Flashcards in Palliative Care Deck (45):
What is advance care planning?
Statement of wishes
Advance decision to refuse treatment
Lasting power of attorney (health & welfare/ finances) - will only come into effect if capacity is lost
Describe the character of bone pain
Dull ache (may be a large area/ localised over the bone)
Worse on weight-bearing/ movement
What are 3 management options for bone pain?
NSAIDs (e.g. diclofenac)
Bisphosphonates (e.g pamindronate)
What is a common SE of bisphosphonates?
What is a serious SE?
Oesophagitis (avoid giving in upper GI disorders)
Osteonecrosis of the jaw
How should colicky pain be managed?
What are two possible treatments to manage neuropathic pain?
Amitriptyline & gabapentin
What is a reasonable starting dose for oral Modified-release morphine?
15-20mg twice daily
Break-through dose of 5mg
What should be prescribed with an opioid?
What side effects would you warn patients about when starting them on opioids?
Constipation (almost universal)
N&V (usually settles in a few days)
Drowsiness (should improve in a couple of days)
Also warn of hallucinations, confusion & reduced RR
What are the 3 strengths of co-codamol?
Weak: 8 mg codeine & 500mg paracetamol
Mod: 15 mg codeine
Strong: 30 mg codeine
Give an example of immediate release morphine
Works in 20-30 mins
Lasts <4 hours
Give an example of modified/ slow release morphine
MST (morphine sulphate tablets)
Lasts <12 hours
What is a non-renally excreted alternative to morphine in patients with renal failure?
How long are fentanyl patches effective for?
Conversion of oral morphone to:
a) S/C morphine
a) divide by 2
b) divide by 3
What is 2nd line for patients who don't tolerate morphine?
What are some causes of gastric stasis?
Tumour, liver mets, hepatomegaly, ascites
What are the characteristics of N&V from gastric stasis?
Lare vomits post-food
How do you manage vomiting from gastric stasis?
Metaclopramide (promotes gastric emptying)
Given 30 mins before a meal
Give 3 toxic causes of vomiting
Electrolyte imbalance (e.g. hypercalcaemia, uraemia)
What is 1st line for treatment of toxic N&V
What are 2 other treatments for toxic vomiting?
How do you treat N&V from raised ICP?
Dexamethasone plus cyclizine
How can anticipatory N&V be managed?
Benzo (e.g. lorazepam)
What anti-emetic is given for chemo-induced N&V
What 3 drugs commonly used in palliative care can cause constipation?
Give 2 examples of stool softeners
lactulose & docusate
What are 2 SEs of lactulose?
bloating & flatulence
When should a stimulant (e.g. SENNA) be avoided?
If the patient has colic
Give 2 examples of combination laxatives
Co-danthrusate & movicol
A patient with lung cancer complains of passing painful, hard stools. What laxative would you give>
Docusate (stool softener)
General NICE guideline for constipation in advanced disease
Start with SENNA
What should you do if a patient hasn't opened their bowels for 3 days?
Consider rectal exam/ use of suppositories & enemas
What are the principles of managing intestinal obstruction?
Antiemetic, analgesic, antispasmodic
Profound weakness, extended periods of drowsiness, disorientation, disinterest in food & drink and confinement to bed may indicate what?
That someone is approaching the last few days of life
What may the benefits of withdrawing artificial hydration & nutrition be?
reduce vomiting & incontinence, less need for venepuncture
What are the 4 anticipatory medications for syringe drivers?
What should they be mixed with?
Analgesic: Morphine sulphate
Anti-secretory: Hyoscine butylbromide
Anti-emetic: Haloperidol/ lecomepromazine
Water for injection
When registering a death, for how long must you observe the body?
At least 5 minutes
What are indications to refer a death to the coroner?
<24 hours of admission, poisoning, violence, use of medicinal product, self-harm, self-neglect, treatment/ procedure, occupational
If you are registering a death, how recently must you have seen the patient alive?
Within the last 14 days
What is the gold standards framework?
1. Identify patients who may be in the last year of life
2. Assess current & future clinical & personal needs
3. Develop a care plan
What 10 things must you consider when discussing death with a patient?
1. Patient's understanding
2. What are their priorities?
3. Preferred place of care & death
4. Level of care
6. Spiritual needs
7. Financial needs
8. Symptom management
Why wouldn't you give diazepam in a syringe driver?
It is an irritant
What sedative can be given 2nd line to midazolam?
Levopromazine (at higher doses, can cause irritation)
Also acts as an antipsychotic & anti-emetic