Ageing and End of Life Care

Question 1

what is the first step in the management of pain?

Answer 1

non opioid (e.g. aspirin, paracetamol, NSAID)

+/- adjuvant

Question 2

what is the second step in the management of pain?

Answer 2

weak opioid for mild-moderate pain (e.g. codeine)

+/- non opioid
+/- adjuvant

Question 3

what is the third step in the management of pain?

Answer 3

strong opioid for moderate-severe pain (e.g. morphine)

+/- non opioid
+/- adjuvant

Question 4

what are the two options for prescribing morphine?

Answer 4

slow release - morphine sulphate M/R

immediate release - morphine sulphate I/R

Question 5

how long does morphine sulphate M/R last and when should it be taken?

Answer 5

12 hours

twice daily

Question 6

name two brands of morphine sulphate M/R

Answer 6

MST

zomorph

Question 7

how long does morphine sulphate I/R last and when should it be taken?

Answer 7

four hours

as required

Question 8

what quantity of morphine sulphate I/R should be given to a patient also on M/R?

Answer 8

1/6 of the total background dose

Question 9

name two brands of morphine sulphate I/R

Answer 9

oramorph

sevredol

Question 10

name three symptoms of opioid toxicity

Answer 10

hallucinations
myoclonus
drowsiness

Question 11

what does opioid toxicity usually respond to?

Answer 11

dose adjustment or switching to another strong opioid

Question 12

what is a severe side effect of morphine?

Answer 12

respiratory depression

Question 13

what drug can be administered to reverse morphine and what dose should be given?

Answer 13

naloxone

small doses e.g. 80mcg IV every 2 mins to avoid pain reversal

Question 14

name a commonly used second line strong opioid

Answer 14

oxycodone

Question 15

what are the two safest opioids in severe renal impairment?

Answer 15

fentanyl

alfentanil

Question 16

which is stronger - oxycodone or morphine?

Answer 16

oxycodone is TWICE as strong

if switching from morphine, half the dose

Question 17

which is stronger - oral or subcutaneous morphine and what should be done when switching between these?

Answer 17

SCUT is twice as strong

divide the total daily oral morphine dose by 2 = SCUT dose

Question 18

name some conditions that can mimic dying

Answer 18

opioid/drug toxicity
sepsis
hypercalcaemia
AKI
hypoglycaemia

Question 19

what is used when the oral route for drugs is not available at the end of life?

Answer 19

syringe drivers (CSCI)

these provide continuous subcutaneous infusion of drugs

Question 20

how many medications can be given via a syringe driver at one time?

Answer 20

up to three

Question 21

what medicine is given in anticipation of pain at the end of life?

Answer 21

morphine 2mg SCUT hourly

if established on opioids - 1/6 daily background dose

Question 22

what medicine is given in anticipation of SOB at the end of life?

Answer 22

morphine 2mg SCUT hourly

Question 23

what medicine is given in anticipation of distress at the end of life?

Answer 23

midazolam 2mg SCUT hourly

Question 24

what medicine is given in anticipation of nausea at the end of life?

Answer 24

levomepromazine 2.5mg SCUT 12 hourly

Question 25

what medicine is given in anticipation of respiratory secretions at the end of life?

Answer 25

buscopan 20mg SCUT hourly

Question 26

what needs to be observed for confirmation of a death?

Answer 26

absence of carotid pulse for 1 min
absence of heart sounds for 1 min
absence of respiratory sounds for 1 min
no response to painful stimulus 
fixed dilated pupils

Question 27

what painful stimulus is used for confirmation of death?

Answer 27

trapezium squeeze