Palliative Care Flashcards
(163 cards)
1
Q
What symptoms are commonly seen in patients nearing the end of life?
A
- Agitation
- Pain
- Excess secretions
- N&V
- Breathlessness
- Constipation
2
Q
What are anticipatory medications?
A
End of life medicines
3
Q
What are the 4 main classes of anticipatory medication?
A
1) Analgesia - for pain
2) Anti-emetic - for N&V
3) Anxiolytic - for agitation
4) Anti-secretory - for respiratory secretions
4
Q
How are anticipatory medications usually prescribed?
A
Anticipatory medications are prescribed as SC injections (injected under the skin) as patients nearing the end of life are often unable to take oral medications.
They should be prescribed PRN, or ‘as needed’, rather than regularly.
Unless the patient has previously received the medications, a low dose should be started and titrated up according to response.
5
Q
When prescribing anticipatory medications, what details should be included?
A
- Drug name
- Drug dose
- Route e.g. (SC)
- Indication for each medication: to make it clear which medication should be used for which symptom
- Frequency of delivery (e.g. 1 hourly)
- Maximum dose in twenty-four hours: to ensure safe levels of medication are given, this will also prompt regular reviews if a patient is requiring frequent doses
6
Q
Choice of medication and starting doses vary depending on several patient factors such as:
A
1) PMH –> e.g. specific considerations for patients with Parkinson’s disease, lower starting doses are used in frail patients.
2) Organ dysfunction –> renal and liver dysfunction affect the choice of medications and require lower starting doses
3) DH –> if patients are already on a background opiate their PRN dose should be calculated based on this, rather than using the dose for an opioid naïve patient
7
Q
Recognising pain in end of life patients is important, especially if patients are less responsive and therefore unable to articulate symptoms.
What changes might be observed that could indicate pain?
A
- Facial expressions such as grimacing
- Verbalisations such as moaning or shouting out
- Body movements such as guarding a particular area/part of the body
- Autonomic reactions such as increased heart rate or temperature
8
Q
What is a common first line analgesic in end of life patients?
A
Morphine sulphate
9
Q
What dose of Morphine sulphate is typically given for opiate naïve patients in end of life care?
A
1 – 2.5mg SC.
Do not repeat within 1-hour
Maximum 4 doses in 24 hours
10
Q
If there is reduced renal function (eGFR <50), what can be used as an alternative to morphine sulphate in end of life care?
A
Oxycodone 1-2 mg SC
Do not repeat within 1-hour, maximum 4 doses in 24 hours
11
Q
For patients already on a background dose of opioid medication, what is the PRN anticipatory dose?
A
Generally 1/6th of the total subcutaneous background dose in 24 hours.
12
Q
Example:
Mr Y has been taking 30mg BD slow-release morphine but is now approaching the last days of life and is not able to swallow his usual medications. This is equivalent to 30mg SC morphine in 24 hours.
What should the PRN anticipatory dose be?
A
5mg SC morphine (30/6)
13
Q
What combination of opioids is typically seen in palliative care?
A
1) Background opioids (e.g., 12-hourly modified-release oral morphine)
2) Rescue doses for breakthrough pain (e.g., immediate-release oral morphine solution) –> these doses arre 1/6 of background dose
14
Q
Patient X is on 30mg of modified-release morphine every 12 hours; what would be the correct breakthrough dose?
A
30x2 = 60 –> patient is receiving 60mg background morphine every 24 gours
60/6 = 10mg –> correct breakthrough dose
REMEMBER each rescue dose is 1/6 of the 24-HOUR background dose.
15
Q
What should you monitor for when prescribing morphine?
A
- Constipation
- Unwanted sedation
16
Q
Opioid conversion
The following table shows dose equivalents of 10mg oral morphine:
A
Codeine/tramadol/dihydrocodeine oral –> 100mg
Diamorphine IM/IV/SC –> 3mg
Morphine IM/IV/SC –> 5mg
Oxycodone oral –> 5mg
Oxycodone SC –> 2.5mg
Alfentanil SC –> 0.3mg
17
Q
Conversion factor from oral codeine to oral morphine?
