Osteosarcomas: A Bone Cancer that Affects Long Bones

Osteosarcomas are a type of bone cancer that primarily affects the metaphysis of long bones, with the knee and proximal humerus being the most commonly affected areas. Although they are more commonly seen in young adults, they can also occur in the elderly in association with Paget’s disease. The most common symptoms of osteosarcomas are bone pain and a palpable lump.

When an x-ray is taken, periosteal elevation (known as Codman’s triangle) and a ‘sunburst’ appearance due to soft tissue involvement are typically seen. Early haematogenous spread is common, and the 5-year survival rate is approximately 50%.

Overall, osteosarcomas are a serious form of bone cancer that require prompt diagnosis and treatment. By understanding the symptoms and diagnostic features of this condition, patients and healthcare providers can work together to develop an effective treatment plan.

Hypercalcaemia in a Patient with Squamous Cell Lung Carcinoma

This patient is presenting with signs and symptoms of hypercalcaemia, including confusion, lethargy, musculoskeletal aches and pains, thirst, abdominal pain, and constipation. The underlying cause of her hypercalcaemia is likely ectopic parathyroid hormone production associated with her squamous cell lung carcinoma.

It is important to consider other potential causes of her symptoms, such as anaemia or an infective cause like atypical pneumonia. However, her medication and superior vena caval obstruction are less likely to be the primary cause of her clinical picture.

Managing hypercalcaemia in patients with advanced cancer is crucial for symptom control and improving quality of life. The Scottish Palliative Care Guidelines provide recommendations for the management of hypercalcaemia, including hydration, bisphosphonates, and corticosteroids. Close monitoring and communication with the patient’s healthcare team are also essential.

Spinal Cord Compression: An Oncological Emergency

Spinal cord compression is a medical emergency that requires immediate attention. The sudden onset of bilateral leg weakness and loss of sensation are common symptoms, along with back pain, urinary retention, and constipation. This condition is often caused by metastatic cancer, with breast, bronchus, prostate, multiple myeloma, and high-grade non-Hodgkin lymphoma being the most common culprits. While patients may already have a cancer diagnosis, spinal cord compression can sometimes be the first sign of cancer.

To diagnose spinal cord compression, a whole spinal MRI scan is necessary. Treatment should begin immediately with intravenous dexamethasone, followed by either neurosurgery or radiotherapy. Peripheral neuropathy and spinal tuberculosis can be ruled out based on the time course and lack of relevant history. Paraneoplastic myelopathy is rare and typically associated with small-cell lung cancer, while a secondary spinal tumor deposit would present similarly but is less common.

In summary, spinal cord compression is a serious condition that requires prompt diagnosis and treatment. Early intervention can improve outcomes and prevent further complications.

Topical sprays are not suitable for providing continuous pain relief throughout the day due to their short duration of action. It is recommended to only use topical local anaesthetics for severe pain.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Scoring Tools in Clinical Practice

In clinical practice, various scoring tools are used to aid in the diagnosis and management of different medical conditions. The Wells score is a tool used to assess the likelihood of deep vein thrombosis (DVT) in patients with symptoms such as pain and swelling in the calf. The Ottawa ankle rules, on the other hand, are guidelines used to determine if a patient with foot or ankle pain should undergo an X-ray to diagnose a possible ankle bone fracture. The National Early Warning Score (NEWS) is a tool developed to improve the detection and response to clinical deterioration in adult patients. The CHA2DS2VASC score is used to assess the stroke risk in patients with atrial fibrillation, while the Child-Pugh score is used to measure the severity of liver cirrhosis. These scoring tools play a crucial role in clinical decision-making and patient management.

Calculating Morphine Dosage for Palliative Care Patients

When prescribing medication for palliative care patients, it is crucial to calculate the correct dosage to effectively manage their pain. The calculation involves two parts: determining the total amount of morphine to be placed in the syringe driver for continuous 24-hour administration and calculating the as required or breakthrough dose.

To calculate the total amount of morphine required, the total amount of morphine the patient needs in 24 hours to control their pain must be added up. It is important to note that morphine is approximately twice as effective when given subcutaneously or intravenously as when given orally. Therefore, the required dose is half of the calculated amount.

The breakthrough dose should always be one-sixth of the total dose placed in the syringe driver. This allows for effective pain management when the patient experiences sudden spikes in pain.

Regular review of the analgesia regime is essential to ensure the patient’s pain is adequately managed. If available, diamorphine is the first drug of choice for treating severe pain in cancer patients parenterally. A conversion factor of 3 should be used when converting from oral morphine to parenteral diamorphine.

