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four most common symptoms managed in palliative care

- constipation
- pain
- nausea and vomiting
- breathlessness


causes of pain in hospices (3)

- the disease itself
- the treatment
- a concurrent disease

pain occurs in 80% of cancer patients so not everyone has pain!


what to ask about to a patient in palliative care with pain? (5)
what is important to do after you have prescribed them medication? (1)

- in Severity ask /10 and effect on mood/sleep/ work
- in Exacerbating/relieving factors ask what treatments tried and results, and any current treatment
- expectations and understanding of illness

- ICE (and what do they expect)

- attention to detail in palliative medicine symptom management: things might change day-to-day!



Bone pain:
describe the pain (4)
management? (3)

- dull ache over large area
- localised tenderness over bone
- may come and go at first, and tends to be worse at night and may get better with movement
- later on ---> constant and may be worse during weight bearing or with movement

- NSAIDs (diclofenac)/ morphine
- radiotherapy
- bispohphonates


neuropathic pain presentation (3)

- autonomic changes (sweating/ pallor)
- altered senstation (numbness/ hyperaesthesia)
- pain (may be localised to dermatomes or over larger area)

common complaints: 'pins and needles' and 'burning'


management neuropathic pain (3)

- amitryptiline
- anticonvulsants (gabapentin, pregabalin)
- corticosteroids if compression of a nerve


visceral pain presention (3)

- deep seated, poorly localised pain
- may be tenderness over particular organ
- may be spasmodic: bladder spasm, bowel colic


management of dull visceral pain? (1) specific to liver capsule pain/ visceral stretch (2) and colic (1)?

- analgesic ladder (non-opioids, weak, strong)

liver capsule pain:
- corticosteroids
(if visceral stretch, as reduce inflammation)

- anticholinergics
bowel colic= subcutaneous hyoscine butylbromide (Buscopan)
bladder spasm= oral oxybutynin


features of ICP pain? (3)
management raised ICP pain (headache) (3)
what else could you consider if not too bad? (2)

- dull, oppressive pain worse on waking
- coughing, sneezing
- a/w nausea and vomitting

(to reduce the oedema,)

- paracetamol


types of nausea and vomitting? (5)

- gastric
- toxins
- vestibular
- cerebral
- anxiety/ anticipatory

Think in terms of drinking booze..
gastric= after lots of beer
toxins= after vodka the next day when you feel constantly sick
cerebral= next day with headache
vestibular= when dizzy
anxiety= if made to drink a drink you hate and you smell it


gastric vomitting: characteristics (4) causes (4) treatment (2) causative drugs (3)?

- early satiety
- epigastric fullness
- hiccups
- heartburn
- often minimal nausea between vomits
- sudden onset, relieved by vomiting

- stomach cancer
- liver mets squashing liver/ hepatomegaly, ascites (‘squashed stomach’)
- pyloric stenosis
- dysmotility (drugs, autonomic failure e.g. diabetes)

- metoclopramide 10-20 mg po/sc 30 minutes before meals or 30-60 mg SC over 24 hours
- consider PPI if gastric irritation.
- OR domperidone 2nd line
- stop causative drugs if possible

- dextromethasone
- aspirin > give PPI or stop


toxic vomitting: characteristics (3) causes (7) treatment (1)?

- persistent/ intermittent nausea (feel sick all the time)
- small vomits/ 'possets'
- retching

- drugs (opioids/ digoxin/ antiepileptics/ chemotherapy)
- hypercalcaemia
- electrolyte abnormality
- uraemia
- infections (UTI/ pneumonia)
- renal/liver failure

- haloperidol


vestibular vomitting: symptoms (4) treatment (2)

- a/w movement
- hearing loss
- vertigo
- tinitus

- antihistamine
- cyclizine
(hyoscine or cinnarizine)

what causes vestibular nausea? I'm unsure


cerebral vomitting: characteristics (4) causes (7) treatment (3)
anxiety induced? (1) treatment (3)

- early morning headache
- vomiting
- little nausea
- associated neurological symptoms/signs

- brain mets
- Raised ICP
- sights/smells
- anxiety (before chemo)
- radiothearpy to brain

