Terminal care

Question 1

What symptoms may indicate that prognosis is short?

Answer 1

• profound weakness
• confined to bed for most of the day
• drowsy for extended periods
• disorientated
• severely limited attention span
• losing interest in food and drink
• too weak to swallow medication

Question 2

What kind of drugs should be prescribed?

Answer 2

• antisecretory: (hyoscine butylbromide aka buscopan)
• sedation (anxiolytic): midazolam/ levomepromazine
• analgesic: morphine sulphate
• antiemetic: cyclizine, haloperidol, metoclopromide

Question 3

what are the indications for a syringe driver?

Answer 3

inability to swallow drugs due to reduced conscious level

• last days of life
• persistent nausea and vomiting
• intestinal obstruction
• malabsorption of drugs
• dysphagia

Question 4

What medications can be given sub cut via a syringe driver? and what dose (over 24 hours)?

Answer 4

• diamorphine/ morphine sulphate (5mg up)
• cyclizine (100-150 mg)
• haloperidol (3-10 mg)
• metoclopramide (30-60 mg)
• levomepromazine(6.25- 100 mg)
• hyoscine butylbromide (60- 120 mg)
• hyoscine hydrobromide (400mcg- 2.4mg)
• midazolam (10-60mg)

Question 5

what common drugs are unsuitable for a syringe driver?

Answer 5

• diazepam
• chlorpromazine
• prochlorperazine

Question 6

when is levomperomazine indicated?

Answer 6

• antiemetic
• antipsychotic
• sedative
• useful second line sedative at higher does

Question 7

how long acting are fentanyl patches?

Answer 7

• duration of 72 hours

Question 8

how can vomiting causes be split up?

Answer 8

• cerebral
• toxic
• vestibular
• gastric

Question 9

what would the symptoms be for gastric stasis?

Answer 9

• early satiety
• epgastric fullness
• hiccups
• heartburn
• minimal nausea between vomits

Question 10

what may be the causes? (of gs)

Answer 10

• tumour
• hepatomegaly
• ascites
• dysmotility

Question 11

treatment of gs nausea? Dose in a syringe driver?

Answer 11

• metoclopramide (10-20 mg) po/sc

- 30-60 mg SC over 24 hr

Question 12

how would toxic nausea present?

what are the causes?

Answer 12

- persistent, small vomits and retching 
Caused by: 
- hypercalcaemia
- uraemia 
- infections 
- drugs

Question 13

how would you treat it?

what is the dose?

Answer 13

• haloperidol 1.5-5 mg po/ sc nocte

Question 14

what symptoms may indicate a cerebral cause of n and v?

treatment?

Answer 14

• early morning headache
• vomiting
• little nausea
• cyclizine 50mg TDS po/sc
• cyclizine 150mg SC/ 24 hours
• Dexamethasone 8-16 mg

Question 15

What might you give in anxiety/ anticipatory n and v?

Answer 15

• benzodiazepines (medazolam)
• CBT
• complementary therapy

Question 16

for intermediate n and v?

Answer 16

• consider levomepromazine (6.25-12.5 mg_ nocte po/sc

Question 17

name the three types of laxatives.

Answer 17

• bulking agents
• stool softener
• stimulants

Question 18

name a bulk forming laxativie

name two stool softeners

Answer 18

• fybogel
• lactulose
• sodium docusate

note that movicol is also softener but also stimulant

Question 19

name two stimulants.

when would you avoid stimulants?

Answer 19

• senna
• dantron
• avoid if patient has colic

Question 20

What are the medications of choice opioid induced constipation?

Answer 20

• most patients require a softener and a stimulant :

- co- danthrusate, co-danthramer or movicol

Question 21

what are the side effects of lactulose?

Answer 21

• significant bloating and flatulence

Question 22

if bowels havent moved what would you do?

Answer 22

• consider rectal exam, suppositories and enemas after 3 days

Question 23

In intestinal obstruction, what medications should the patient be taken off?

what should be prescribed instead?

Answer 23

• stimulant laxatives
• prokinetic drugs (metoclopramide)
• antispasmodics should be prescribed (hyoscine butylbromide)

Question 24

what is the pharmacological treatment of breathlessness in terminal illness?

Answer 24

• opioids, decrease respiratory effort
• low dose, that does not cause respiratory depression
• benzodiazepines:
  may help anxiety associated with breathlessness

(lorzepam/ midazolam for those who can not tolerate sublingual)

Question 25

what may cause a cough in palliative care?

Answer 25

• excessive production of fluid in the lungs caused by:

- (bleeding from a tumour/ excessive mucus production)

Question 26

how might you treat this?

Answer 26

• saline nebulisers

- dry cough, codeine linctus/ normal release morphine)