Palliative Care

Question 1

What is the GMC guidance of defining end of life?

Answer 1

Likely to die within the next 12 months
Those facing imminent death
Those with
- advances, progressive, incurable conditions
- general frailty
- at risk of dying from sudden crisis of condition
- life threatening conditions caused by sudden catastrophic events

Question 2

Give examples of diseased that require palliation of symptoms

Answer 2

Motor neuron disease 
End-stage cardiac failure
End-stage COPD
Advanced renal disease 
Cancer

Question 3

What are the key themes for development in palliative care?

Answer 3

Early identification of patients who may need palliative care
Advanced care planning
Care in last days/ hours of life
Delivery of effective and timely care

Question 4

What are the palliative care aims?

Answer 4

Whole person approach
Focus of QoL, including good symptom control
Care encompassing the patient and those that matter to them

Question 5

Give 6 principles of good end of life care

Answer 5

Communication 
Anticipating care need and encouraging discussion 
Multidisciplinary team input 
Symptom control 
Preparing for death 
Support for relatives

Question 6

Describe bone pain

Answer 6

Worse on pressure or weight bearing

Question 7

Describe pain associated with raised ICP

Answer 7

Headache, worse with lying down, often present in the morning

Question 8

Name a form used to document pain

Answer 8

Brief pain inventory

Question 9

Describe step 1 of the WHO analgesic ladder

Answer 9

Non-opioid e.g. aspirin, paracetamol, NSAID

+/- adjuvant

Question 10

Describe step 2 of the WHO analgesic ladder

Answer 10

Weak opioid e.g. codiene, dihydrocodeine, tramadol
For mild to moderate pain
+/- non-opioid, adjuvant

Question 11

Describe step 3 of the WHO analgesic ladder

Answer 11

Strong opioid e.g. morphine, diamorphine, fentanyl, oxycodone
Moderate to severe pain
+/- non-opioid, adjuvant

Question 12

What are the 5 principals of the WHO analgesic ladder?

Answer 12

By the clock
By mouth 
By the ladder
For the individual
Attention to detail

Question 13

What is the mechanism of action of morphine?

Answer 13

Centrally acting opioid receptor agonist

Question 14

What are the common side effects of morphine?

Answer 14

N/V
Constipation 
Dry mouth 
Bronchospasm 
Opioid toxicity

Question 15

What are the signs of opioid toxicity?

Answer 15

– Shadows edge of visual field – Increasing drowsiness
– Vivid dreams / hallucinations – Muscle twitching / myoclonus – Confusion
– Pin point pupils
– Rarely, respiratory depression

Question 16

Give examples of immediate release morphine preparations

Answer 16

Oramorph liquid

Sevredol tablet

Question 17

What should always be prescribed alongside opiates?

Answer 17

Laxative e.g. macrogol

Anti-emetic e.g. metaclopramide

Question 18

What principles should be followed when moving from step 2 to 3?

Answer 18

Stop step 2 weak opioids
Titrate immediate release strong opioid - how much they needed over 24 hours
Convert to modified release form
Monitor response and side effects

Question 19

What drugs are used for neuropathic pain?

Answer 19

Amitriptyline
Gabapentin
Carbamazepine

Question 20

How does oxycodone compare to morphine?

Answer 20

Less hallucinations, itch, drowsiness and confusion

Question 21

What are the features of a fentanyl patch?

Answer 21

Lasts 72 hours
Only used in stable pain
Useful if oral and subcutaneou route not available

Question 22

Why are syringe drivers useful?

Answer 22

Oral route inappropriate
Rapid symptom control
Usually used very close to end of life

Question 23

What medications are commonly put in syringe drivers alongside pain killers?

Answer 23

Anti-emetics e.g. haloperidol
Secretion treatments e.g. Glycopyrronium
Anxiolytics e.g. midazolam