- dextremethazone
- cyclizine

- specific precipitant, overly anxious/ depressed

- benzodiazepine
- complementary therapies

if indeterminate consider levomepromazine


anxiety/ anticipatory vomitting: characteristics (1) treamtment (3)

- overly anxious or depressed

- bezodiazepines
- complementary therapy


medication for nausea and vomitting in:
gastric stasis
raised ICP
renal failure

- metroclopramide
- cyclizine
- increased uring output/ haloperidol (I think!)
- haliperidol
- haliperadol


causes of dry mouth problems (3)

- reduced oral intake
- adverse effect of drugs
- radiotherapy


complications of dry mouth (5)

- loss of taste
- anorexia
- halitosis
- dysphagia
- oral infections


Main components/aspects of palliative care? (6)

1- relief from symptoms
2- integrates physical, psychological, social and spiritual care
3- neither hastens nor postpones death
4- affirms life and regards dying as normal process
5- helps live ACTIVELY AS POSSIBLE until death
6- offers support to help family/carers during illness and into bereavement

remember not just cancer patients.. also COPD, heart failure, and motorneuron disease/Parkinsons


what does phycosocial care encompass in palliative care? (1)
to whom? (2)

psychological, social and spiritual care of
- patients
- and families


What is advanced care planning? (1)
What two main groups of people may want an advanced care plan? (2)
Advanced statement? (1)
Lasting power of attorney? (1)
Advanced decisions? (1)

“a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment”
used to inform best interest judgments

Used in:
- people anticipating progressive decline (PALLIATIVE)
- people with fluctuating mental capacity (PSYCH)

Advance decisions:
- to refuse treatment which are legally binding if valid and applicable
Lasting Power of Attorney
- for 'Health and Walfare' and/or 'Property and Affairs'

Advanced Statements:
- not legally binding but used in consideration; any info important to health/care
- 1+ person legal authority to make decisions about health/ welfare/ finances/ property
- decisions to reduce specific treatments and legally binding


when would you consider alternative drug administration to oral? (4)

Any disturbance to usual PO drugs:
MOUTH- impaired consciousness
NECK- dysphagia
STOMACH- intractable vomiting
INTESTINES- gastric stasis

also when rapidly changing drugs (i.e. in palliative you may need to titrate) but they'll likely have one of the above by then..

i.e. not just for poorly controlled pain


adjuvant painkillers to morphine? (4)

- accupuncture
- massage therapy
- aromatherapy

Neuropathic pain:
- antiepileptic (gabapentin)
- amitryptiline

- paracetamol has a different analgesic effect from opioids and may provide additional benefit for patients taking strong opioids.

(co-codamol also available in 3 strenghts)


side effects strong opioids (2)
what do you prescribe to limit side effects? (2)
what effects would show taken too much? (5)
if new signs of toxicity on a stable dose, what could cause this? (1)

1- nausea and vomiting in 1/3 but settles in a couple days --> PRN antiemetic (e.g. haloperidol)

2- contsipation --> give laxative ALWAYS concurrently e.g. senna 1 tablet once a day

only give PRN antiemetic as usually settles in 1-3 days so can be no need for it

- itch
- hallucinations
- decreased RR
- sleepy
all signs of toxicity NOT side effects --> decrease dose

RENAL failure (decreased excretion of morphine) --> consider oxycodone


Strong opioids (5) and types of patches (2)

morphine, oxycodone, alfentanil, methadone and different preparations of fentanyl (sublingual, buccal and nasal)

-72hr patches: transfermal fentanyl transdermal, transfermal BUPENORPHINE

*tramadol is seen as a weak opioid and isn't a controlled drug*


non-pharmacological treatments for pain?

