Care of the dying

Question 1

what to prescribe first for EoL patients?

Answer 1

PRN as required medications

Question 2

to avoid patient receiving lots of injections?

Answer 2

syringe driver

Question 3

the major 4 PRN drugs in caring for the dying?

Answer 3

1) antisecretion
- HYOSCINE H (400 mcg 4 hrly, or continuous S/C infusion 1.2–2 mg/24 hrs)
- hyoscine BB (S/C infusion 20–120 mg/24 hours)

2) agitation
- MIDAZOLAM (10-20mg/24hrs)

3) pain
- MORPHINE 10mg/24hr if new

4) nausea
- CYCLIZINE 150mg/24hr

Question 4

how often is morphine/opioid given for pain?

Answer 4

• either immediate-release 30mg 4 hrly
• or modified- release 100mg 12 hrly
• • rescue doses

Question 5

how to manage breakthrough pain?

Answer 5

rescue dose immediate-release
1/10 to 1/6 of regular 24-hour dose
repeated every 2–4 hours PRN

Question 6

how to increase background regular dose of morphine?

Answer 6

(n.o. rescue doses & response to them should be taken into account)

increase should not exceed 1/3 to 1/2 total daily dose

Question 7

when to stop the upward titration of morphine?

Answer 7

when pain is relieved or unacceptable S/E

Question 8

what to use if patients cannot tolerate morphine?

Answer 8

cxycodone hydrochloride

Question 9

when to avoid oral drugs?

Answer 9

dysphagia
vomiting
bowel obstruction
terminal phase

Question 10

Tx to use for ↑ ICP, nerve compression, liver capsule pain, soft tissue infiltration?

Answer 10

steroids

Question 11

Tx for muscle cramp/spasms, myofascial pain?

Answer 11

Muscle relaxants (e.g. baclofen, benzodiazepines)

Question 12

Tx for bone pain?

Answer 12

Bisphosphonates

Question 13

Tx for bowel colic, bladder spasm?

Answer 13

Antispasmodic (e.g. hyoscine butylbromide)

Question 14

opioids if GFR<30?

Answer 14

avoid regular codeine, morphine and oxycodone (low dose immediate release (IR) oxycodone with increased dose intervals may be appropriate sometimes)

Consider fentanyl, buprenorphine or alfentanil depending on type of
pain and preferred route

Question 15

Tx S/E of opioids?

Answer 15

• C: stimulant laxative (senna) +/- softener (docusate)
• N/V: PRN anti-emetic (haloperidol/metoclopramide)
• Sedation: dose reduction, alternative analgesic
• Dry mouth: good oral hygiene +/- saliva stimulants/artificial

Question 16

Sx of opioid toxicity?

Answer 16

myoclonic jerks
pin-point pupils
hallucination
confusion
↓RR

Question 17

Tx opioid toxicity? (if severe - RR<12, difficult to rouse, cyanosed

Answer 17

Stop opioid.
IV 400 micrograms naloxone in 10mls 0.9% sodium chloride
IV 0.5ml (i.e. 20 micrograms naloxone) every 2mins until respiratory recovery

(if mild Sx, ↓ opioid dose by 30-50% + check renal function)

Question 18

how to Tx V from gastric stasis?

Answer 18

Metoclopramide or domperidone

Consider trial of steroid

Question 19

how to Tx V from ↑ICP?

Answer 19

Cyclizine

Consider steroids

Question 20

Lung CA patient has facial swelling, redness, headache, periorbital oedema, swelling of the arms, prominent distended veins on neck and chest wall.
She’s breathless with a cough, chest pain and cyanosed.
She reports visual disturbance.

what’s going on ?

Answer 20

superior vena cava obstruction (SVCO)
malignant tumour in the mediastinum
preventing venous drainage from the head, arms and upper trunk

Question 21

Tx for SVCO?

Answer 21

dexamethasone 16mg stat, daily
oxygen 
manage SOB & agitation
escalate: imaging
\+/- anticoagulation

stent insertion

Question 22

what are the FIVE KEY PRIORITIES defined by the Leadership Alliance for the Care of Dying People?

Answer 22

• Recognise: that a person may die within the next few days or hours
• Communicate sensitively with the dying person and those close to them
• Involve all in making decisions as far as they indicate they want to be
• Support the family
• Plan individualised care

Question 23

what for breakthrough pain if patient receiving >25 mcg of transdermal fentanyl per hour?

Answer 23

nasal fentanyl
maximum initial 50 mcg into one nostril, repeated once if necessary after 10 minutes
(max two sprays for each pain episode and a minimum of 4 hours between treatment of each pain episode)

Question 24

can you use buprenorphine for breakthrough pain?

Answer 24

has both opioid agonist and antagonist properties (may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids)