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4th Year CCC > Palliative care > Flashcards

Palliative care Flashcards

1
Q

Analgesia should be ‘done’ by what three things?

A

By the ladder, by the clock, by the mouth (if poss)

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2
Q

How many times stronger than morphine is oxycodone?

A

2x

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3
Q

How many times stronger than morphine is fentanyl?

A

3x

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4
Q

Which two opioids are suitable for end stage renal failure?

A

Fentanyl or bupranorphine

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5
Q

What does a co-codamol dose of 30/500 mean?

A

30mg codeine, 500mg paracetamol

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6
Q

Why might you give co-codamol on the analgesic ladder?

A

It keeps ‘step 1’ paracetamol going as well as step 2, but combined in a tablet

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7
Q

SEs morphine

A

Constipation

N+V

Drowsy/clouded consciousness

Dry mouth

Itching

Reduced perception of breathlessness

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8
Q

Symptoms opioid toxicity

A

delirium

vivid dreams

visual hallucinations

myoclonus

decreased resp rate

pinpoint pupils

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9
Q

Immediate release morphine takes how long to work and lasts for how long?

A

within 30mins

Lasts 2-4hrs

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10
Q

Examples of IR morphine?

A

Oramorph

Sevredol

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11
Q

Modified release morphine lasts for how long

A

12 (or 24) hours

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12
Q

Examples modified release morphie

A

MST

Zomorph

Morphgesic

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13
Q

If a patient is on co-codamol 30/500 two tablets QDS and you want to add some morphine for breakthrough pain how much morphine would you prescribe?

A

30 x 2 x 4 = 240mg

240mg codeine = 24mg morphine

1/6 daily dose for breakthrough so 24/6 = 4

Prescribe 5mg (no more than 6-8 doses in 24hr)

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14
Q

What is the breakthrough morphine dose compared to MR dose?

A

1/6 daily total

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15
Q

How do you increase someone who is on MR and IR morphine?

A

Increase the MR to the current total daily dose, including IR (but only 1/3-1/2 increase is safe).

MR given BD

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16
Q

Is oramorph prescribed in mg or ml?

A

mg because it comes in 10mg/5ml and 100mg/5ml

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17
Q

What specific signs are there that you should reverse the opioid?

A

RR <8 and not rousable- reverse with naloxone

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18
Q

The SC dose of morphine is ____ the oral dose

A

half

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19
Q

Four causes of nausea and vomiting?

A

Cerebral

Toxicity (mainly nausea)

GI (mainly vomiting)

Ear

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20
Q

Two cerebral causes of nausea?

A

SOL

Anxiety/perception

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21
Q

Rx for cerebral nausea

A

SOL- Dex or cyclizine

Anxiety/perception- benzo/SSRI

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22
Q

Rx for chemo nausea

A

Ondansetron

Graniestron

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23
Q

Rx for the rest of the toxicity causes of nausea

A

Haloperidol

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24
Q

Which antipsychotics help with nausea?

A

Levomepromazine and olanzapine (but typical so SEs)

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25
Q

Can you give metaclopromide and cyclizine?

A

No they counteract each other

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26
Q

What are the four types of laxative?

A

Bulking agent

Softener

Stimulant

Combination

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27
Q

Fybogel is what sort of laxative?

A

Bulking agent

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28
Q

Senna is what sort of laxative?

A

Stimulant

29
Q

Docusate is what sort of laxative?

A

Softener

30
Q

Movicol is what sort of laxative?

A

Combination

31
Q

Condranthamer is what sort of laxative?

A

Combination

32
Q

How do you know whether to give oral or enema laxative?

A

If can feel hard stool in rectum- enema. Oral will cause overflow.

33
Q

What can an advanced care plan say regarding treatment?

A

It can refuse in specific circumstances, can’t demand

Decisions to refuse treatment are legally binding if valid and appliable

34
Q

Why do people make ACPs?

A

In case they lose capacity in future

35
Q

What is the Gold Standards Framework?

A

Approach to optimising EoL care

36
Q

What are three steps in the GSF?