- palliative radiotherapy (e.g. bone pain)
- palliative chemo (tumour mass compressing viscera/nerves)
- surgery (intramedullary nail for pain form a femoral metastasis)
- anaesthetic and neurosurgical interventions
- psychological interventions (e.g. CBT)
- TENS; transcutaaneous electrical nerve stimulation
- complementary therapies e.g. aromatherapy accumpunture


two main mouth problems in palliative care (2)
reasons for dry mouth in palliative care? (2)
sequalae of dry mouth? (5)
other mouth problems in palliative care? (1)
treatment? (1)

- dry mouth
- thrush

- SE of drugs (antiemetics/ antidepressants/ radiotherapy to head and neck/ chemo)
- decreased oral intake

- loss of taste
- anorexia
- halitosis
- dysphagia
- oral infection

- oral thrush (candosis) may be asymptomatic or cause altered taste --> give systemic antifungals (fluconazole 50mg o.d. 7days) or topical agents (nystatin 1ml g.d.s 7 days)


causes of anorexia in palliative care symptom-wise? (5)
how to manage anorexia in a palliate setting? (3)
drug treatment and side effects (2)

look for reversible causes:
- thrush
- nausea
- pain
- constipation
- depression

- give nicely presented food
- small portions
- educate family not to pressure pt. to eat

- dextramethasone; increases appetite remember as causes people to gain weight (but wears off after 2-3wks)
- megestrol acetate (but --> urinary retention)


GI problems in palliative care? (5)

- mouth problems
- anorexia
- nausea and vomiting
- constipation
- obstruction (can cause diarrhea and constipation!)


causes of N&V in palliative care? (3)
how to find suitable antiemetic? (1) four mechanisms (4)

COMMON (Up to 70% of patients have it!)
1/3 have identifiable cause
1/3 have multiple causes
1/3 no identifiable cause

- thorough history and identify REVERSIBLE factors to find SUITABLE antiemetic

N&V is caused bystimulation of the vomiting centre by one of four main mechanisms:
- gastric stasis
- 'toxic' causes
- cerebral causes
- vestibular causes


less worrying causes of constipation in palliative care (5)
which ones are you most worried about? (2)
treatment (2)

- immobility
- reduced food/fluid intake
- drugs (opioids)
- bowel pathology


if severe may ---> overflow diarrhoea

1- find cause and reverse if possible
2 - laxatives: ask if prefer liquid or tablet


4 classifications of laxatives (4)
when to monitor their effectiveness (1)
what to do it not worked? (2)
describe these methods? (1)

- bulking e.g. fybrogel (the rubbish ones!)
- softner (lactulose and doccusate) - remember SDL
- stimulant (senna)
- mixed (movicol/aka laxido softner and stimulant) - remember has "CO" in it

- avoid stimulant if patient has colic
- basically always avoid bulking lol

- For opioid induced constipation co-danthrusate, co-danthramer or movicol are the drugs of choice (use a mix)

- review bowels every 2 days
- if haven't moved in 3 days consider rectal examination and suppositories/ enemas

Enema= is an injection of fluid into the lower bowel by way of the rectum
Suppository= another way to deliver a drug


intestinal obstruction:
which cancers most common in? (2)
symptoms? (5)
management options? (3)
what drugs to give? (3)
what to alter? (1)

- ovarian
- bowel

Can be...
- intermittent
- incomplete
- at multiple sites
patient may survive several weeks or occasionally months

- colicy pain
- N&V
- dull achy pain
- abdo distension
- diarrhoea (overflow)/ constipation

1- surgery (depending on disease status and co-morbidity, level of the obstruction, and co-existing symptoms)
2- IV fluids and nasogastric tubes as short-term
3- Oral intake of food and drink can continue for the patients’ enjoyment and is often surprisingly well tolerated; pt can decide if risk of vomiting << pleasure of eating.

Give antiemetis, analgesia, antispasmodics

Alter medications:
- give by SC continuous infusion

If colic is a feature, stimulant laxatives and prokinetic drugs (metoclopramide) should be stopped and antispasmodics prescribed (hyoscine butylbromide). Dexamethasone and octreotide may also be used.  


main respiratory symptoms in palliative care? (2)
management (2)

- cough
- dyspnoea: uncomfortable awareness of breathing and occurs commonly in patients with advanced cancer, cardio-respiratory and neurological diseases

1- look for reversible causes
2- treat the symptoms
as with all palliative symptoms!


causes of dyspnoea:
sudden? (3)
several days? (4)
gradual onset (5)

- asthma -->bronchodilators
- pulmonary oedema --> diuretics, diamorphine
- pulmonary embolism --> anticoagulants e.g. tinzaparin

