Managing Malodorous Fungating Tumours with Metronidazole

Fungating tumours require meticulous nursing care, including regular dressings and frequent monitoring. However, in cases where the tumour emits a foul odour, additional measures may be necessary. Metronidazole is a medication that can be used to reduce malodour in these instances. It can be administered both systemically and topically, with the latter being the preferred method.

Topical metronidazole is typically applied to the wound once or twice a day. This medication has been found to have good activity against anaerobic bacteria, which are often responsible for the unpleasant odour associated with fungating tumours. Other treatment options are unlikely to be effective in managing malodour in these cases.

In summary, managing malodorous fungating tumours requires a comprehensive approach that includes good nursing care and the use of appropriate medications such as metronidazole. By following these guidelines, patients can experience improved quality of life and greater comfort during their palliative care journey.

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.

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.

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 the Potencies of Opioid Analgesics

It is crucial to have a good understanding of the relative potencies of opioid analgesics as patients may need to switch from one opioid to another or from one route of administration to another.

Codeine is the weakest opioid on the list and is often prescribed alone or in combination with paracetamol in co-codamol preparations.

Oxycodone is twice as potent as oral morphine salts for the same dose. When converting between the two, the dose of oral morphine needs to be halved to provide the equivalent dose of oxycodone.

Diamorphine is the most potent opioid listed and is typically administered subcutaneously to palliate terminal symptoms. To convert from oral morphine to subcutaneous diamorphine, the 24-hour oral morphine dose should be divided by 3 to give an approximate equivalent 24-hour dose of diamorphine. To convert from oral oxycodone to subcutaneous diamorphine, the 24-hour oxycodone dose should be divided by 1.5. For example, oxycodone 7.5 mg equals 5 mg diamorphine.

Understanding the potencies of opioid analgesics is essential for healthcare professionals to provide safe and effective pain management for their patients.

Interpreting Blood Test Results: A Case Study of Hypercalcaemia

The patient’s blood test results show a serum calcium concentration of 3.42 mmol/l, indicating hypercalcaemia most likely caused by cancer. This constitutes an emergency, and the patient should be immediately offered admission to the hospital. Intravenous fluids and bisphosphonates are the usual management for hypercalcaemia. The other blood test results, including alanine aminotransferase, potassium, sodium, and urea, are all within normal limits or near the upper end of the reference range and are not a cause for concern. This case study highlights the importance of recognizing significant abnormalities in blood test results, especially in emergency situations.

It is probable that the patient passed away due to the initial fall, which necessitates referral to the coroner as per the guidance that mandates all deaths related to injury or poisoning.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

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 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

When it comes to palliative care, the type of antiemetic used should be based on the underlying cause of nausea. For instance, if the cause is gastric dysmotility and stasis, dopamine (D2) receptor antagonists like metoclopramide would be appropriate. On the other hand, cyclizine can be used to treat nausea that is related to movement by blocking signals from the vestibular apparatus in the middle ear that trigger the vomiting center. In John’s case, his symptoms suggest gastric stasis, and therefore, metoclopramide would be a suitable option to alleviate his symptoms.

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.

In recent years, the issue of assisted suicide has gained relevance as UK patients have been travelling to Switzerland ‘Dignitas’ clinic. However, aiding someone to commit suicide is currently illegal. As a healthcare professional, it is important to address the patient’s fears about the terminal phase and discuss the advancements in palliative care. It may also be helpful for the patient to speak with others who have gone through similar experiences for reassurance. If the patient still insists on travelling to Switzerland, it is necessary to inform them of the legal implications of aiding suicide by providing information about appropriate clinics. It is important to note that the ‘double-effect’ principle only applies to accepting the side-effects of pain relief and not to intentionally hastening death. Implying otherwise is inappropriate.

Acute Personality Change in Lung Cancer Patients: A Possible Sign of Cerebral Metastases

When a patient with known lung cancer experiences an acute personality change, it is important to consider the possibility of cerebral metastases. While depression associated with the condition may be a factor, an abrupt shift in behavior without an obvious trigger warrants immediate specialist assessment. This was the case for a real patient with lung cancer who presented with withdrawal and quietness, and was found to have brain metastases on CT imaging.