Management of Pruritus in Palliative Care Patients with Advanced Pancreatic Cancer

When treating a patient with advanced pancreatic cancer who has declined stenting for relief of cholestasis, the focus should be on palliative symptom management. The underlying cause of widespread pruritus should be treated if possible, but in this case, emollients have been tried and a sedating antihistamine such as hydroxyzine or chlorphenamine is the next appropriate medication. While pregabalin and gabapentin may be considered, they should only be used after discussion with a specialist/dermatologist. Topical calamine lotion is not recommended by NICE for pruritus treatment. Hydralazine, a vasodilator antihypertensive drug, has no indication for use in pruritus.

The breakthrough dose is calculated as 1/6th of the daily morphine dose, which is equivalent to 5mg (30 mg total daily dose divided by 6).

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Understanding the Symptoms of Cancer-Related Cachexia

Cancer-related cachexia is a complex condition that involves the progressive loss of muscle mass, often accompanied by a loss of appetite and changes in taste. This condition is not reversed by standard nutritional support and can lead to functional impairment, fatigue, and respiratory complications. Skeletal muscle wasting is a common feature of many cancers, particularly those affecting the gastrointestinal tract, and is a significant contributor to cancer-related deaths. While weight loss may be present in cachexia, it is not the most specific diagnostic feature. Anorexia, on the other hand, is a common symptom that supports the diagnosis. Immobility may result from cachexia, but it is not a causal factor and can have multiple other causes. Vomiting may or may not be present in cachexia, but it can be contributory to the diagnosis. Overall, understanding the symptoms of cancer-related cachexia is crucial for early detection and management of this debilitating condition.

Advance Decisions to Refuse Treatment (ADRTs)

An Advance Decision to Refuse Treatment (ADRT) is a legally binding document that comes into force once a person loses capacity. It is applicable and valid, and family members cannot override it. It is important to note that there is no legal definition of next of kin.

For an ADRT that refuses potentially life-sustaining treatment to be valid, it must be written, signed, and witnessed. It should also include a statement indicating that the person completing the ADRT accepts the consequences, even if it means their life is at risk.

A Lasting Power of Attorney for Health and Welfare can only override the ADRT if it was made after the ADRT and the attorney has the authority to give or refuse consent for treatment related to the ADRT.

It is essential to complete an ADRT when one is 18 years or older and has the capacity to do so. The document comes into force when the person loses capacity.

Management of Mild Hypercalcaemia in Palliative Care

Mild hypercalcaemia, with an adjusted serum calcium concentration of 3.0 mmol/L or less, is a common complication in palliative care, particularly in patients with cancer. While asymptomatic cases may not require hospital admission, specialist advice should be sought to determine the necessity of treatment. In the meantime, patients should be advised to increase their fluid intake to 3-4 L per day to maintain good hydration. Non-steroidal anti-inflammatory drugs may be useful as adjuvant analgesics, but caution should be exercised to avoid renal toxicity from future bisphosphonate treatment. Calcitonin and intravenous bisphosphonates are effective in reducing serum calcium levels, but hospital admission may be necessary for their administration. A low calcium diet is not necessary as intestinal absorption of calcium is usually impaired. Overall, management of mild hypercalcaemia in palliative care requires a tailored approach based on the patient’s individual circumstances and preferences.

Understanding Inquests

An inquest is a public investigation into the circumstances surrounding a person’s death. It is held at a Coroner’s Court and aims to determine the who, where, when, and how of the death. As a healthcare professional, you may be required to attend an inquest to provide evidence about your involvement in the care of a patient who has died. It is important to note that an inquest is a legal proceeding, but it is not a criminal one. This means that it cannot assign blame or responsibility to a person or organization. Instead, its purpose is to gather information and establish facts. During an inquest, you may be questioned by a lawyer representing the patient, and there may be a jury and members of the press present. It is essential to be prepared and understand the process to ensure that you can provide accurate and helpful information.

Importance of Psychological Assessment and Support for Cancer Patients

Cancer patients often experience psychological distress related to their diagnosis and treatment. To address this, providers of cancer services should ensure that all patients undergo systematic psychological assessment at key points of their treatment, as recommended by the National Institute for Health and Care Excellence guidelines. Referrals to community or specialist services should be made as needed.

