Palliative Care - Scenarios

Question 1

A palliative care patient is currently taking 15mg PO oxycodone q4h and is calling for breakthrough pain/dyspnea. Calculate a breakthrough dose of:

• Oxycodone PO
• Morphine SC

Explain why breakthrough dosing of one or the other may be preferred

Answer 1

• oxycodone PO
  
  • TDD = 90mg PO
  • Breakthrough = 9mg PO oxycodone
• Morphine SC
  
  • TDD of oxycodone PO = 90mg = 60mg morphine PO
  • Breakthrough = 6.0mg PO morphine
  • Breakthrough = 3.0mg SC morphine
• Generally preferred to use patient’s own medications
• Oxycodone has noa ctive metabolites, preferred in frail population
• Morphine SC may have faster onset
• PO oxycodone may not be available in required dose

Question 2

You are called to a palliative care patient with restlessness/agitation in the context of end stage lung Ca. Describe important differential Dx and treatments for each

Answer 2

• Delirium
  
  • midazolam (1.25-10mg SC dependending on status)
• Dyspnea
  
  • morphine (2.5-5mg SC OR 0.1mg/kg SC OR breakthrough dosing)
  • bronchodilators
• Pain
  
  • morphine (2.5-5mg SC OR 0.1mg/kg SC OR breakthrough dosing)

Note that pain and dyspnea may cause delirium. Focus on adressing these first!

Understand that this presentation may be unrelated to patient’s cancer, and therefore not appropriate for ASTaR

Question 3

You are called to a palliative patient who is showing signs of svere upper GI bleed following radiation therapy for end-stage throat Ca. They are obtunded, cold, with peripheral mottling and irregular respirations. They have intermittent periods of restlessness/agitation.

Describe patient management.

Answer 3

• Complete thorough assessment
• Discuss goals of care with family
• Recognize that this is likely an end-of-life event
• Use dark towels to collect bleeding
• Position to facilitate clearance of blood/secretions
• Provide sedation/analgesia
  
  • Morphine: 2.5mg SC q.20m
  • Midazolam: 2.5mg SC q.20m
• Consult with clinicall and palliative care team to formulate a collaborative care plan.

Question 4

You are called for a 13-year-old patient receiving palliative care for end-stage brain Ca. The family is calling because they have recently come home from hospital for an expected death at home. The patient is complaining of severe pain and nausea. They are currently receiving 1.5mg hydromorphone SC via a butterfly q4h and metoclopramide 5mg SC PRN for nausea. The family has run out of pre-pulled medications and is uncomfortable preparing their own. They have not yet given the patient’s scheduled dose of hydromorphone

1. Is this patient eligible for the ASTaR pathway?
2. Describe dosing for analgesia
3. Should you use the patient’s in situ SC butterflies?
4. Describe breakthrough dosing of hydromorphone and morphne for this patient
5. May you prepare medications for deferred use for the family?

Answer 4

1. Yes! There is no age restriction.
   
   • They must meet the usual requirements
     
     • Palliative patient, presentation related to palliative Dx, agrees to treatment in place
2. DO NOT USE breakthrough dosing! Assist in administering the regularly scheduled dose of hydromorphone!
   
   • Breakthrough dosing DOES NOT REPLACE regularly scheduled dosing
   • Give 1.5mg hydromorphone SC
3. Do not use in situ butterflies unless trained in their use
4. Breakthrough = 0.9mg hydromorphone or 4.5mg morphine
5. YES! Just remember:
   
   • Their meds, their care plan, your call, your license
   • Use their meds (not yours) according to their care plan
   • Make sure you call clinicall and have the appropriate license endorsements

Question 5

You are called for a palliative care patient with acute dyspnea. On arrival, they are supine, notably distressed and tachypneic. PCP crew states they have them on hi-flow O2 and have given 4x100mcg salbutamol MDI with no effect. The patient currently takes 1mg hydromorphone PO q4h for dyspnea/pain, but was not seen by his palliative care team due to weather conditions and ran out of medications.

1. Describe non-pharmacological treatments for this patient
2. What is appropriate breakthrough dosing for this patient? Is breakthrough dosing appropriate?
3. Is this patient appropriate for the ASTaR pathway?
4. May you leave some of your prepared morphine for them to use?

Answer 5

1. non-pharmacological treatments include
   
   • position patient (likely upright/sitting)
   • Improve airflow (fan, open windows)
   • Reassurance
   • Look for other causes of pain/dyspnea (pressure sore, etc.)
2. Breakthrough dosing:
   
   • TDD = 6mg Hydromorphone SC = 30mg morphine SC
   • Breakthrough = 3mg morphine SC
   • Breakthrough only appropriate if they are not due for their regularly scheduled dose!
3. Patient is only appropriate for the ASTaR pathway if there is a way to ensure followup with their PCT, otherwise they will run out of medications again
4. NO!!! You can only prepare their own medications for them