According to a review of psychiatric aspects of brain tumors, changes in behavior and personality are common in patients with cerebral metastases. These changes can include depression, anxiety, irritability, and apathy. It is important for healthcare providers to be aware of these potential symptoms and to promptly refer patients for further evaluation and treatment. By doing so, patients can receive appropriate care and support to manage their condition and improve their quality of life.

Mental Health Issues in Young Cancer Patients: Understanding the Symptoms

Young cancer patients often experience mental health issues that can affect their treatment, survival, and quality of life. Depression and anxiety are common, affecting up to 20% and 10% of patients, respectively. In diagnosing major depression, symptoms such as depressed mood, diminished interest in activities, and significant weight changes are present. Brain metastases typically present with symptoms such as headaches, seizures, or neurological disease, which this patient doesn’t have. Acute psychotic reactions involve symptoms of delusions, hallucinations, or thought disorders, which are not present in this case. Phobic anxiety disorder involves anxiety out of proportion with the threat posed, which is not present in this patient. PTSD involves recurrent intrusive thoughts about a traumatic event, which this patient doesn’t exhibit. Understanding these symptoms can help healthcare professionals provide appropriate support and treatment for young cancer patients with mental health issues.

If a doctor has not examined the deceased within 28 days prior to their death, the case must be referred to the coroner. This time frame was extended from 14 days due to the COVID pandemic.

While it may be appropriate to list myocardial infarction as the cause of death in section 1a, the GP is not authorized to issue the death certificate in such cases. It is generally not recommended to cite old age as the cause of death.

Only a medical practitioner who is registered can complete a death certificate.

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 Lasting Power of Attorney for Health and Welfare

Lasting Power of Attorney (LPA) for Health and Welfare is a legal document that allows a person to appoint one or more attorneys to make decisions on their behalf when they are unable to do so themselves. This LPA can only be invoked when the donor loses mental capacity, which may occur if they have a living will or have been sectioned.

It is important to note that the LPA for Health and Welfare doesn’t give the attorney the right to make decisions about pensions and benefits. For such decisions, a separate LPA for Property and Financial Affairs must be considered.

Once registered, the appointed attorney can make decisions about the donor’s health and care. It is not necessary for the appointed attorney to be a family member; they can be a friend, relative, or even a professional such as a solicitor.

It is also important to renew the LPA every 12 months. The LPA will endure unless revoked by the donor while they still have mental capacity, revoked by the attorney, the donor loses mental capacity, they divorce or end a civil partnership, or they pass away.

In summary, understanding the LPA for Health and Welfare is crucial for ensuring that a person’s wishes are respected and their best interests are protected when they are unable to make decisions for themselves.

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.

Regular review of pain management is crucial in palliative care patients, especially if rescue analgesia is needed frequently. Each patient should be assessed individually, taking into account factors such as pain relief efficacy, adverse effects, and patient preference. For opioid-naïve patients, a safe starting dose of morphine is between 20-30 mg daily, while patients switching from a regular weak opioid can start with 40-60 mg daily. The dose can be given as an immediate-release preparation every four hours or as a modified-release preparation every 12 hours, with additional rescue doses for breakthrough pain. Dose adjustments should be made based on the number of rescue doses required and the patient’s response to them, with increases not exceeding one-third to one-half of the total daily dose every 24 hours. Adjuvant analgesics can also be considered during dose titration. Oxycodone can be used as an alternative to morphine for patients who cannot tolerate it, with a conversion rate of 6.6mg orally to 10 mg of oral morphine. Subcutaneous infusion may be necessary if swallowing is an issue. The equivalent dose of morphine is about half the daily oral requirement, and for diamorphine, one third. A ceiling of morphine immediate-release 30 mg every four hours (or modified-release 100 mg every 12 hours) is usually sufficient for most patients, although higher doses may be necessary in some cases.