A
Divide by 10
I.e. 100mg of oral codeine = 10mg of oral morphine
18
Q
Conversion factor from oral tramadol to oral morphine?
A
Divide by 10
19
Q
Conversion factor from oral morphine to SC morphine?
A
Divide by 2
20
Q
Conversion factor from oral morphine to oral oxycodone?
A
Divide by 1.3-2 (depends on trust guidelines)
If in doubt, always opt for the lower dose and titrate up.
21
Q
Conversion factor from oral morphine to SC diamorphine?
A
Divide by 3-3.3 (trust guidelines)
22
Q
Conversion rate from oral oxycodone to SC diamorphine?
A
Divide by 1.5
23
Q
What is the equivalent dose of oral tramadol to 10mg oral morphine?
A
100mg
24
Q
What is the equivalent dose of SC diamorphine to 10mg oral morphine?
A
3mg
25
What is the equivalent dose of SC morphine to 10mg oral morphine?
5mg
26
It is also possible to use opioid patches for background analgesia. What 2 opioid patches are used?
1) Buprenorphine patches
2) Fentanyl patches
27
When increasing the dose of opioids, what should the next dose be increased by?
30-50%
28
How do the side effects of oxycodone differ from morphine?
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but MORE constipation.
29
What should be prescribed for all patients initiating strong opioids?
laxatives
30
What are some potential causes of N&V in endof life patients?
- Constipation
- Medication side effects
- Biochemical disturbance e.g. hypercalcaemia
31
What medications can be given for N&V in palliative care?
Levomepromazine
Cyclizine
Haloperidol
Metoclopramide
32
What are the six broad nausea and vomiting syndromes seen in palliative care?
1) Reduced gastric motility --> may be opioid related, related to serotonin (5HT4) and dopamine (D2) receptors
2) Chemically mediated --> 2ary to hypercalcaemia, opioids, or chemotherapy
3) Visceral/serosal --> e.g. Ddue to constipation, oral candidiasis
4) Cerebral
5) Vestibular
6) Cortical
33
What are the symptoms of gastric stasis/irritation nausea and vomiting syndrome?
o Sickness comes on very suddenly and is relieved by vomiting
o Early satiety
o Hiccups
o Heart burn
34
Causes of gastric stasis/irritation nausea and vomiting syndrome?
o Stomach cancer
o Liver mets squashing liver, ascites
o Pyloric stenosis
o Gastritis from NSAIDs etc – stop drug, consider PPI
o Diabetes → slow motility
o May be opioid related
o May be related to serotonin and dopamine receptors
35
1st line pharmacological management (anti-emetic) of reduced gastric motility N&V in palliative care?
1) Metaclopramide
- 10-20mg PO/SC (30 mins before meals)
- 30-60mg SC over 24 hours
2) Or Dopmeridone
36
When is Metaclopramide NOT indicated in reduced gastric motility N&V in palliative care?
Should not be used when pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery
37
What class of drug is metoclopramide?
Anti-emetic --> dopamine (D2) receptor antagonist
38
Mechanism of action of metoclopramide?
Dopamine D2 antagonist.
Antiemetic effects --> dopamine D2 antagonist in the chemoreceptor trigger zone (CTZ) in the brain. This relieves the symptoms of nausea and vomiting.
Gut motility --> Increases gastric emptying
39
Via what 3 mechanisms does metoclopramide promote gut motility?
1) inhibition of presynaptic and postsynaptic D2 receptors
2) stimulation of presynaptic excitatory 5-HT4 receptors
3) antagonism of presynaptic inhibition of muscarinic receptors
40
Why are pro-kinetic agents (e.g. metoclopramide) useful in reduced gastric motility N&V?
