Palliative Care

Question 1

What is an advanced care plan and who creates it?

Answer 1

A document indicating a patients wishes for treatment/care they will receive as their illness worsens and they near the end of their life

Created and updated by the GP, can be shared with other healthcare professionals involved

Question 2

What is an advanced care plan also known as in Scotland?

Answer 2

Key Information Summary (KIS)

Question 3

Who should have a KIS?

Answer 3

Any patient identified to have a life limiting illness who are at risk of decline

Question 4

What is the first step in pain management (mild pain)?

Answer 4

Paracetamol 1g 4x daily
+/- NSAID e.g. naproxen 500mg 2x daily
+/- other adjuvant

Question 5

What is the second step in pain management (moderate pain)?

Answer 5

Opioid for mild/moderate pain e.g. codeine

+/- adjuvant

Question 6

Which dose of codeine should be prescribed?

Answer 6

30-60mg 4x daily OR

co-codamol 30/500 2 tabs 4x daily

Question 7

What is the third step in pain management (severe pain)?

Answer 7

Stop codeine and switch to strong opioid –> usually morphine
Use in conjunction with paracetamol/NSAIDs/other adjuvant

Question 8

Describe the principles of prescribing morphine for pain in palliative medicine?

Answer 8

Background pain:

• modified release (MR), twice daily tablet
• MST or zomorph

Breakthrough pain:

• immediate release (IR)
• tablet (sevredol) or liquid (oromorph)
• as required (PRN)

Question 9

How do you work out the dose of morphine for breakthrough pain?

Answer 9

1/6 of total daily background dose

Question 10

Describe how you would initiate a patient on morphine if they are currently take codeine at max dose (60mg 4x daily):

Answer 10

Stop codeine
Start morphine sulphate MR 10-15mg twice daily
+ morphine sulphate IR 5mg PRN
Titrate up background morphine depending on amount of breakthrough used

Question 11

What is the maximum morphine dose?

Answer 11

No ‘max dose’ as such –> monitor pain and side effects

Question 12

What are the symptoms of opioid toxicity?

Answer 12

Hallucinations
Myoclonus
Drowsiness

Question 13

If someone is showing symptoms of opioid toxicity what should you do?

Answer 13

Dose adjustment or switch to another strong opioid
–> senior advice

If severe (respiratory depression) –> naloxone

Question 14

Why should you check renal function if a patient is opioid toxic?

Answer 14

A reduction in renal function may have caused the toxicity

–> morphine is excreted by the kidneys so a reduction in function would cause morphine to accumulate

Question 15

What should you change if a patient develops morphine toxicity due to worsening renal function?

Answer 15

Switch to oxycodone

Question 16

How does the dose of oxycodone compare to morphine?

Answer 16

Oxycodone is twice as strong as morphine

Question 17

What is the equivalent dose of oxycodone if a patient is on morphine MR 10mg 2x daily?

Answer 17

Oxycodone MR 5mg 2x daily

Question 18

What is the other name for CSCI (continuous subcutaneous infusions) used in palliative care?

Answer 18

Syringe drivers

Question 19

When are syringe drivers used and how do they work?

Answer 19

SC infusion once oral intake not possible
Butterfly needle with connector tubing
Up to 3 medicines in syringe
Infusion over 24 hours, changed daily

Question 20

How do you work out the dose of morphine to put in the syringe driver?

Answer 20

SC morphine 2 x as strong as oral morphine
—> divide TOTAL daily oral morphine by 2 to work out SC infusion dose

SC breakthrough approx 1/6 of regular daily dose

Question 21

Which drugs should you consider for anticipatory prescribing/just in case box and what for?

Answer 21

Morphine 2mg SC –> pain
Midazolam 2mg SC –> distress
Levomepromazine –> nausea
Buscopan –> secretions

Question 22

When a person is dying and they stop taking fluids, which part of their care is vital?

Answer 22

Meticulous mouth care (dehydration)

Question 23

How long should be spent on an examination to verify death?

Answer 23

At least 5 minutes

Question 24

Describe the examination done to verify death

Answer 24

Check patient identification
Check for verbal response
Check for pain response (sternal rub/supraorbital pressure)
Check pupils are fixed and dilated
Palpate two major pulses for at least 1 minute
Auscultate for cardiac output + respiratory effort for 1 minute
Check for pacemaker
Document clearly in notes

Question 25

Who registers a death and how long do they have to do it?

Answer 25

Death certificate given to family for them to register

Within 8 days of death in Scotland