Palliative care

Question 1

Analgesia should be ‘done’ by what three things?

Answer 1

By the ladder, by the clock, by the mouth (if poss)

Question 2

How many times stronger than morphine is oxycodone?

Answer 2

2x

Question 3

How many times stronger than morphine is fentanyl?

Answer 3

3x

Question 4

Which two opioids are suitable for end stage renal failure?

Answer 4

Fentanyl or bupranorphine

Question 5

What does a co-codamol dose of 30/500 mean?

Answer 5

30mg codeine, 500mg paracetamol

Question 6

Why might you give co-codamol on the analgesic ladder?

Answer 6

It keeps ‘step 1’ paracetamol going as well as step 2, but combined in a tablet

Question 7

SEs morphine

Answer 7

Constipation

N+V

Drowsy/clouded consciousness

Dry mouth

Itching

Reduced perception of breathlessness

Question 8

Symptoms opioid toxicity

Answer 8

delirium

vivid dreams

visual hallucinations

myoclonus

decreased resp rate

pinpoint pupils

Question 9

Immediate release morphine takes how long to work and lasts for how long?

Answer 9

within 30mins

Lasts 2-4hrs

Question 10

Examples of IR morphine?

Answer 10

Oramorph

Sevredol

Question 11

Modified release morphine lasts for how long

Answer 11

12 (or 24) hours

Question 12

Examples modified release morphie

Answer 12

MST

Zomorph

Morphgesic

Question 13

If a patient is on co-codamol 30/500 two tablets QDS and you want to add some morphine for breakthrough pain how much morphine would you prescribe?

Answer 13

30 x 2 x 4 = 240mg

240mg codeine = 24mg morphine

1/6 daily dose for breakthrough so 24/6 = 4

Prescribe 5mg (no more than 6-8 doses in 24hr)

Question 14

What is the breakthrough morphine dose compared to MR dose?

Answer 14

1/6 daily total

Question 15

How do you increase someone who is on MR and IR morphine?

Answer 15

Increase the MR to the current total daily dose, including IR (but only 1/3-1/2 increase is safe).

MR given BD

Question 16

Is oramorph prescribed in mg or ml?

Answer 16

mg because it comes in 10mg/5ml and 100mg/5ml

Question 17

What specific signs are there that you should reverse the opioid?

Answer 17

RR <8 and not rousable- reverse with naloxone

Question 18

The SC dose of morphine is ____ the oral dose

Answer 18

half

Question 19

Four causes of nausea and vomiting?

Answer 19

Cerebral

Toxicity (mainly nausea)

GI (mainly vomiting)

Ear

Question 20

Two cerebral causes of nausea?

Answer 20

SOL

Anxiety/perception

Question 21

Rx for cerebral nausea

Answer 21

SOL- Dex or cyclizine

Anxiety/perception- benzo/SSRI

Question 22

Rx for chemo nausea

Answer 22

Ondansetron

Graniestron

Question 23

Rx for the rest of the toxicity causes of nausea

Answer 23

Haloperidol

Question 24

Which antipsychotics help with nausea?

Answer 24

Levomepromazine and olanzapine (but typical so SEs)

Question 25

Can you give metaclopromide and cyclizine?

Answer 25

No they counteract each other

Question 26

What are the four types of laxative?

Answer 26

Bulking agent Softener Stimulant Combination

Question 27

Fybogel is what sort of laxative?

Answer 27

Bulking agent

Question 28

Senna is what sort of laxative?

Answer 28

Stimulant

Question 29

Docusate is what sort of laxative?

Answer 29

Softener

Question 30

Movicol is what sort of laxative?

Answer 30

Combination

Question 31

Condranthamer is what sort of laxative?

Answer 31

Combination

Question 32

How do you know whether to give oral or enema laxative?

Answer 32

If can feel hard stool in rectum- enema. Oral will cause overflow.

Question 33

What can an advanced care plan say regarding treatment?

Answer 33

It can refuse in specific circumstances, can't demand Decisions to refuse treatment are legally binding if valid and appliable

Question 34

Why do people make ACPs?

Answer 34

In case they lose capacity in future

Question 35

What is the Gold Standards Framework?

Answer 35

Approach to optimising EoL care

Question 36

What are three steps in the GSF?