Managing Pruritus in Palliative Care Patients: Causes and Treatment Options

Pruritus, or severe itching, is a common symptom in palliative care patients with advanced disease. It can be caused by various factors such as uraemia, cholestasis, opioids, solid tumors, and hematologic disorders. Dry skin is also a common accompanying factor in all causes of pruritus. Therefore, regular skin lubrication is a crucial part of managing pruritus in palliative care patients.

Topical agents such as levomenthol cream, lidocaine ointment, capsaicin, and topical corticosteroids can also be helpful in managing pruritus. However, the use of H1 receptor antagonists (antihistamines) is not always effective as they only work in cases where histamine release occurs in the skin, which is not the primary cause of pruritus in palliative care patients.

Cholestasis is one of the causes of pruritus, but the pathogenesis is still unclear. Lowering the level of bile acids with cholestyramine is often ineffective as there is no correlation between the level of bile acids and the severity of pruritus. Serotonin may have a role in pruritus secondary to malignant disease, cholestasis, uraemia, and opioids. Therefore, medications such as paroxetine, mirtazapine, and ondansetron can be used to manage pruritus in palliative care patients.

In conclusion, managing pruritus in palliative care patients requires a comprehensive approach that addresses the underlying causes and provides symptomatic relief. Regular skin lubrication and the use of topical agents and medications such as paroxetine, mirtazapine, and ondansetron can be helpful in managing pruritus in palliative care patients.

Causes and Treatment of Excessive Sweating in Advanced Cancer Patients

Excessive sweating is a common issue among patients with advanced cancer, and it can be caused by various factors. One of the main causes is sex hormone suppression, which is a common treatment for cancer. However, other factors such as infection, lymphoma, widespread cancer, and medication (such as SSRI antidepressants, hormone therapies, and opioids) can also contribute to excessive sweating.

Endocrine issues such as oestrogen deficiency, androgen deficiency, hypoglycaemia, and hyperthyroidism can also cause excessive sweating. Autonomic neuropathy is another potential cause.

To alleviate excessive sweating, patients can try reducing the room temperature, removing excess bedding and clothing, increasing ventilation, and using a fan. If necessary, patients can seek advice from their oncologist about hormone replacement therapy using diethylstilboestrol.

Clinical Indicators for End-of-Life Care in Various Conditions

The Gold Standards Framework (GSF) Prognostic Indicator Guidance provides specific clinical indicators for various conditions that suggest the patient is approaching the end of life. For motor neurone disease, the indicators include marked rapid decline in physical status, first episode of aspiration pneumonia, increased cognitive difficulties, weight loss, significant complex symptoms and medical complications, low vital capacity, dyskinesia, mobility problems, falls, and communication difficulties. Lack of improvement three months after a stroke is an indicator for someone with severe paralysis. Wheelchair-bound multiple sclerosis patients may have quite a long life. Frail elderly people with co-morbidities may experience significant weight loss, but it needs to be accompanied by deteriorating function or at least two of weakness, slow walking speed, low physical activity, exhaustion, or depression. For patients with heart failure, repeated hospital admissions carry prognostic significance. These indicators can help healthcare professionals provide appropriate end-of-life care for patients with various conditions.

Old age or frailty due to old age can only be listed as the cause of death if specific criteria are fulfilled. These include personally caring for the deceased over a long period, observing a gradual decline in their health and functioning, not being aware of any identifiable disease or injury contributing to the death, being certain that there is no other reason to report the death to the procurator fiscal, and the patient being 80 years or older. Other options such as terminal events or vague phrases like cardiovascular event are not appropriate as they do not identify a specific disease or pathological process.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

Starting Strong Opioids for Pain Management

When beginning strong opioids for pain management, it is recommended to use regular oral sustained-release or immediate-release morphine, depending on the patient’s preference. Immediate-release morphine can be used as needed for breakthrough pain, but it should not replace regular oral morphine. For patients without renal or hepatic comorbidities, a typical starting dose of 20-30 mg of oral morphine per day is recommended. This can be divided into two doses of sustained-release morphine or taken as 5mg of immediate-release morphine every 4 hours. However, patients switching from a weak opioid may require a higher starting dose of 40-60mg per day.

