Flashcards in Palliative Care Deck (45):
1
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
2
Describe the character of bone pain
Dull ache (may be a large area/ localised over the bone)
Worse on weight-bearing/ movement
3
What are 3 management options for bone pain?
NSAIDs (e.g. diclofenac)
Radiotherapy
Bisphosphonates (e.g pamindronate)
4
What is a common SE of bisphosphonates?
What is a serious SE?
Oesophagitis (avoid giving in upper GI disorders)
Osteonecrosis of the jaw
5
How should colicky pain be managed?
Anticholinergics (
6
What are two possible treatments to manage neuropathic pain?
Amitriptyline & gabapentin
7
What is a reasonable starting dose for oral Modified-release morphine?
15-20mg twice daily
Break-through dose of 5mg
8
What should be prescribed with an opioid?
laxative
9
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
10
What are the 3 strengths of co-codamol?
Weak: 8 mg codeine & 500mg paracetamol
Mod: 15 mg codeine
Strong: 30 mg codeine
11
Give an example of immediate release morphine
Oramorph
Works in 20-30 mins
Lasts <4 hours
12
Give an example of modified/ slow release morphine
MST (morphine sulphate tablets)
Lasts <12 hours
13
What is a non-renally excreted alternative to morphine in patients with renal failure?
Fentanyl patches
14
How long are fentanyl patches effective for?
72 hours
15
Conversion of oral morphone to:
a) S/C morphine
b) Diamorphine
a) divide by 2
b) divide by 3
16
What is 2nd line for patients who don't tolerate morphine?
Oxycodone
17
What are some causes of gastric stasis?
Tumour, liver mets, hepatomegaly, ascites
18
What are the characteristics of N&V from gastric stasis?
Lare vomits post-food
early satiety
Heart burn
Hiccups
19
How do you manage vomiting from gastric stasis?
Metaclopramide (promotes gastric emptying)
Given 30 mins before a meal
20
Give 3 toxic causes of vomiting
Drugs
Electrolyte imbalance (e.g. hypercalcaemia, uraemia)
Infection
21
What is 1st line for treatment of toxic N&V
Haloperidol
22
What are 2 other treatments for toxic vomiting?
Cyclizine
Levomepromazine
23
How do you treat N&V from raised ICP?
Dexamethasone plus cyclizine
24
How can anticipatory N&V be managed?
Benzo (e.g. lorazepam)
consider CBT
25
What anti-emetic is given for chemo-induced N&V
Ondansetron
26
What 3 drugs commonly used in palliative care can cause constipation?
Opioids
Amitriptyline
Ondansetron
27
Give 2 examples of stool softeners
lactulose & docusate
28
What are 2 SEs of lactulose?
bloating & flatulence
29
When should a stimulant (e.g. SENNA) be avoided?
If the patient has colic
30
Give 2 examples of combination laxatives
Co-danthrusate & movicol
31
A patient with lung cancer complains of passing painful, hard stools. What laxative would you give>
Docusate (stool softener)
32
General NICE guideline for constipation in advanced disease
Start with SENNA
33
What should you do if a patient hasn't opened their bowels for 3 days?
Consider rectal exam/ use of suppositories & enemas
34
What are the principles of managing intestinal obstruction?
Antiemetic, analgesic, antispasmodic
35
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
36
What may the benefits of withdrawing artificial hydration & nutrition be?
reduce vomiting & incontinence, less need for venepuncture
37
What are the 4 anticipatory medications for syringe drivers?
What should they be mixed with?
Analgesic: Morphine sulphate
Anti-secretory: Hyoscine butylbromide
Anxiolytic: Midazolam
Anti-emetic: Haloperidol/ lecomepromazine
Water for injection
38
When registering a death, for how long must you observe the body?
At least 5 minutes
39
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
40
If you are registering a death, how recently must you have seen the patient alive?
Within the last 14 days
41
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
42
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
5. DNACPR
6. Spiritual needs
7. Financial needs
8. Symptom management
9. ACP
10. GSF
43
Why wouldn't you give diazepam in a syringe driver?
It is an irritant
44
What sedative can be given 2nd line to midazolam?
Levopromazine (at higher doses, can cause irritation)
Also acts as an antipsychotic & anti-emetic
45