- COPD exarc.-->Abx, bronchodilators
- pneumonia-->Abx, physio
- bronchial obstruction by tumour--> dexamethasone, stents, or laser
- SVCO --> dex., urgent stent

- heart failure congestive--> diuretics, digoxin, ACE
- aneamia _->transfusion
- pleural effusion--> pleural aspiration/ pleurodesis
- ascietes --> paracentesis
- lymphangitis carcinomatosis--> trial dexamethasone

MAY just be to the advancing disease and irreversible..


management of irreversible dyspnoea:
non-pharmological treatment (2)
pharmalogical? (2)

Discuss with family and patient..
- lifestyle: breathing retraining and relaxation
- oxygen if long term but probably wont help much in palliative

- opioids (decrease respiratory effort and therefore breathlessness)
- benzodiazepines (help with anxiety)


what causes the cough in palliative care?

excessive production of fluid in the lung (e.g. excessive mucus production by tumour, bleeding from a tumour), inhaled foreign bodies, or abnormal stimulation of the airways receptors

- reverse cause
if cause can't be revered -->
- opioids (as a cough suppressant) +laxative

- dry cough=give linctus
- productive=give saline nebuliser


metastatic spinal cord compression:
- management? (3)
- when to stop drugs? (1)

1- DEX 16mg + PPI NOW if clinical suspicion (omeprazole 20mg I THINK)
2- whole spine MRI within 24 hours
3- refer to ONCOLOGISTS who will liase with neurosurgery and consider surgery/ radio/ chemo (or all the above!)

- if not MSCC then taper down dose of dexamethasone by 2mg each day, if there is MSCC then keep at 16mg once daily for a few days then taper

Surgery is usually favored in situations of mechanical collapse of a vertebral body (where radiotherapy will rarely reverse the situation) but is less likely to be used if there is extensive disease elsewhere.


causes of obstruction? (3)

- extrinsic compression
- thrombosis
- invasion of wall of SVC

remember to consider germ cell tumours for fast growing tumours in younger people or lymphoma

breast/lung too


Which cancers does major hemorrhage occur in? (1)
management (3)

- head and neck eroding major vessel
(think of that lady at St Gemmas waiting for a carotid blowout)

Fast and effective symptom control:

- MIDAZOLAM IM (into the deltoid muscle) or SC, as a sedative and amnesic
- GREEN/RED/DARK coloured towels;
to make blood look less traumatic
- MEMBER OF STAFF with the patient for reassurance as very traumatic


recognising terminal care:
- signs/symptoms (6)

- if all other reversible causes have been considered and appropriately managed
- profound weakness
- confined to bed for most of day
- drowsy for extended periods
- disorientated
- severely limited attention span
- loosing interest in food/drink
- too weak to swallow medication


Management in end of life consultation- what to address?
What to do RE feeding? (1)
benefits of this? (3)

6Ps and 2As

- check patients understanding
- discuss fears/concerns

People: family/friends (consider + offer support), spiritual/priest/rabbai, GP, Macmillan nurse
Place: home/hospice/hospital; consider wants of family and patient
Power: negotiate appropriate treatment, future of treatments (Advance Directive, Advanced Statement, lasting power of attorney, will)

Axe uncessary meds (and any other treatments e.g. IV fluids)
Anticipatories start

-Patients and carers will often have “unfinished business” (frequently legal, financial, interpersonal or spiritual issues).

- treat dry mouth
- assess immobility and pressure areas
- catheter/ convene/ pads
- bowel care if constipation--> discomfort/ agitation
- fast track/continuing care funding

give by mouth as long as tolerated but don't give clinically assisted
- clinically assisted (artificial) hydration doesn't contribute to comfort and may --> peripheral or pulmonary oedema

Benefits of withdrawing:
- less vomiting and incontinence
- reduce barriers between patient and family, careers
- prevent painful venepuncture

Remember patients are dying from their disease and not from lack of food or fluids. Dry mouth is usually related to medication, mouth breathing and/or oxygen therapy and is relieved by good mouth care.