Answer 36

Identify EoL patients Assess current and future clinical and personal needs Plan (MDT)

Question 37

What should be discussed with a patient about their last days? (6)

Answer 37

Medication review Symptom control Family needs Nursing needs Psycho-spiritual needs Preferred place of death and goals of care

Question 38

What are 4 essential medications to continue at EoL

Answer 38

the anticipatories analgesic, antiemitic, anxiolytic, anti-secretory

Question 39

Are antidepressants essential to continue at EoL?

Answer 39

No

Question 40

Are laxatives essential to continue at EoL?

Answer 40

No

Question 41

Are anticoagulants essential to continue at EoL?

Answer 41

No

Question 42

Are LT Abx essential to continue at EoL?

Answer 42

No

Question 43

Are corticosteroids essential to continue at EoL?

Answer 43

Maybe- consider stopping

Question 44

Are diuretics essential to continue at EoL?

Answer 44

No

Question 45

Are hypoglycaemics essential to continue at EoL?

Answer 45

Consider stopping

Question 46

Are anticonvulsants essential to continue at EoL?

Answer 46

Consider stopping

Question 47

How should children be involved in death?

Answer 47

Involve them, be honest and factual (age appropriate). Recognise that they grieve and share sadness Create a new routine

Question 48

How is death confirmed?

Answer 48

Absence of central pulse or heart sounds. After 5 mins of cardio-resp arrest (e.g. listen to HS for 2 mins and Resp sounds 3 min), confirm absence of 1. Pupillary light reflexes 2. Corneal reflexes 3. Motor response to supra-orbital pressure May also include asystole on ECG, absence of pulsatile flow on intra arterial pressure monitor or absence of contraction on echo.

Question 49

When is time of death?

Answer 49

After it has been confirmed

Question 50

What might the body be examined for after death?

Answer 50

Pacemaker, bruises, pressure sores

Question 51

When should you not issue death certificate

Answer 51

Coroner needed

Question 52

Who must do the death certificate

Answer 52

A doctor who attended the person during their last illness. Must have seen them within 14 days. Provide within 24hrs

Question 53

How should the date be written on a death cert?

Answer 53

Write the numbers out in letters e.g. twenty

Question 54

Can you put 'old age' on a death certificate?

Answer 54

No

Question 55

What is section II of cause of death

Answer 55

Other significant conditions contributing to the death but not related to the disease causing it

Question 56

Is the mode of dying e.g. resp arrest put on the death certificate?

Answer 56

No

Question 57

Can you use abbreviations e.g. CKD on death cert?

Answer 57

No

Question 58

When is referral to coroner needed

Answer 58

No doctor attended during last illness, or not in the last 14 days Cause of death unknown (post mortem required) If death occured: - during operation or before anaesthetic ended - industrial poisoning or at work - sudden or unexpected (including <24h in hosp) - unnatural (medical mistake) - violence of neglect - other suspicious cause - in prison, custody or other state detention

Question 59

If post mortem reveals the death was not unnatural what happens?

Answer 59

Pink form issued to registrar Death can be registered Body released for cremation or burial

Question 60

What happens to the MCCD (medical certification of cause of death) or coroner's certificate?

Answer 60

Given to registrar of births and deaths within 5 days Death certificate issued to family

Question 61

What can be used in patients who require an opioid but cannot tolerate morphine?

Answer 61

Oxycodone hydrochloride

Question 62

What laxative should be given with opioids?

Answer 62

Co-danthramer (softener + peristalsis) Or lactulose with senna

Question 63

Do patients taking an opioid require an anti-emetic?

Answer 63

Maybe for the first few days but then ok

Question 64

What should be discussed when talking to a pt about escalation plan and ceiling of care?

Answer 64

Other Rx ward vs ICU CPR? Nutrition and hydration Interventions Medication and symptom management Preferred place of death

Question 65

What is 'fast track' in palliative care?

Answer 65

Unlocks funding for care at home if short time left to live

Question 66

Give examples of the anticipatories

Answer 66

Analgesic- morphine Antiemitic- haloperidol 1.5-3mg Anxiolytic- midazolam 2.5-5mg Antisecretory- hyoscine butylbromide 10-20mg

Question 67

Can you give diazepam, chlorpromazine or prochlorperazine SC?

Answer 67

No

Question 68

Can you mix the usual anticipatories?

Answer 68

Yes, but nb drugs do exist that need a separate syringe driver e.g. dex, diclofenac, ketorolac