As the nausea and vomiting is usually resulting from gastric dysmotility and stasis
41
What are some causes of toxic/chemically mediated N&V?
o Alcohol
o Chemotherapy/radiotherapy
o Opiates
o Digoxin
o Hypercalcaemia (bone mets)
o Electrolyte abnormality
o Renal/liver failure
o Infections
42
Symptoms of toxic/chemically mediated N&V?
o Feel sick a lot of the time
o May be sick a little bit but won’t feel much better --> ‘possets’
o Retching
43
Which anti-emetic is used in toxic/chemically mediated N&V in palliative care?
1) Haloperidol - 1.5-5mg PO/SC nocte
2) Or cyclizine
44
What are some cerebral causes of N&V in palliative care?
o Brain metastases
o Raised intracranial pressure (usually in context of cerebral metastases)
o Sights/smells
o Anxiety --> before chemo
o Radiotherapy to brain
45
Symptoms of cerebral causes of N&V in palliative care?
o Early morning headache
o Vomiting
o May be little nausea
o Associated neurological symptoms/signs
46
Which anti-emetic is used in management of cerebral causes of N&V in palliative care?
1) Cyclizine if rased ICP
2) Dexamethasone
3) Unless Anxiety --> Lorazepam
47
Which anti-emetic is used in management of anxiety/anticipatory nausea
in palliative care?
Benzos e.g. lorazepam (short dose)
48
Describe the steps of the analgesic ladder
Don’t use 2 from same step – move up ladder
Step 1:
- Nonopioid analgesics e.g. NSAIDs, paracetamol 1g QDS
Step 2:
- Weak opioids e.g. co-codamol 30/500 2 QDS
Step 3:
- Strong opioids e.g. methadone (oral, transdermal), morphine, codeine
Step 4:
- Nerve block e.g. epidurals
Can use adjuvants at any stage e.g. NSAIDs
49
What are some potential causes of agitation in palliative care?
- Pain
- Medications (side effects and withdrawals)
- Constipation
- Urinary retention
- Infection
- Hypercalcaemia
Look for and treat underlying causes.
50
Potential signs of agitation?
Fidgeting/moving arms and legs
Confused
Vocalisations
51
1st line choice of anxiolytic (for agitation)?
Haloperidol
Other options --> chlorpromazine, levomepromazine
52
In the terminal phase, what is agitation of restlessness best treated with?
Midazolam
2.5 – 5mg SC. Do not repeat within 1 hour, maximum 4 doses in 24 hours.
53
Why can end of life patients experience increased secretions?
With reduced levels of consciousness, patients may become unable to swallow or clear their normal respiratory secretions/saliva, resulting in pooling in the upper respiratory tract.
This can cause noisy breathing/a rattling noise as air passes over the pooled secretions.
54
Non-pharm management of secretions in palliative care?
Offering reassurance to those looking after the patient that it is not a distressing symptom, as well as repositioning the patient may be helpful.
55
anticipatory medications used for respiratory tract secretions?
Hyoscine butylbromide
20mg SC. Do not repeat within 1-hour, maximum dose 120mg in 24 hours
Others:
- Hyoscine hydrobromide
- Hyoscine butylbromide
- Glycopyrronium
56
Mechanism of Hyoscine butylbromide?
Has anticholinergic effect --> reduces saliva production (dry mouth)
57
Potential signs of end of life?
* Profound weakness
* Confined to bed for most of the day
* Drowsy for extended periods
* Disorientated
* Severely limited attention span
* Losing interest in food and drink
* Too weak to swallow medication
58
When should clinical hydration/nutrition be stopped?
Continue with clinically assisted hydration if there are signs of clinical benefit. Reduce or stop clinically assisted hydration if there are signs of possible harm to the dying person, such as fluid overload, or if they no longer want it.
59
What are some possible benefits of withdrawing artificial hydration/nutrition?
