Palliation of symptoms

Question 1

Anorexia / loss of appetite

Answer 1

very common

often a major source of distress

Question 2

fatigue

Answer 2

disease
treatment
concurrent illness
anaemia
unrelieved symptoms
cachexia / malnutrition
depression
physical de-conditioning

Question 3

dyspnoea

Answer 3

opioids can be helpful
benzos for anxiety / panic

opioids:
diamorphine 5-10mg/24hr sc via SD

benzodiazepines
midazolam 5-30mg/24hr via SD and 2.5-5mg sc pm

Question 4

nausea and vomiting

Answer 4

vestibular nuclei

• h1 receptor antagonist
• muscarinic receptor antagonist

CTZ (D2 and HT3 receptors)

• dopamine antagonist
• 5HT3 anagonist

vomiting centre
- muscarinic receptor antagonist

visceral afferents
- 5HT3 antagonist

Question 5

emetic pathways

Answer 5

motion sickness to labyrinth to vestibular nuclei

pain/repulsive sight/smell/emotion to sensory afferent pathways = higher centres = vomitin centres

endogernous toxins or drugs in blood, release of emetogenic agents (prostanois, free radicals) to CTZ and visceral afferents = nucleus of soliatry tract = vomiting cnetre

stimuli from pharynx and stomach = visceral afferent = vomiting centre

Question 6

nausea and vomiting

Answer 6

prokinetic antiemetics (gastric stasis, peristaltic failure)- *metoclopramide, *domperidone

acting at CTZ (chemical causes)
*haloperidol

acting on the vomiting centre (raised intracranial pressure, vestibular causes, bowel obstruction)
*cyclizine H1

Question 7

nausea and vomiting management

Answer 7

reversible causes (calcium)

route (syringe driver)

rehydration

metoclopramide +/- levomepromazine

dexamethasone

Question 8

constipation mx

Answer 8

screen and monitor
anticipate and titrate laxatives
soften and push
peripheral opioid antagonist like methylnaltrexone, naloxegol

Question 9

ubiquitous dexamethasnoe

Answer 9

Tumour compression
spinal cord compression
SVCO
bronchial/tracheal
bowel obstruction
Cerebral oedema
Pain
neuropathic
liver capsule
radiotherapy flare
Nausea
Appetite / well being

2mg-16mg/day

look out for:
Glucose intolerance (BM peak late afternoon)
Proximal myopathy
Agitation / psychosis (occasionally)
Gastritis (but most patients already on PPIs)

Question 10

buscapan

Answer 10

(smooth muscle spasm, anti secretory)
Colic / reduce volume of vomits in bowel obstruction
Reduce salivary secretions (? evidence) (also glycopyrronium, hyoscine hydrobromide)

Question 11

octreotide

Answer 11

anti secretory)
Reduce volume of vomits in bowel obstruction
High output fistulae

Question 12

baclofen

Answer 12

Muscle spasm

Hiccups

Question 13

midazolam

Answer 13

Anxiety, breathlessness, seizures, pain crises

Question 14

meds

Answer 14

secretions- glycopronium, hyoscine

breathless- opioid, benzodiazepines

Question 15

physiological changes in death

Answer 15

increase weakness
fatigue
loss of ability to close eyes
decrease appetite/fluid intake/oral meds
decrease blood perfusion
neurological dysfunction
pain

Question 16

physiological changes in death

Answer 16

increase weakness
fatigue
loss of ability to close eyes
decrease appetite/fluid intake/oral meds
decrease blood perfusion (tachycardia, hypotension, mottling of skin, diminished UO)
neurological dysfunction
pain

Question 17

2 roads to death

Answer 17

sleepy, lethargic, obtunded, bed bound, semicomatose, comatose.

Question 18

meds for terminal delerium

Answer 18

benzodiazepines
lorazepam
midazolam
haloperidol
levompromazine
seizures.

Question 19

changes in respiration

Answer 19

altered breathing patterns
diminished tidal volume
apnoea
Cheyenne stokes resp
accessory muscle use 
alas reflex breath

Question 20

death rattle

Answer 20

glycoperonium
hyoscine (2 types= buscapan which does not cross BBB and does not cause sedatoin or agigtation) (hyoscine hydrobromide- patches, does cross the BBB)

postural drainage
positioning
suctionign

Question 21

death rattle

Answer 21

glycoperonium
hyoscine (2 types= buscapan which does not cross BBB and does not cause sedation or agitation) (hyoscine hydrobromide- patches, does cross the BBB)

postural drainage
positioning
suctioning

Question 22

TEP and CPR

Answer 22

would the patient survive? yes / no

discuss good dying, why CPR not being offered, why inappropriate, obtained informed decision.