It is important to note that psychological support should be available throughout a patient’s cancer journey and need not be limited to the end of active treatment. While patients with a previous history of mental health problems may require a referral to a psychiatrist, other services may be more appropriate for some patients.

In addition, Admiral Nurses, who specialize in Alzheimer’s support, are not directly involved in cancer care and may not be the best source of emotional support for cancer patients. Overall, the importance of psychological assessment and support for cancer patients cannot be overstated.

According to NICE guidelines, dopamine (D2) receptor antagonists such as metoclopramide or domperidone should be used as the first-line treatment for nausea and vomiting caused by gastric dysmotility and stasis in palliative care. Cyclizine, an antihistaminic and anticholinergic anti-emetic, would not be appropriate for this condition. Hyoscine butylbromide is another anticholinergic anti-emetic that can be used. Levomepromazine, a broad-spectrum anti-emetic, is useful for persistent nausea and vomiting that is not controlled by other anti-emetics, as well as for mechanical obstruction.

Nausea and Vomiting in Palliative Care: Mechanistic Approach to Prescribing

Nausea and vomiting in palliative care can have multiple causes, but identifying the most prominent one is crucial in guiding the choice of anti-emetic therapy. Six broad syndromes have been identified, with gastric stasis and chemical disturbance being the most common. In general, pharmacological therapy is the first-line method for treating nausea and vomiting in palliative care. There are two approaches to choosing drug therapy: empirical and mechanistic. The mechanistic approach matches the choice of anti-emetic drug to the likely cause of the patient’s nausea and vomiting.

For reduced gastric motility, pro-kinetic agents such as metoclopramide and domperidone are useful. However, metoclopramide should not be used when pro-kinesis may negatively affect the gastrointestinal tract. For chemically mediated nausea and vomiting, the chemical disturbance should be corrected first. Key treatment options include ondansetron, haloperidol, and levomepromazine. Cyclizine and levomepromazine are first-line for visceral/serosal causes, while anticholinergics such as hyoscine can be useful. For raised Intracranial pressure, cyclizine and dexamethasone are recommended. For vestibular causes, cyclizine is the first-line treatment, while atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases. If anticipatory nausea is the clear cause, a short-acting benzodiazepine such as lorazepam can be useful.

NICE CKS recommends that oral anti-emetics are preferable and should be used if possible. If the oral route is not possible, the parenteral route of administration is preferred. The intravenous route can be used if intravenous access is already established. By using a mechanistic approach to prescribing, healthcare professionals can tailor anti-emetic therapy to the specific cause of nausea and vomiting in palliative care patients.

The woman in question is likely suffering from intestinal obstruction, a condition that affects 3% of all cancer patients and up to 25% of those with advanced ovarian cancer. This can be caused by peristaltic failure due to opioid drugs or nerve damage, or by mechanical factors such as bowel wall infiltration, compression, or constipation. The presence of painful colic and hyperactive bowel sounds suggests a mechanical obstruction. To address her nausea and vomiting, a sequence of subcutaneous infusions of cyclizine, haloperidol, and levomepromazine may be tried until the most effective agent is found. However, stimulant laxatives like senna should be avoided due to the patient’s colic, and all oral laxatives should be stopped if there is complete obstruction. Bisacodyl, another stimulant laxative, should also be avoided in patients with colic, with sodium docusate being the preferred laxative for constipation. Metoclopramide, a prokinetic agent, is the drug of choice for functional obstruction but is contraindicated in the presence of colic and mechanical obstruction. For pain relief, continuous subcutaneous morphine/diamorphine or a fentanyl patch may be used, but the patient would benefit more from an antiemetic and addressing the underlying cause if possible.

Treatment for Symptoms of Raised Intracranial Pressure in Brain Metastases Patients

This patient is experiencing symptoms of raised intracranial pressure due to brain metastases. Depending on the treatment aims and ceiling of treatment, radiotherapy may be indicated. However, pharmacotherapy can also aid in palliating symptoms. High dose corticosteroids, such as dexamethasone at 16 mg daily for four to five days, followed by a reduced dose of 4-6 mg daily, can help alleviate headaches caused by raised intracranial pressure. Other options may be considered as adjuncts to treatment for pain, nausea, and agitation. Nevertheless, dexamethasone is the best option as it directly targets the underlying problem causing the symptoms in this case.

Understanding Advance Decisions under the Mental Capacity Act

The Mental Capacity Act provides individuals with the right to make advance decisions, which replace advanced directives. These decisions allow a person to refuse certain medical treatments in specific circumstances, even if it may result in their death. However, to make an advance decision, the person must be 18 years or older (16 years in Scotland) and have mental capacity.