▪ Less vomiting and incontinence
▪ Reduction in barriers between patient and family
▪ Prevention of painful venepuncture
60
In palliative care, what medications should be stopped and which should be continued?
Only continue medication needed for symptom management:
Stop:
o Vitamins/iron
o Hormones
o Anticoagulants
o Antibiotics
o Anticonvulsants used for pain
o Antidepressants
o Cardiovascular drugs
o Think about corticosteroid
Keep:
o Analgesics
o Antiemetics
o Antisecretories
o Anxiolytics
o Type 1 diabetics – keep insulin
o May keep anticonvulsants also
o Give SC if needed
61
What are syringe drivers?
Syringe drivers are small battery-powered pumps used to deliver medications as a continuous subcutaneous infusion (CSCI) over a 24-hour period.
62
What are 2 indications for the use of a syringe driver in patients nearing the end of life?
1) Requiring two or more doses of any one of the anticipatory medications in a 24 hour period
2) Being unable to take oral medications that need replacing (e.g. modified release opiates, anti-epileptic medications)
63
Why can syringe drivers help to achieve better symptom control?
Continuous infusion provides a constant level of medication to the patient
64
What associated features should you ask about when a patient with cancer presents with pain?
- Cough (productive or not), fever, malaise
- Weakness in legs, sensory changes
- Back pain, bladder/bowel symptoms
- Facial swelling, distended veins in neck/chest, swelling of hands/arms
- Skin changes, reflux symptoms (radiotherapy)
65
Differentials for chest pain in palliative oncology patient?
Cancer:
- Invasion; bone, pleura, chest wall
- Neuropathic pain
- Bone mets
- SVCO
- MSCC
Cancer related:
- Radiotherapy; skin, oesophagitis
- Chemotherapy; peripheral neuropathy
Co-exsisting:
- Pneumonia
- MI
- PE
- Anxiety
- GORD
- MSK
Most of these can be ruled in/out by taking a thorough pain history.
66
What are the 5 principles of the WHO analgesic ladder?
1) Oral administration of analgesics should be used whenever possible
2) Analgesics should be given at regular intervals with the duration and dose of medication supporting the patient’s level of pain
3) Analgesics should be prescribed according to the pain intensity characterised by the patient (this should be free from judgement from the clinician)
4) Dosing of pain medication should be adapted to the individual, starting at the lowest dose and duration possible but titrating accordingly to response
5) Consistent administration of analgesics is vital for effective pain management
67
Describe the steps of the WHO analgesic ladder
1) Non-opioids (e.g. paracetamol or NSAIDs) +/- adjuvants
2) Weak opioids (e.g. co-codamol, codeine, dihydrocodeine, tramadol) +/- adjuvants
3) Strong opioids (e.g. morphine, oxycodone, methadone, buprenorphine, fentanyl) and non-opioids +/- adjuvants
N.B. adjuvants can be used along any step of the ladder e.g. antidepressants, anticonvulsants, corticosteroids, anxiolytics
68
What 2 groups can pain be broadly split into?
1) Nociceptive
2) Neuropathic
69
What is nociceptive pain?
Nociceptive pain is a type of pain caused by damage to body tissue.
70
What are the 2 types of nociceptive pain?
1) Somatic (muscle, skin, bones)
2) Visceral (internal organs)
71
What is neuropathic pain?
Caused by direct damage to nerve tissue (central or peripheral)
72
What are adjuvant analgesics?
1) Neuropathic agents --> amitriptyline, pregabalin, gabapentin
2) NSAIDs
3) Corticosteroids
4) Non-pharmalogical --> TENS, radiotherapy, acupuncture, heat
73
General principles of prescribing opioids?
Patients will be on a regular BACKGROUND opioids
AND
A PRN immediate release opioid.
74
Give some administration options for the regular background opioid
1) Oral - modified release 12 hours apart/BD e.g. MST, zomorph, oxycontin, longtec
2) 24 hourly CSCI syringe driver
3) Transdermal patch change every 3-7 days e.g. buprenorphine, fentanyl
75
How is the PRN immediate release opioid given?
