E - End of life and palliative care

Question 1

There are four principles for the Scottish guidelines on end of life care of a patient (EOLC 2014 guidelines) What are the 4 principles?

Answer 1

1. Informative, timely and sensitive communication with the individual 2. Significant decisions are made as part of a MDT 3. Each individuals needs are addressed as far as is possible 4. Consideration is given to the wellbeing of the relatives or carers

Question 2

What are the usual signs and symptoms when a person is approaching death?

Answer 2

Symptoms - pain, breathlessness, respiratory secretions, nausea/vomiting Signs - person loses interest in food and fluids, worsening weakness and sleeping more

Question 3

What is the 4 principles of the scottish end of life care guidelines?

Answer 3

1. Informative, timely and sensitive communication for the individual 2. Significant decisions regarding the person’s care are made as a MDT 3. Each of the individuals needs are addressed as far as possible 4. Consideration of well-being of relatives and carers

Question 4

Cancer pain management has an analgesic ladder developed by WHO There are 3 steps in the ladder At stage 1 of pain, what is the management?

Answer 4

Stage 1 of pain - Give patient a non-opioid (paracetamol) +/- adjuvant (NSAID)

Question 5

As pain increases, what is given at stage 2 and 3 of the cancer pain management? Why are NSAIDs debated to be given?

Answer 5

Stage 2 after increasing pain - prescribe a weak opioid eg codeine or tramadol Stage 3 - prescribe a strong opioid eg morphine

Question 6

When starting morphine it is important to decide on a starting dose to prescribe the patient, Therefore the patient is prescribed oramorph regularly and a breakthrough dose to decide after a day or two the dose of oramoprh Aim to establish regimen of long acting morphine MST as background analgesia ) What is usually the starting regular and breakthrough dose? How often is the regular dose given?

Answer 6

Start at 2.5mg oramorph Oramoprh 2.5mg qds (regular) Oramorph 2.5mg prn (breakthrough)

Question 7

What is the drug usually given as the background analgesia? Plus oral immediate release morphine (oramorph) for “breakthrough” pain. 1/6 total daily dose

Answer 7

Usually long acting MST (morphine sulfate) is given as background

Question 8

What drugs are usually prescribed alongside the morphine regime?

Answer 8

A laxative and an anti-emetic PRN

Question 9

The oral oramorph given for the breakthrough dose will be what percentage of the total daily dose of MST? What anti-emetic is generally prescribed when for the side effect and when should it not be used?

Answer 9

The oral oramoprh given for the breakthrough dose will be prescribed at 1/6th of the daily dose Metoclopramide Should not be used in Parkinson’s disease as it is a dopamine antagonist and parkinson’s treatment relies upon dopamine agonists

Question 10

This is the breakthrough dose of oramorph required for this patient and is currently on 2.5mg oramph qds WHat is the dose of MST and oral oramporh to be prescribed now after calculation?

Answer 10

Person took - 15mg breakthrough in one 24 hour period + 10mg regular = 25mg in one day Since you want to start the patient on the MST regime which is twice daily, start on 10mg MST with a breakthrough dose of 4 oramoph as required (remember the breakthrough dose is meant to be 1/6th of the total dose required in one day)

Question 11

Patient taking MST 5mg bd What is the breakthrough dose? Patient taking MST 50mg bd What is the breakthrough dose?

Answer 11

Patient taking MST 5mg bd - this means it is likely that the patient had a total daily dose of 10mg Breakthrough dose will be 1/6th of 10mg so 2mg oral oramorph is nearest Patient taking MST 50mg bd - this means it is likely that the patient had a total daily dose of 100mg Breakthrough dose will be 1/6th of 100mg so 15mg oral oramoprh nearest

Question 12

The oral route is often not available for symptom control of an end of life patient What is often used instead?

Answer 12

Smoothest delivery of medicines is via continuous subcutaneous infusion using a syringe driver (CSCI)

Question 13

What type of needle does the syringe driver gain subcutaneous access through? How many medications can be mixed in the syringe driver at once?

Answer 13

Access via a butterfly needle Up to 3 medicines can be mixed together in the syringe E.g Opioid, antiemetics, anxiolytics ,dexamethasone, antimuscarinics….many others

Question 14

How often is the syringe driver changed?

Answer 14

Syringe driver is changed daily

Question 15

Morphine is twice as potent when given SC compared to PO Therefore if a patient is on 10mg MST bd, what should the syringe driver infusion become?

Answer 15

The CSCI becomes 10mg MST over 24 hours Remember to write the syringe drivers infusion in the continuous infusins box in the cardex

Question 16

What are the 5 end of life care symptoms that tend to arise and what are the anticipatory prescribing medications?

Answer 16

Pain - Morphine Breathlessness - morphine Anxiety/distress - Midazlam (benzodiazepines) Nausea/vomiting - levomepromazine Respiratory secretions - buscopan (hyoscine butylbromide)

Question 17

What receptors does levomepromazine block?

Answer 17

It is a broad spectrum anti-emetic blocking the D2-like dopamine receptors

Question 18

When the anticipatory medications are prescribed, what would the medication frequency be prescribed as?

Answer 18

The patients on EOLC are sometimes prescribed pre-emptive medications to be given as required. (PRN) This is to prevent any unnecessary wait for medication should symptoms arise in a patient.

Question 19

If a person’s main symptoms when nearing end of life care was agitation, what would be prescribed?

Answer 19

Probably prescribe midazolam - has sedatory effects and helps with severe agitation

Question 20

Pain - Morphine Breathlessness - morphine Anxiety/distress - Midazlam (benzodiazepines) Nausea/vomiting - levomepromazine Respiratory secretions - buscopan (hyoscine butylbromide) What doses are each medication started on when prescribing as required?

Answer 20

Moprhine injection 2mg subcutaneously hourly as required Midazolam injection 2mg subcutaneously hourly as required Buscopan injection 20mg subcutaneously hourly as required Leveomepromazine injection 2.5mg subcutaneously 8hourly as required

Question 21

In an opioid naive patient at the end of life, the dose of morphine for management of pain and dyspnoea is 2mg hourly as required. Midazolam is a short acting sc benzodiazepine, for a person not used to these medicines, the dose is 2mg hourly for distress /anxiety. What type of drug is hyoscine butylbromide? Why is leveomeproamzine only able to be given 8 hourly?

Answer 21

Hyoscine butylbromide is an anti-muscarinic and reduces respiratory secretions Levemepromazine is very sedative and has a long half life and is therefore only prescribed 8 hourly