While any treatment can be refused, measures needed for comfort, such as warmth, shelter, and offering food or water by mouth, cannot be refused. A person may express a wish for particular treatments in advance, but these do not have to be followed. An advance decision has the same weight as decisions made by a person with capacity at the present time and must be followed, so the concept of patient’s best interests doesn’t apply.

Advance decisions about life-sustaining treatment must be in writing, signed, and witnessed, and include a statement that the decision applies even if life is at risk. Other decisions may be verbal but should be recorded in medical records. An advance decision becomes invalid if it is withdrawn or amended when capacity is still present or changed by someone with ‘lasting powers of attorney.’

An advance decision takes precedence over decisions made in a patient’s best interest by other people. In making a best interest decision, the Mental Capacity Act requires doctors to try to find out the individual’s views, including their past and present wishes and feelings, as well as any beliefs or values.

Ignoring an advance decision can result in claims for criminal charges of assault. In Scotland, advance directives are not legally enforceable under the Adults with Incapacity (Scotland) Act 2000, but the Act states that the wishes of the adult should be taken into consideration when acting or making a decision on their behalf.

Understanding Advance Decisions and the Mental Capacity Act

Treatment Options for Restlessness and Agitation in Palliative Care

Restlessness and agitation are common symptoms in palliative care patients, and they can be distressing for both the patient and their caregivers. One option for managing these symptoms is through the use of a syringe driver, which delivers medication continuously over a 24-hour period. The three main medications used in this context are haloperidol, levomepromazine, and midazolam.

Haloperidol is an antipsychotic medication that has minimal sedative properties and is effective in managing restlessness and confusion. Levomepromazine, on the other hand, is more sedating than haloperidol and may be more appropriate for patients who require greater sedation. Midazolam is a benzodiazepine that has both sedative and antiepileptic effects and is often used in combination with an antipsychotic for very restless patients.

It is important to note that diazepam should not be used in a syringe driver as it can cause injection site reactions. Phenobarbital and propofol are also not typically used in this context and should only be considered under the guidance of a specialist palliative care physician and pharmacist. Propranolol is not administered via subcutaneous injection and is not typically used for managing restlessness and agitation.

In summary, haloperidol is the preferred medication for managing restlessness and agitation in palliative care patients via a syringe driver. The appropriate dose ranges from 5-15 mg over a 24-hour period. However, the choice of medication and dose should always be made in consultation with a healthcare professional.

Common Medications Used in Palliative Care

When introducing an opioid in palliative cancer care, it is recommended to prescribe a stimulant laxative such as senna or a dantron-containing laxative to prevent constipation. Amitriptyline is commonly prescribed as an adjuvant analgesic for neuropathic pain, while ibuprofen is used for bone pain or pain due to soft tissue infiltration. Metoclopramide is a pro-kinetic drug used for vomiting due to gastric stasis, while prochlorperazine is not typically used in palliative care. It is important to consider the specific needs of each patient when selecting medications for palliative care.

Treatment Options for Anorexia/Cachexia Syndrome in Palliative Care

The anorexia/cachexia syndrome is a complex metabolic process that occurs in the end stages of many illnesses, resulting in loss of appetite, weight loss, and muscle wasting. While drugs can be used to improve quality of life, their benefits may be limited or temporary. Corticosteroids, such as dexamethasone, are a commonly used treatment option for short-term improvement of appetite, nausea, energy levels, and overall wellbeing. However, their effects tend to decrease after 3-4 weeks. Proton pump inhibitors, like omeprazole, should be co-prescribed for gastric protection. Amitriptyline is unlikely to be beneficial in these circumstances, but may be useful for depression or neuropathic pain. Cyclizine may help with nausea, but doesn’t have a role in anorexia/cachexia. Levomepromazine is commonly used for end-of-life care to alleviate nausea, but is unlikely to target anorexia or cachexia specifically. Overall, treatment options for anorexia/cachexia syndrome in palliative care should be carefully considered and tailored to each individual patient’s needs.

If a doctor has not seen the deceased in the 28 days prior to their death, the death must be referred to the coroner. This is a notifiable death and may require further investigation and a post-mortem. However, the first step is to refer the death to the coroner’s office. Alerting the safeguarding lead or calling 999 is not necessary in this situation, and completing the death certificate should not be done until after the coroner’s investigation is complete.

