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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

Why is Hyoscine butyl bromide 1st line over hyoscine hydrobromide?

Doesn't cross the BBB so doesn't cause agitation or sedation