Managment in end of life in terms of:
previous mediation (2)
anticipatory medicines (4)

- switch route to rectal, transdermal or subcutaneous
- stop when no longer able to swallow: vitamins/iron, hormones, anticoagulants, corticosteroids, antibiotics, antidepressants, cardiovascular drugs, anticonvulsant drugs used for pain

some meds you'd consider keeping e.g. insulin/ some heart drugs/ dex if healping headache but check with senior

- analgesic
- antiemetic
- anti-secretory
- anxiolytic


Management in end of life in terms of:
terminal restlessness (2)
'death rattle'? (3)
what else should you ensure if the patient is reaching these palliative symptom stages? (1)

1- look for reversible causes: pain, urinary retention, faecal impaction, respiratory secretions
2- if none reversible--> sedation with MIDAZOLAM
(short acting sedative/ anxiolytic/ muscle relaxant/ anticonvulsant) SC 2.5-5mg or infusion

1- REPOSITION patient
2- ANTISECRETORY DRUGS: hyoscine butylbromide (Buscopan®) or hyoscine hydrobromide (which may cause paradoxical agitation)
3- REASSURE family:
- secretions in upper airways in patients too weak to expectorate effectively
- not stressful for patient but can be for relatives/ carers

- DNACPR/ RESPECT form: discuss with clinical team and document as per local policy
- documentation is key!


Bereavement is increased in... (6)

• previous multiple losses or recent losses
• ambivalent relationships
• dependent children
• lost a child
• previous psychological problems or substance abuse
• live alone or feel unsupported


What to do after death? (3)
what to do with family? (2)

- inform patients GP within 24 hours
- ensure prompt death certificate
- anticipate if patients religion may need special procedures

To family:
- warn relatives if coroner referral
- information about the role of the funeral director, how to register a death, common feelings of grief, and support available


most common cancers to cause SVCO? (4)

1st= NSCLC
2nd= SCLC
3rd= non-Hodkins lymphoma
4th= breast/ mediastinal/ germ cell/ thyroid cancer


symptoms? (5)
signs? (3)
managment? (5)

- headache or 'fullness' in head
- facial swelling
- dyspnoea (worse lying flat)
- cough
- hoarse voice

- facial/upper limb oedema
- prominent blood vessels on neck, trunk and arms
- cyanosis

- high dose corticosteroids (dex 16mg) + PPI
- ask senior to get involved
- urgent vascular stenting
- followed by radiotherapy/ chemotherapy depending on primary tumour type
- biopsy if first presentation of cancer
- if a germ cell tumour is possible then tumour markers (AFP, βhCG, LDH) may be useful

many of cancers presenting this way can spread rapidly: rapidly (eg small cell lung cancer, lymphoma, germ cell tumours)


which cancers most commonly cause hypercalcaemia? (4)

- breast cancer
- lung cancer
- squamous cell carcinomas NSCLC (release PTHrP)
- myeloma
(but can be in all cancers!)

n.b. can get hypercalcaemia without bone metastasis caused by hormonal changes

remember SCLC is the neoplastic one, NSCLC is the squamous one that causes PTHrP


symptoms; early (8) and late (4)
investigation (1)

- lethargy
- malaise
- anorexia
- polyuria
- thirst
- nausea
- vomiting
- constipation

- confusion
- drowsiness
- fits
- coma

Serum calcium corrected for serum albumin.


management (2)
response rate (1)

- rehydration saline (1L /4hours for first 24 hours, then 1L/6hrs for next 48hrs (CHECK this as from my memory!)
- IV bisphosphonate e.g. zoledronic acid or pamidronate

~70% patients respond
max response 6-11 days, average duration of response 3-4 weeks
(can be refractory like that lady signing Oh happy day)


syringe driver:
practical points e.g. how to insert it and where? (5)

Inadequate pain control is not an indication for syringe driver use unless there is reason to believe oral analgesics are not being absorbed.

