Palliative Care Prescribing

Question 1

Give the 4 key symptoms to be aware of when a patient is approaching the end of life

Answer 1

Pain
Nausea and vomiting
Agitation
Airway secretions

Question 2

Give some non-pharmacological management methods of airway secretions

Answer 2

Reposition
Postural drainage
Review whether IV fluid is the cause and thus whether this can be stopped

Question 3

What is the mechanism of action of the drugs used in the management of airway secretions?

Answer 3

All anti-cholinergic so reduce the production of secretions

Question 4

Give 3 agents which are used to reduce airway secretions in palliative care?

Answer 4

Hyoscine hydrobromide 400mcg
Hyoscine butyl bromide 20mg
Glycopyrronium 200mcg

All s/c PRN

Question 5

Which agent used in the management of airway secretions at the end of life crosses the blood brain barrier?

Answer 5

Hyoscine hydrobromide

Question 6

What is Buscopan?

Answer 6

Hyoscine butylbromide

Question 7

Which agent used in the management of airway secretions at the end of life is most useful in conscious patients? Why?

Answer 7

Hyoscine butylbromide - It does not cross the blood brain barrier and therefore does not cause sedation

Question 8

What is the strength of hyoscine butylbromide given for the management of secretions in palliative care?

Answer 8

20mg

Question 9

What is the strength of hyoscine hydrobromide given for the management of secretions in palliative care?

Answer 9

400mcg

Question 10

Which 2 anti-emetics should not be given together? Why?

Answer 10

Cyclizine and metoclopramide - their actions are opposing

Question 11

Which 2 anti-emetics are pro kinetic?

Answer 11

Metoclopramide

Domperidone

Question 12

Give 2 clinical situations which might prompt you to prescribe cyclizine as an anti-emetic rather than others?

Answer 12

Raised ICP

Bowel obstruction

Question 13

Which anti-emetics would you avoid in bowel obstruction? Why?

Answer 13

Metoclopramide and domperidone - these are prokinetics and so are less appropriate in bowel obstruction

Question 14

Give an appropriate dose of cyclizine for management of nausea and vomiting

Answer 14

50mg TDS

Question 15

Give an appropriate dose of metoclopramide for management of nausea and vomiting

Answer 15

10mg TDS

Question 16

Give an appropriate dose of domperidone for management of nausea and vomiting

Answer 16

10mg TDS

Question 17

Which anti-emetic would be less useful to give for management of nausea and vomiting in a patient on a syringe driver? Why?

Answer 17

Domperidone - It can only be given orally (higher doses given PR but unpleasant for the patient so best to choose an alternative)

Question 18

Give 6 examples of anti-emetics

Answer 18

Cyclizine
Domperidone
Metoclopramide
Haloperidol
Levomepromazine
Ondansetron

Question 19

What is an appropriate choice of laxatives to give to a patient at the end of life on opioid pain control?

Answer 19

Senna

Sodium docusate

Question 20

What type of laxative is sodium docusate?

Answer 20

Softener

Question 21

What type of laxative is senna?

Answer 21

Predominantly stimulant

Question 22

What type of laxative is Movicol?

Answer 22

Osmotic

Question 23

What is the 1st line treatment for agitation in palliative care?

Answer 23

Midazolam 2.5-5mg

Question 24

What is the 2nd line treatment for agitation in palliative care?

Answer 24

Levomepromazine 12.5-25mg

Question 25

When should levomepromazine be avoided?

Answer 25

If there is a risk of seizures

Question 26

On the infusions section of a drug chart, how do you write up a continuous subcutaneous infusion?

Answer 26

Put a bracket around the drugs you wish to be included in the CSCI and then write: Made up to 24ml with water for injection to run via continuous subcutaneous infusion over 24 hours at a rate of 1ml/hour