total dose of oral morphine in this case is 180mg/24hrs. 1/6th of this is 30mg and 1/10th of this is 18mg. For practicality in administration, this has been rounded to 20-30mg
An 85-year-old patient is nearing the end of her life. Despite reassurance, her relatives are becoming distressed by the gurgling and rattling noises that the patient is making as she breathes.
Which medication may be used to manage the noisy secretions?
Haloperidol
Morphine
Levomepromazine
Hyoscine butylbromide
Prochlorperazine
Hyoscine butylbromide
Hyoscine butylbromide is a first-line medication used to relieve noisy respiratory secretions in the last days of life. It is an antimuscarinic drug that acts by drying out the secretions and thereby reducing the noise. It is usually given as a subcutaneous medication in doses of up to 20 mg every 6–8 hours.
A 90 year old gentleman is admitted to the medical ward with an infected sacral sore. He has a background of advanced dementia and previous stroke. During his stay, he develops aspiration pneumonia and his condition begins to deteriorate.
He is reviewed by the Palliative team who plan to start him on end of life medications via a syringe driver. He is currently on oral morphine 10mg TDS and has required three breakthrough doses of oral morphine 2mg in the past day. What is the most appropriate subcutaneous breakthrough dose he should be prescribed?
2mg hourly as required
5mg hourly as required
5mg 6-8 hourly
10mg hourly as required
2mg 6-8 hourly
2mg hourly as required
Syringe drivers are given as continuous subcutaneous infusions over 24 hours. The oral morphine dose needs to be halved for subcutaneous (SC) administration via the syringe driver. The total daily oral morphine dose is (10mg x 3) + (2mg x 3) = 36mg. This would be SC morphine 18mg. As breakthrough doses should be one-sixth to one-tenth of the total daily dose, you should therefore prescribe him 2-3mg every hourly as required. The lower limit of the dose range may be prescribed to avoid concerns of toxicity. If more than 6 doses are required in 24 hours, consider seeking senior advice or review
A patient with severe PAIN is currently prescribed Co-Codamol (30/500) regularly (2 tablets 4 times a day). She is still in 10/10 pain and you have been asked to review her pain medication
- Curret codeine dose = 30 x8 = 240mg
- 240mg of codeine = 24mg of Morphine (divide by 10)
- however patient is still in pain on this dose, so could up the morphine dose to 30mg
- give slow release morphine BD = 15mg BD 12 hourly (30mg in total)
- on top of this can give PRN Oromorph fast release 10mg/5mls- (30/6= 5mg)
- PRN oromorph up to 6 times a day or once an hour (may need to review baseline if needs 6 times)
which laxitive best to give in cancer patients
Macrogrol - less sweet and more tolerable
e.g. Movicol, Laxido
MOA:
- is an osmotically acting laxative; that is, an inert substance that passes through the gut without being absorbed into the body. It relieves constipation because it causes water to be retained in the bowel instead of being absorbed into the body.
Anticipatory medication for end of life
Anticipatory medication
- Breakthrough pain: Morphine sulphate 2.5-5mg /24 hourly subcut
- Secretions: Glycoporronium bromide 200-400micrograms/24 hourly
- Restlessness: Midazolam 2/5-5mg /24 hourly subcut
- Nausea and vomiting: Levomepromazine 2.5-5mg hourly/ 24 hour
if more than 2 of the anticiaptory medication in 24 hours -> add into syringe driver
Patient is in the last few days of life and wants to go home to die. It is deemed appropriate to transfer her to syringe driver to keep her comfortable at home. How would you convert her current oral morphine to syringe driver
slow release: 30 BD = 60mg
fast release: amount given in last 24 hours = 75mg
slow release: 30 BD = 60mg
fast release: amount given in last 24 hours = 75mg
therefore total daily dose: 60+75 =135mg
Converting oral to subcut (syringe driver) = 135mg/2
= 65mg for the syringe driver
prescribing: look at photo
-> draw circle with arrow to represent Syringe driver
A 70-year-old man with metastatic lung cancer is admitted to the oncology ward. Given his worsening pain, a decision is made to commence regular opioid pain control. He has never received opiates in the past and has no other medical conditions. He has normal renal function.
Which of the following options represents the most effective initial dosing regimen of opioid analgesia for this patient?
Morphine sulphate 5 mg immediate release preparation, to be given four-hourly
Morphine sulphate 10 mg immediate release preparation, to be given four-hourly
Oxycodone 1 mg immediate release preparation, to be given four-hourly
Morphine sulphate 20 mg modified release preparation, to be given twice daily
Morphine sulphate 5 mg modified release preparation, to be given twice daily
Morphine sulphate 5 mg immediate release preparation, to be given four-hourly
This is the correct answer. This regimen represents a total daily oral Morphine dose of 30mg. The National Institute for Healthcare and Excellence (NICE) recommends that a dose of 20-30 mg oral Morphine is safe and effective for opiate naïve patients initially commenced on opioid analgesia. Though dependent on patient choice, immediate release oral morphine solution given four-hourly (also known as Oramorph) is the recommended formulation used to initially determine a patient’s pain control requirements. The total daily oral Morphine dose can later be converted to twice daily modified release Morphine sulphate tablets, also known as MST Continus tablets.
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST (oral, modified-release morphine) 60mg bd for pain. He has become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine should be prescribed for the syringe driver, to cover a 24-hour period?
60 mg
40 mg
120 mg
30 mg
20 mg
40mg
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 = 40mg)