If oral opioids are not suitable, transdermal patches or subcutaneous infusions can be used as an alternative. In most cases, a general practitioner should not require specialist advice at this stage of pain management.

The Ethics of Palliative Sedation: Applying the Doctrine of Double Effect

The use of palliative sedation raises ethical concerns regarding the distinction between symptom relief and euthanasia. While the former aims to alleviate suffering, the latter involves the intentional hastening of death. The doctrine of double effect provides a framework for evaluating the ethical implications of palliative sedation.

The doctrine of double effect consists of four conditions that can be applied to the use of palliative care. Firstly, the act itself must be morally neutral or good, such as the administration of medication for pain or sedation. Secondly, the intention of giving medication should be to produce a good effect, such as relief of pain or suffering, even if a harmful effect, such as death, is likely in some cases. Thirdly, the good effect should not be brought about by means of the bad effect. Finally, there must be proportionality between the good and bad effects, meaning that the relief of suffering must be significant enough to justify the potential harm caused by the medication.

In summary, the doctrine of double effect provides a useful framework for evaluating the ethical implications of palliative sedation. It emphasizes the importance of intention, proportionality, and the distinction between symptom relief and euthanasia.

Continuous Subcutaneous Infusions in Palliative Care: Medications to Consider and Avoid

Continuous subcutaneous infusions are a popular method of delivering medications in palliative care when other modes of delivery are no longer suitable. This method involves administering medication into the fatty tissue under the skin, providing constant dosing over a calculated period of time. Commonly used drugs include opioids, antiemetics, anticholinergics, sedatives, and others such as dexamethasone, ketorolac, ketamine, and octreotide. However, some medications are not suitable for subcutaneous infusion. Amoxicillin can damage tissue and is unlikely to have a role in end-of-life care. Chlorpromazine and prochlorperazine must not be given by this route as they may cause tissue necrosis. Diazepam can also cause tissue necrosis and should be avoided, with midazolam being the preferred benzodiazepine for subcutaneous infusion if needed. It is important to consider the suitability of medications for continuous subcutaneous infusion in palliative care to ensure safe and effective treatment.

Understanding Equivalent Morphine Dose for Codeine Patients

When prescribing pain medication, it is important to consider the equivalent morphine dose for patients taking codeine. This can be calculated by dividing the dose of codeine by 10. For example, a patient taking 60 mg of codeine four times a day would have a total daily dose of 240 mg, which is equivalent to 24 mg of morphine.

Failing to consider the equivalent morphine dose can result in inadequate pain relief for the patient. It is important to note that some patients may metabolize codeine at different rates, but this should not be a major concern in most cases. The majority of patients are normal metabolizers, converting 10% of codeine to morphine.

Overall, understanding the equivalent morphine dose for codeine patients is a crucial aspect of pain management and should be taken into consideration when prescribing medication.

The Gold Standards Framework (GSF) Prognostic Indicator Guidance aims to identify patients who are nearing the end of their life. The first step is to ask the surprise question to determine if the doctor would be surprised if the patient were to die in the next few months, weeks, or days. If the answer is no, measures should be taken to improve the patient’s quality of life. If the answer is yes, two further steps outline general indicators of decline and specific indicators for different diseases. For COPD, at least two of the following indicators should be present: severe disease, recurrent hospital admissions, long-term oxygen therapy criteria, MRC grade 4/5, signs and symptoms of right heart failure, combination of other factors, or more than six weeks of systemic steroids for COPD in the preceding six months.