Oral or SC
76
What dose is the PRN immediate release opioid?
1/6 of regular 24 hourly dose
77
Give 2 examples of a PRN immediate release opioid?
Oramorph, oxynorm (these are liquid opioids given orally)
78
Onset and duration of PRN immediate release opioid?
Onset: 30 mins
Duration: 4 hours
79
What is usual starting dose of a strong opioid?
5-10mg modified release morphine
5mg (or 2mg if patient is frail) immediate release opioid
80
What are some side effects of opioids?
- Constipation
- Drowsiness & impaired concentration (may alter someone's ability to drive)
- N&V
- Dry mouth
- Flushing
- Hallucinations
- Headaches
- Itch
All opioids carry a risk of dependence and addiction.
Longer term side effects:
- Falls
- Erectile dysfunction
- Amenorrhoea
- Infertility
- Depression
- Fatigue
- Opioid induced hyperalgesia
81
How can N&V be managed in patients taking opioids?
anti-emetics (e.g. cyclizine)
82
How can constipation be managed in patients taking opioids?
all patients who start strong opioids should be prescribed a laxative to prevent constipation
83
Symptoms of opioid overdose?
1) Constricted pupils (miosis)
2) Respiratory depression
3) Reduced consciousness
84
How are opioids excreted?
Renally --> caution prescribing in renal impairment due to increased risk of opioid accumulation and subsequent toxicity
85
For patients with renal impairment, what opioid is preferred? Why?
Oxycodone - it is primarily metabolised by the liver, with only a small proportion excreted by the kidney.
86
In patients with mild renal or hepatic impairment, how should an opioid dose be changed?
Doses should be reduced by 50%
Specialist advice should be sought before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.
87
Contraindications of opioids?
- Severe renal & hepatic impairment (specialist advice needed)
- Pregnancy
- Breastfeeding (presence in breast milk)
Other notes:
- Reduced doses in elderly
- Cessation of treatment should be tapered slowly
88
What should be discussed with the patient when considering the need for analgesia?
1) The severity of the pain, its impact on lifestyle and activities of daily living, including sleep disturbance
2) The cause of the pain and whether there has been a deterioration
3) Why a particular treatment is being offered
4) The benefits and adverse effects of pharmacological treatment when considering the patient’s underlying health condition
5) The importance of adherence to medication and dosage titration
89
What is typical drug dosing for (oral) paracetamol?
0.5-1g every 4-6 hours, maximum 4g daily
90
Side effects of NSAIDs?
- Dyspepsia
- Peptic ulcer disease
- Skin reactions
91
What should be prescribed alongside NSAIDs?
PPI
92
Contraindications to NSAIDs?
Active bleeding or history of active bleeding
IHD
Severe hepatic impairment
Severe renal impairment
Uncontrolled HTN
Asthma
93
What 3 classes of drugs can interact with NSAIDs and increase risk of bleeding?
1) Anticoagulants (e.g. warfarin)
2) Antiplatelets (e.g. aspirin)
2) Selective serotonin reuptake inhibitors (e.g. sertraline)
94
How do NSAIDs affect the kidneys?
1) sodium levels
2) potassium levels
Can decrease renal function and lead to:
1) hyponatraemia
2) hyperkalaemia
95
What 2 classes of drugs can interact with NSAIDs and increase risk of electrolyte imbalances?
1) ACEi e.g. ramipril (increased risk of hyperkalaemia)
2) Diuretics e.g. spironolactone (increased risk of hyponatraemia or hyperkalaemia)
96
How do NSAIDs affect seizure activity?
Can worsen seizure activity
97
What class of drugs can interact with NSAIDs and increase risk of seizures?
Fluoroquinolone antibiotics (e.g. ciprofloxacin)
98
Typical dose for (oral) ibuprofen for mild to moderate pain?