1- butterfly needle at 45° and covered by a transparent dressing; oedematous areas/ broken skin avoided
2- possible sites include the chest, abdomen, upper arm and thigh.
3- special syringe driver prescription chart
4- careful monitoring of site for redness, induration or soreness
5- rotate site every few days if inflamed
6- check syringe for precipitation: a sign the drugs aren't compatible (some drugs can't go in the syringe together! - shouldn't put >3 in a driver together anyway!)

there's a massive book saying all the drugs that aren't compatible together


syringe driver:
- which drugs can be given? (6)
- which are unsuitable? (3)

- diamorphine or morphine sulphate
- cyclizine
- haloperidol
- metoclopramie
- levomepromazine
- hyposine butylbromide
- midazolam
try not to give >3 in one driver

diazepam, chlorpromazine, prochlorperazine
(cause too much skin irritation)


How do you identify a palliative patient in the hospital (i.e. which features?) (3)

- approaching end stage of a terminal illness
- worsening frailty and multi-morbidity
- long term condition with life threatening exacerbation

(not necessarily last hours/days of life, and with sudden catastrophic events)
hard to work out sometimes

- increasing comorbidity
- sytemic inflammatory response (increased CRP, decreased Albumin)
- unplanned hospital admissions
- unplanned weight loss (muscle)
- escalating frailty score


What treatment decisions need to be made if a patient is classified as palliative? (3)
what treatments are considered? (6)
how are these decisions made? (3)

ON ANOTHER CARD read for fun

1- initial treatment plan
2- treatment escalation plan (i.e. if plan 1 doesn't work, do we want to do dialysis in renal failure for example)
3- what happens next?

e.g. think about the 6Ps
People/ Place/ Prognosis/ Power (and ceiling of care)/ cPr/ post-death
- ward vs critical care
- CPR - decision
- preferred place of death (PPOD)

any other treatment?
- nutrition and hydration e.g. NG tubes
- interventions
- medication and symptom management

common thing in notes is if the patient would be escalated beyond ward level care e.g. ICU

- capacity of patient
- does patient want to be involved?
- who else does the patient want to be involved?


how to broach difficult conversations ?


- set the scene
- preparation
- ask if they want anyone there

- check their understanding

- ask if they want to know everything

- repeat info if needed
- plan for future
- give space to breath even if awakward! silence is good

- comment they're upset
- allow asking of questions
- arrange follow-up

(see OSCE notes)


Who chooses the DNACPR? (2)
What does RESPECT form stand for? (1)
What is the purpose of it? (2)

1- MDT makes decision, then if NO to DNACPR then explains that to family that risks>>>benefit
2- if YES to DNACPR then give pt. the choice of what they want

Balance of what the patient wants and what might work (AGREEMENT between doctors and patient, joint decision making). Balance risk vs benefit. By law must offer an opportunity to discuss DNACPR before formally recording decision.

REcommended Summary Plan for Emergency Care and Treatment

National process, transition from regional DNACPR to RESPECT allowing for:

1- PERSONALISED planning of
2- APPROPRIATE emergency care and treatment options including DNACPR


cardiopulmonary resuscitation:
when might you do a DNACPR? (3)
what % recover after CPR? (1)
what patients have a good prognosis for CPR? (1)

1- CPR won't work
2- patient doesn't want it
3- might work but not in their best interests

~50% get spontaneous circulation again
~25% survival to discharge

- used to restart the heart
- often at that point patients are so unwell already, that even if we did get it started again it would only be fore short period and make them even more unwell


6 components of a good death? (6)

1. pain control + symptom management
2. clear decision making and being involved
3. preparation for death
4. completion-importance of spirituality and meaningfulness of end of life
5. contribute to others
6. affirmation of the whole person

have to prioritize what is best; location may not be as important as some of these other factors!


What is 'overflow diarrohea'?

- bowel obstruction --> watery faeces to leak around the blockage


Increasing morphine PRN:
what to remember if using the method where you add PRN dose to total morphone dose? (1)

- PRN can't increase by more than 50% from previous PRN
e.g. if lady on 30mg MST PRN before, you can't increase to above 45mg even if your calculation is above this


What is the Liverpool Care Pathway? (1)
what healthcare professionals to involve in end of life care? (1)

- guidance on end-of-life care nicknamed “a conveyer belt to death"
discontinued in the UK
(while it might be good guidance it was not well used!)

involve palliative care team and nurses, depends WHERE they want to die but consider:
- progressively increasing nursing care needed as they get closer to end of life