Principles for End-of-Life Decision Making

When making decisions regarding end-of-life care, it is important to adhere to certain principles. These principles include equality and human rights, which dictate that patients approaching the end of their life should receive the same quality of care as all other patients. Additionally, there should be a presumption in favor of prolonging life, meaning that decisions about potentially life-prolonging treatments should not be motivated by a desire to bring about the patient’s death. It is also important to presume capacity in terminally ill patients and to maximize their capacity to make decisions through shared decision making. Finally, when a patient lacks capacity, the overall benefit of a potentially life-prolonging treatment must be weighed against the burdens and risks for the patient, with consultation from those close to the patient. By following these principles, end-of-life decisions can be made with the patient’s best interests in mind.

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.

Cyclizine is a recommended first-line anti-emetic for nausea and vomiting caused by intracranial or intra-vestibular issues, as well as for managing gastrointestinal obstruction in palliative care. Domperidone is effective for gastro-intestinal pain in palliative care, as it stimulates gastric muscle contraction by blocking dopamine inhibition. Metoclopramide is useful for acute migraine, chemotherapy or radiotherapy-induced nausea and vomiting, but is unlikely to relieve nausea related to increased intracranial pressure. Ondansetron is indicated for preventing and treating chemotherapy-related nausea and vomiting. Dexamethasone is often the first choice steroid in palliative care, as it can treat multiple symptoms including nausea, anorexia, spinal cord compression, and liver capsule pain. If the patient’s nausea is due to raised intracranial pressure, cyclizine should be the first-line option, but dexamethasone may also be considered as an additional treatment.

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.

Reporting to the coroner is necessary when a patient dies by suicide, as none of the other options meet the reporting criteria outlined in the notes.

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.

Opioid Prescription Guidelines

About 10-30% of patients cannot use morphine due to side effects or poor analgesic response. However, oxycodone is not shown to have fewer unwanted effects than morphine. On the other hand, hydromorphone is seven times more potent than morphine on a mg for mg basis. Fentanyl should only be used second line, and when a daily requirement is established.

To ensure safe and appropriate opioid prescription, it is important to remember the STOPP criteria. Prescription is potentially inappropriate if a strong, oral or transdermal opioid (i.e. morphine, oxycodone, fentanyl, buprenorphine, diamorphine, methadone, tramadol, pethidine, pentazocine) is prescribed as first-line therapy for mild pain (WHO analgesic ladder not observed). Additionally, regular use without concomitant laxative can lead to severe constipation. Lastly, prescribing a long-acting (modified-release) opioid without a short-acting (immediate-release) opioid for breakthrough pain can result in the persistence of severe pain.

It is important to follow these guidelines to ensure the safe and effective use of opioids in pain management.

Opioid Toxicity and Pain Management in MRCGP Curriculum

Pinpoint pupils, confusion, nightmares, agitation, hypotension, depressed respiration, and myoclonus are all indicative of opioid toxicity. It is important to recognize these symptoms as they can be life-threatening. As part of the MRCGP curriculum, it is essential to have a thorough understanding of pain management, including the most commonly used drugs and any potential adverse effects or interactions. This knowledge will enable healthcare professionals to provide effective pain relief while minimizing the risk of opioid toxicity. Therefore, it is crucial to prioritize this aspect of the curriculum to ensure that doctors are equipped to manage pain in their patients safely and effectively.

Chlorine salicylate gel

Managing Dyspnoea in Terminally Ill Patients: Treatment Options

Dyspnoea is a common symptom in terminally ill patients and can significantly impact their quality of life. When managing dyspnoea, it is important to identify and treat any reversible causes, such as cardiac failure or pneumonia. However, in cases where the cause cannot be reversed, there are several treatment options available.

One such option is the use of opioids, such as morphine, which can reduce breathlessness at rest and in the end-of-life phase. A therapeutic trial should be given, and the patient should be monitored for response and side-effects. If morphine is not tolerated, alternative opioids can be used.

Dexamethasone is another option, particularly in cases of lymphangitis carcinomatosis and superior vena cava airway obstruction. It reduces inflammatory oedema and can also be used post-radiotherapy.

Furosemide is not likely to be of benefit unless there is evidence of cardiac failure.

Lorazepam, a benzodiazepine, may relieve anxiety and panic associated with severe breathlessness, but it is less effective than opioids and should be considered a second-line treatment.