Initially 300-400mg 3-4 times a day; increased up to 600mg 4 times a day if necessary; maintenance 200-400mg three times a day
99
Typical drug dose for oral codeine?
30-60mg every 4 hours as required
100
What 3 doses does co-codamol come in?
8/500mg, 15/500mg and 30/500mg.
101
What is an alternative if codeine/co-codamol is ineffective or cannot be tolerated?
Tramadol
102
Before prescribing any strong opiate, consider ABC.
What is this?
A - start Antiemetic
B - consider Breakthrough pain
C - prescribe laxative for Constipation
103
For patients with renal impairment, what opiate can be used?
Consider oxycodone
104
Typical drug dosing for (oral) morphine in acute pain?
initially 10mg every 4 hours; use a lower initial dose in the elderly (5mg every 4 hours)
105
Typical drug dosing for (oral) morphine in chronic pain?
5-10mg every 4 hours
106
What is neuropathic pain?
Neuropathic pain is caused by damage to the somatosensory nervous system, which can result in allodynia, hyperalgesia, and paraesthesia.
107
Common causes of neuropathic pain?
Diabetic neuropathy
Chronic alcohol use
Infection
Trigeminal neuralgia
Trauma
Spinal cord injuries
Multiple sclerosis
Malignancy
108
What are some non-pharmacological treatments for neuropathic pain?
Physical and psychological treatments
Surgery
109
1st line pharmacological options for neuropathic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
110
What class of drug is amitriptyline?
tricyclic antidepressant
111
Side effects of amitriptyline?
The most common side effects are anticholinergic:
Dry mouth
Blurred vision
Dry eyes
Constipation
Urinary retention
Postural hypotension
CAUTION - overdose is associated with a high mortality rate.
112
What class of drug is duloxetine?
selective serotonin noradrenaline uptake inhibitor (SNRI).
113
Side effects of duloxetine?
Increased BP (caution in CVS disease)
Anxiety
Dry mouth
Flushing
Gastrointestinal discomfort
Palpitations
Sexual dysfunction
114
What class of drug is gabapentin and pregabalin ?
Anticonvulsants
115
Side effects of pregabalin and gabapentin?
Drowsiness
Dizziness
Ataxia
116
What is 1st line in trigeminal neuralgia?
Carbamazapine
117
What can be considered for people with localised neuropathic pain who wish to avoid oral treatments?
capsaicin cream
118
Give some cerebral causes of N&V
Raised ICP
Brain mets
Intracranial haemorrhage
Pain
Anxiety
Primary CNS tumour
Psychological
119
Give some toxic causes of N&V
Medication
Biochemical
Uraemia
Hypercalcaemia
Hyponatraemia
Hyperbilirubinaemia
Infection
Hyperglycaemia
120
Give some gastric causes of N&V
Bowel obstruction
Gastroparesis
Pancreatitis
Hepatomegaly
Gastroenteritis
Ascites
Constipation
Dyspepsia
121
Give some vestibular causes of N&V
Inner ear pathology
Labyrinthitis
Motion sickness
Vertigo
122
Describe typical N&V in cerebral causes
- Nausea > vomiting
- Timing
- Position dependent
- Headache
- Neuro symptoms
123
What are the 4 major groups of N&V
1) Toxic
2) Cerebral
3) gastric
4) vestibular
124
What class of drug is cyclizine?
Antihistamine with anticholinergic activity
125
Which 3 types of N&V are most like to respond to cyclizine?
1) cerebral
2) gastric
3) vestibular
due to presence of histamine receptors in CNS and vestibular system and presence of ACh receptors in GI and vestibular area.
126
Side effects of cyclizine?
Dry mouth
Hypotension
Drowsiness
127
What also can be used in cerebral N&V to reduce peri-tumoural oedema?
Steroids e.g. dexamethasone (but this is not an anti-emetic)
128
What are 2 anti-emetics that are prokinetics with dopaminergic activity?
