Palliative Care

Question 1

What is advance care planning?

Answer 1

Statement of wishes
Advance decision to refuse treatment
Lasting power of attorney (health & welfare/ finances) - will only come into effect if capacity is lost

Question 2

Describe the character of bone pain

Answer 2

Dull ache (may be a large area/ localised over the bone)
Worse on weight-bearing/ movement

Question 3

What are 3 management options for bone pain?

Answer 3

NSAIDs (e.g. diclofenac)
Radiotherapy
Bisphosphonates (e.g pamindronate)

Question 4

What is a common SE of bisphosphonates?

What is a serious SE?

Answer 4

Oesophagitis (avoid giving in upper GI disorders)

Osteonecrosis of the jaw

Question 5

How should colicky pain be managed?

Answer 5

Anticholinergics (

Question 6

What are two possible treatments to manage neuropathic pain?

Answer 6

Amitriptyline & gabapentin

Question 7

What is a reasonable starting dose for oral Modified-release morphine?

Answer 7

15-20mg twice daily

Break-through dose of 5mg

Question 8

What should be prescribed with an opioid?

Answer 8

laxative

Question 9

What side effects would you warn patients about when starting them on opioids?

Answer 9

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

Question 10

What are the 3 strengths of co-codamol?

Answer 10

Weak: 8 mg codeine & 500mg paracetamol
Mod: 15 mg codeine
Strong: 30 mg codeine

Question 11

Give an example of immediate release morphine

Answer 11

Oramorph
Works in 20-30 mins
Lasts <4 hours

Question 12

Give an example of modified/ slow release morphine

Answer 12

MST (morphine sulphate tablets)

Lasts <12 hours

Question 13

What is a non-renally excreted alternative to morphine in patients with renal failure?

Answer 13

Fentanyl patches

Question 14

How long are fentanyl patches effective for?

Answer 14

72 hours

Question 15

Conversion of oral morphone to:

a) S/C morphine
b) Diamorphine

Answer 15

a) divide by 2

b) divide by 3

Question 16

What is 2nd line for patients who don’t tolerate morphine?

Answer 16

Oxycodone

Question 17

What are some causes of gastric stasis?

Answer 17

Tumour, liver mets, hepatomegaly, ascites

Question 18

What are the characteristics of N&V from gastric stasis?

Answer 18

Lare vomits post-food
early satiety
Heart burn
Hiccups

Question 19

How do you manage vomiting from gastric stasis?

Answer 19

Metaclopramide (promotes gastric emptying)

Given 30 mins before a meal

Question 20

Give 3 toxic causes of vomiting

Answer 20

Drugs
Electrolyte imbalance (e.g. hypercalcaemia, uraemia)
Infection

Question 21

What is 1st line for treatment of toxic N&V

Answer 21

Haloperidol

Question 22

What are 2 other treatments for toxic vomiting?

Answer 22

Cyclizine

Levomepromazine

Question 23

How do you treat N&V from raised ICP?

Answer 23

Dexamethasone plus cyclizine

Question 24

How can anticipatory N&V be managed?

Answer 24

Benzo (e.g. lorazepam)

consider CBT

Question 25

What anti-emetic is given for chemo-induced N&V

Answer 25

Ondansetron

Question 26

What 3 drugs commonly used in palliative care can cause constipation?

Answer 26

Opioids Amitriptyline Ondansetron

Question 27

Give 2 examples of stool softeners

Answer 27

lactulose & docusate

Question 28

What are 2 SEs of lactulose?

Answer 28

bloating & flatulence

Question 29

When should a stimulant (e.g. SENNA) be avoided?

Answer 29

If the patient has colic

Question 30

Give 2 examples of combination laxatives

Answer 30

Co-danthrusate & movicol

Question 31

A patient with lung cancer complains of passing painful, hard stools. What laxative would you give>

Answer 31

Docusate (stool softener)

Question 32

General NICE guideline for constipation in advanced disease

Answer 32

Start with SENNA

Question 33

What should you do if a patient hasn't opened their bowels for 3 days?

Answer 33

Consider rectal exam/ use of suppositories & enemas

Question 34

What are the principles of managing intestinal obstruction?

Answer 34

Antiemetic, analgesic, antispasmodic

Question 35

Profound weakness, extended periods of drowsiness, disorientation, disinterest in food & drink and confinement to bed may indicate what?

Answer 35

That someone is approaching the last few days of life

Question 36

What may the benefits of withdrawing artificial hydration & nutrition be?

Answer 36

reduce vomiting & incontinence, less need for venepuncture

Question 37

What are the 4 anticipatory medications for syringe drivers? | What should they be mixed with?

Answer 37

Analgesic: Morphine sulphate Anti-secretory: Hyoscine butylbromide Anxiolytic: Midazolam Anti-emetic: Haloperidol/ lecomepromazine Water for injection

Question 38

When registering a death, for how long must you observe the body?

Answer 38

At least 5 minutes

Question 39

What are indications to refer a death to the coroner?

Answer 39

<24 hours of admission, poisoning, violence, use of medicinal product, self-harm, self-neglect, treatment/ procedure, occupational

Question 40

If you are registering a death, how recently must you have seen the patient alive?

Answer 40

Within the last 14 days

Question 41

What is the gold standards framework?

Answer 41

1. Identify patients who may be in the last year of life 2. Assess current & future clinical & personal needs 3. Develop a care plan

Question 42

What 10 things must you consider when discussing death with a patient?

Answer 42

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

Question 43

Why wouldn't you give diazepam in a syringe driver?

Answer 43

It is an irritant

Question 44

What sedative can be given 2nd line to midazolam?

Answer 44

Levopromazine (at higher doses, can cause irritation) | Also acts as an antipsychotic & anti-emetic

Question 45

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

Answer 45

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