Notifiable Deaths and Reporting to the Coroner

When it comes to death certification, certain deaths are considered notifiable and should be reported to the coroner. These include unexpected or sudden deaths, as well as deaths where the attending doctor did not see the deceased within 28 days prior to their passing (this was increased from 14 days during the COVID pandemic). Additionally, deaths that occur within 24 hours of hospital admission, accidents and injuries, suicide, industrial injury or disease, deaths resulting from ill treatment, starvation, or neglect, deaths occurring during an operation or before recovery from the effect of an anaesthetic, poisoning (including from illicit drugs), stillbirths where there is doubt as to whether the child was born alive, and deaths of prisoners or people in police custody are also considered notifiable.

It is important to note that these deaths should be reported to the coroner, who will then investigate the circumstances surrounding the death. This is to ensure that any potential criminal activity or negligence is properly addressed and that the cause of death is accurately determined. By reporting notifiable deaths to the coroner, we can help ensure that justice is served and that families receive the closure they need during a difficult time.

Understanding Symptoms in Palliative Care: Indicators of End-of-Life

As a patient approaches the end of their life, it can be difficult to determine the exact moment of passing. However, certain symptoms may indicate that the end is near. Cheyne-Stokes breathing, characterized by cycles of increasingly deep and shallow respiration with possible periods of apnea, is a poor prognostic sign often seen in palliative care. Rectal bleeding may indicate progression of colorectal carcinoma, but doesn’t necessarily indicate the end of life. Abdominal distension may be related to the cancer or constipation caused by pain medication, but is not an indicator of prognosis. Grand mal seizures may require further investigation or treatment, but do not necessarily give an idea of prognosis. Pain management should be regularly reviewed, but the amount of pain doesn’t necessarily correlate with entering the end-of-life phase. Understanding these symptoms can help healthcare providers provide appropriate care and support for patients and their families during this difficult time.

Managing Dysphagia in Palliative Care

When managing dysphagia in a palliative care setting, it is crucial to identify the underlying cause of the condition. Depending on the cause, different treatments may be necessary. For instance, a physical obstruction caused by a tumour may require a corticosteroid such as dexamethasone, while oesophageal spasm may respond to a muscle relaxant like nifedipine or baclofen.

In the case of a patient with oesophageal cancer who experiences progressive difficulty in swallowing and food getting stuck on the way down, the most likely cause is a gradually enlarging tumour mass causing obstruction and progressive dysphagia. In this scenario, dexamethasone is the most appropriate treatment to prescribe.

It is worth noting that oesophageal spasm typically causes odynophagia in addition to dysphagia. Therefore, a careful assessment of the patient’s symptoms and medical history is necessary to determine the most effective treatment plan.

Managing Fatigue in Advanced Chronic Illness: Non-Pharmacological Interventions Recommended

Fatigue is a common symptom in advanced chronic illness, but it is often under-recognised by healthcare professionals. While potentially reversible factors should be treated, the cause of fatigue may remain poorly understood. Non-pharmacological interventions such as pacing activities, graded exercise, stress/anxiety management, and sleep hygiene advice may help reduce the impact of fatigue on daily life. Vitamin supplements are not recommended unless there is a proven deficiency, and dexamfetamine and fluoxetine are not indicated for treating fatigue in this context. Methylphenidate may be an option under specialist supervision, but non-pharmacological interventions should be tried first. Overall, managing fatigue in advanced chronic illness requires awareness, acknowledgement, and a focus on non-pharmacological interventions.

The preferred diluent in syringe drivers is ‘water for injection’.

When a patient in palliative care is unable to take oral medication due to various reasons such as nausea, dysphagia, intestinal obstruction, weakness or coma, a syringe driver should be considered. In the UK, there are two main types of syringe drivers: Graseby MS16A (blue) and Graseby MS26 (green). The delivery rate for the former is given in mm per hour, while the latter is given in mm per 24 hours.

Most drugs are compatible with water for injection, but for certain drugs such as granisetron, ketamine, ketorolac, octreotide, and ondansetron, sodium chloride 0.9% is recommended. Commonly used drugs for various symptoms include cyclizine, levomepromazine, haloperidol, metoclopramide for nausea and vomiting, hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide for respiratory secretions/bowel colic, midazolam, haloperidol, levomepromazine for agitation/restlessness, and diamorphine as the preferred opioid for pain.