1) metoclopramide (acts centrally)
2) domperidone (acts peripherally only)
129
Major contraindication of metoclopramide?
Parkinson's
130
Can domperidone be used in Parkinson's?
Yes
131
What type of N&V can metoclopramide & domperidone be used in?
Gastric
132
What anti-emetic is typically chosen for toxic causes of N&V?
Haloperidol
133
What are the 2 chosen anti-emetics for end of life?
1) haloperidol
2) levomepromazine
134
Contraindications of haloperidol
and levomepromazine?
Parkinson's disease
135
Which anti-emetic is typically used for chemo-related N&V?
Ondansetron
136
Most common side effect of ondansetron?
Constipation
137
What is a common cause of N&V in dvanced intra-abdominal malignancy ie ovarian, bowel, peritoneal?
Malignant bowel obstruction
138
Medical management of bowel obstruction?
1) Give IV fluids.
2) Give an anti-secretory e.g. hyoscine butylbromide (buscopan) or ranitidine - to reduce how much bowel is secreting into lumen
3) Give steroids
4) Give anti-emetic (depends on presence or absence of colick, if not present can give metoclopramide, if present give haloperidol)
5) Give pain relief
139
What are the 4 main types of laxatives?
1) bulk forming e.g. fybogel
2) softeners e.g. docusate
3) stimulants e.g. senna, bisacodyl
4) osmotic e.g. lactulose
Combination (softeners and stimulants) e.g. macrogols (movicol/laxido)
140
What is the 1st line laxative in palliative care?
Senna
141
Typical management of SVCO?
SVC stent
142
What can be used in reducing the discomfort associated with a painful mouth that may occur at the end of life?
Benzydamine hydrochloride mouthwash or spray
143
1st line anti-emetic for intracranial causes of nausea and vomiting?
Cyclizine
144
3 options for metastatic bone pain?
1) analgesia
2) bisphosphonates
3) radiotherapy
145
Pharmacological managment of confusion/agitation in palliative care but for patients NOT in the terminal phase?
Oral haloperidol (if the patient was in the terminal phase and agitated then subcutaneous midazolam would be indicated)
146
What is analgesic of choice in patients with:
a) mild-moderate renal impairment
b) severe renal impairment (eGFR <10)
a) oxycodone
b) buprenorphine or fentanyl
147
Why is buprenorphine or fentanyl preferred in patients with severe renal impairment?
not renally excreted and therefore are less likely to cause toxicity than morphine
148
What can be used to manage bowel colic in palliative care?
Hyoscine butylbromide
149
Conversion from oral morphine to SC diamorphine?
Total daily morphine dose divided by 3
150
Pharmacological management of hiccups in palliative care?
chlorpromazine or haloperidol
151
What is the benzodiazepine of choice in terminal agitation/restlessness?
Midazolam
152
Why is diazepam not given as an end of life drug?
It is an irritant when given subcut
153
What is 1st line in cancer related breathlessness when no reversible element?
Low dose immediate release PO morphine (i.e. oramorph)
154
Describe performance status 1-5
0 = normal
1 = symptomatic & ambulatory, cares for self
2 = ambulatory >50% of the time
3 = ambulatory <50% of the time, nursingcare required
4 = bedridden
5 = dead
155
What drug is indicated for agitation and confusion in patients who are NOT in the terminal phase?
Haloperidol
156
What drug is indicated for agitation and confusion in patients who are in the terminal phase?
SC midazolam
157
What is the codeine to morphine conversion?
divide by 10
158
What class of medication is metoclopramide?
D2 receptor antagonist
159
What drug can be used in the management of intractable hiccups in palliative care?
Chlorpromazine or haloperidol.
160
What are 3 management options for metastatic bone pain?
1) strong opioids
2) bisphosphonate infusion
3) radiotherapy
161
Conversion of oral morphine to diamorphine?
Divide by 3
162
What may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life?
Benzydamine hydrochloride mouthwash or spray
163