A

Identify EoL patients

Assess current and future clinical and personal needs

Plan (MDT)

37
Q

What should be discussed with a patient about their last days? (6)

A

Medication review

Symptom control

Family needs

Nursing needs

Psycho-spiritual needs

Preferred place of death and goals of care

38
Q

What are 4 essential medications to continue at EoL

A

the anticipatories

analgesic, antiemitic, anxiolytic, anti-secretory

39
Q

Are antidepressants essential to continue at EoL?

A

No

40
Q

Are laxatives essential to continue at EoL?

A

No

41
Q

Are anticoagulants essential to continue at EoL?

A

No

42
Q

Are LT Abx essential to continue at EoL?

A

No

43
Q

Are corticosteroids essential to continue at EoL?

A

Maybe- consider stopping

44
Q

Are diuretics essential to continue at EoL?

A

No

45
Q

Are hypoglycaemics essential to continue at EoL?

A

Consider stopping

46
Q

Are anticonvulsants essential to continue at EoL?

A

Consider stopping

47
Q

How should children be involved in death?

A

Involve them, be honest and factual (age appropriate).

Recognise that they grieve and share sadness

Create a new routine

48
Q

How is death confirmed?

A

Absence of central pulse or heart sounds.

After 5 mins of cardio-resp arrest (e.g. listen to HS for 2 mins and Resp sounds 3 min), confirm absence of

  1. Pupillary light reflexes
  2. Corneal reflexes
  3. Motor response to supra-orbital pressure

May also include asystole on ECG, absence of pulsatile flow on intra arterial pressure monitor or absence of contraction on echo.

49
Q

When is time of death?

A

After it has been confirmed

50
Q

What might the body be examined for after death?

A

Pacemaker, bruises, pressure sores

51
Q

When should you not issue death certificate

A

Coroner needed

52
Q

Who must do the death certificate

A

A doctor who attended the person during their last illness. Must have seen them within 14 days. Provide within 24hrs

53
Q

How should the date be written on a death cert?

A

Write the numbers out in letters e.g. twenty

54
Q

Can you put ‘old age’ on a death certificate?

A

No

55
Q

What is section II of cause of death

A

Other significant conditions contributing to the death but not related to the disease causing it

56
Q

Is the mode of dying e.g. resp arrest put on the death certificate?

A

No

57
Q

Can you use abbreviations e.g. CKD on death cert?

A

No

58
Q

When is referral to coroner needed

A

No doctor attended during last illness, or not in the last 14 days

Cause of death unknown (post mortem required)

If death occured:

  • during operation or before anaesthetic ended
  • industrial poisoning or at work
  • sudden or unexpected (including <24h in hosp)
  • unnatural (medical mistake)
  • violence of neglect
  • other suspicious cause
  • in prison, custody or other state detention
59
Q

If post mortem reveals the death was not unnatural what happens?

A

Pink form issued to registrar

Death can be registered

Body released for cremation or burial

60
Q

What happens to the MCCD (medical certification of cause of death) or coroner’s certificate?

A

Given to registrar of births and deaths within 5 days

Death certificate issued to family

61
Q

What can be used in patients who require an opioid but cannot tolerate morphine?

A

Oxycodone hydrochloride

62
Q

What laxative should be given with opioids?

A

Co-danthramer (softener + peristalsis)

Or lactulose with senna

63
Q

Do patients taking an opioid require an anti-emetic?

A

Maybe for the first few days but then ok

64
Q

What should be discussed when talking to a pt about escalation plan and ceiling of care?

A

Other Rx

ward vs ICU

CPR?

Nutrition and hydration

Interventions

Medication and symptom management

Preferred place of death

65
Q

What is ‘fast track’ in palliative care?

A

Unlocks funding for care at home if short time left to live

66
Q

Give examples of the anticipatories

A

Analgesic- morphine

Antiemitic- haloperidol 1.5-3mg

Anxiolytic- midazolam 2.5-5mg

Antisecretory- hyoscine butylbromide 10-20mg

67
Q

Can you give diazepam, chlorpromazine or prochlorperazine SC?

A

No

68
Q

Can you mix the usual anticipatories?

A

Yes, but nb drugs do exist that need a separate syringe driver e.g. dex, diclofenac, ketorolac

4th Year CCC (19 decks)

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