When mixing drugs, diamorphine is compatible with most other drugs used, including dexamethasone, haloperidol, hyoscine butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide, and midazolam. However, cyclizine may precipitate with diamorphine when given at higher doses, and it is incompatible with a number of drugs such as clonidine, dexamethasone, hyoscine butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, and sodium chloride 0.9%.

Superior Vena Cava Obstruction: A Potentially Urgent Condition

Superior vena cava obstruction is a rare but serious condition that requires prompt treatment. Although it is not immediately life-threatening, it can cause swelling of the face and fixed elevation of the jugular venous pulse. In the UK, lung cancer is the most common cause, but lymphoma can also be a factor.

Treatment options may include steroids or stenting, but in a primary care setting, the first step is to admit the patient as an emergency for further investigation and treatment. It is important to act quickly to prevent any potential complications and ensure the best possible outcome for the patient.

Understanding Myasthenia Gravis

Myasthenia gravis (MG) is a possible diagnosis for a patient with slowly progressive proximal myopathy and a history of autoimmunity. The main symptoms are proximal muscle weakness and ptosis, without muscle wasting or fasciculation. Sensation is unimpaired, and tendon reflexes are normal. Anti-acetylcholine receptor antibodies are found in 85% of patients with generalised myasthenia. Treatment involves acetylcholinesterase inhibitors and oral corticosteroids.

Other conditions, such as Lambert-Eaton syndrome, myotonic dystrophy, motor neurone disease, and Guillain-Barré syndrome, have different presentations and are unlikely to be the cause of the patient’s symptoms. It is important to consider all possible diagnoses and conduct appropriate tests to ensure an accurate diagnosis and effective treatment.

Palliative Care for Chronic Obstructive Pulmonary Disease (COPD)

It is important to note that palliative care is not just for cancer patients but also for those with chronic conditions that progress to end stage terminal disease, such as Chronic Obstructive Pulmonary Disease (COPD). COPD patients may experience intractable cough and breathlessness despite home oxygen, nebulised bronchodilators/saline, and maximal inhaled treatment. Shortness of breath can be due to various factors, including anxiety.

To ensure an acute problem has not developed, it is crucial to examine the patient. Nebulisers and oxygen can be helpful, and non-pharmacological strategies such as relaxation techniques and breathing exercises may be of use. Oral medications, such as opioids and benzodiazepines, can palliate symptoms of breathlessness. Oral morphine is the preferred opioid, starting at a dose of 2.5-5 mg every four to six hours. Morphine reduces respiratory drive and the sensation of breathlessness.

In addition to breathlessness, COPD patients may also experience an intractable cough. Moist inhalations and regular use of oral morphine can help alleviate this symptom. Dexamethasone can be useful in certain situations, such as superior vena caval obstruction and tumour oedema in patients with an underlying malignancy. Diazepam and lorazepam are useful in treating breathlessness, especially if anxiety symptoms are prominent. Hyoscine hydrobromide is useful in treating excessive respiratory secretions. Methadone linctus can treat cough but should be avoided due to its long half-life and tendency to accumulate.

In summary, palliative care for COPD patients involves a comprehensive approach to alleviate symptoms such as breathlessness and cough. Oral morphine is a preferred medication for both symptoms, and non-pharmacological strategies can also be of use.

The Gold Standards Framework: A Framework for Anticipatory End-of-Life Care

The Gold Standards Framework (GSF) was originally designed for use in primary care, but has since been adapted for use in care homes and nursing homes. Its anticipatory approach to care has been shown to have positive effects on pain and symptom control, and improved planning has helped to prevent some hospital admissions. The GSF is not a prescriptive model, but rather a framework that can be tailored to meet local needs and resources. It can also be adapted for patients with non-cancer diagnoses who require end-of-life care. Ultimately, the GSF aims to help patients live and die well in their preferred place of care.

Converting Oral Morphine to Subcutaneous Infusion

In order to convert oral morphine to a 24 hour subcutaneous infusion of morphine, the total 24 hour oral dose must be calculated. For example, if the patient is taking a 12 hour release preparation of 60mg, the total daily dose of oral morphine is 120mg. To convert this to a 24 hour subcutaneous infusion of morphine, the figure must be divided by two. For diamorphine, the figure would be divided by three. Therefore, the patient needs 60mg morphine over 24 hours.

It is important to note that the question asks for the volume of morphine over 24 hours, not the dose. If the ampoules are 10 mg/ml, then to deliver 60mg in 24 hours, 6 x 10 mg/ml = 6 ml is needed. It is crucial to read the question carefully to ensure the correct answer is given.