Finally, if oxygen saturations are below 92%, a trial of oxygen can be considered for symptom relief. However, it is important to note that there may be a poor relationship between hypoxaemia, dyspnoea, and response to oxygen.

In conclusion, managing dyspnoea in terminally ill patients requires a multi-faceted approach, including identifying and treating reversible causes and utilizing appropriate medications for symptom relief.

Considerations for a Patient with Metastatic Cancer and Acute Change in Mental Status

A variety of factors need to be considered when a patient with metastatic cancer presents with an acute change in mental status. In this scenario, potential causes such as infection, hypercalcaemia, and brain metastases should be ruled out. It is also important to review the patient’s drug history to rule out any iatrogenic causes.

In this case, the patient’s observations, including temperature, pulse rate, and blood pressure, are normal, and there are no signs of infection. The urine dipstick test doesn’t reveal any significant abnormalities. The symptoms are also not consistent with hypercalcaemia.

However, the patient’s acute change in mental status with disinhibition requires urgent referral to the hospital and a CT head scan to look for frontal lobe metastases. A full ‘confusion’ screen would also be carried out to further investigate the underlying cause.

In summary, when a patient with metastatic cancer presents with an acute change in mental status, a thorough evaluation of potential causes is necessary to ensure appropriate management and treatment.

In this scenario, the BNF suggests administering half the usual oral dose of morphine.

When morphine is given through injection (subcutaneous, intramuscular, or intravenous), the recommended dose is approximately half of the oral dose. If the patient is no longer able to swallow, a continuous subcutaneous infusion of morphine is typically used.

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.

Hypercalcaemia: Symptoms, Complications, and Treatment Options

Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. This condition can cause a range of symptoms, including constipation, nausea, polyuria, confusion, depression, lethargy, weakness, and bone pain. In chronic cases, hypercalcaemia can lead to the formation of renal stones. If left untreated, calcium levels greater than 3.5 mmol/l can cause renal failure and arrhythmias.

The treatment of hypercalcaemia involves identifying and removing the underlying causes, rehydration, and, if necessary, the use of bisphosphonates. In cases where primary hyperparathyroidism is the cause, surgical treatment may be necessary.

In summary, hypercalcaemia is a serious medical condition that can cause a range of symptoms and complications. Early diagnosis and treatment are essential to prevent further health problems.

When an individual’s life expectancy is less than 6 months, a DS1500 form is filled out to expedite the process of receiving benefit payments.

Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.

Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.

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.

Recognizing the Signs of Dying: What to Look For

Recognizing the signs of dying is crucial in providing appropriate care for patients and their caregivers during the end-of-life phase. This final phase can last for hours or even days, and patients may exhibit several signs that indicate they are nearing death.

One of the most common signs is a gradual deterioration in their condition, which may occur over several days or even more rapidly. Patients may also experience reduced mobility and become increasingly fatigued without any apparent cause. They may also become aware of their impending death and express this to their caregivers.

Other signs include reduced cognition, difficulty communicating, and social withdrawal. Patients may also experience a decline in their level of consciousness, become delirious, and become bed-bound. They may also have difficulty taking food, fluids, and oral medication.

As death approaches, patients may exhibit peripheral cyanosis, mottled skin, and feel cold to the touch. They may also experience episodes of apnea or Cheyne-Stokes breathing.

While the four incorrect options may also be present near death, they do not necessarily indicate that death is imminent. However, recognizing the signs of dying can help caregivers provide appropriate care and support during this difficult time.

If a patient or their representative believes that the patient may have a terminal illness, they can request a form DS1500 to be issued. According to Social Security legislation, a terminal illness is a disease that is advancing and is expected to result in death within six months.

Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.

Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.

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.

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.

Bicalutamide and its Side Effects According to BNF

Bicalutamide is a medication used to treat locally advanced prostate cancer at high risk of disease progression. The British National Formulary (BNF) lists the frequency of side effects, with hepatic disorders (including jaundice) being among the most common. Photosensitivity reactions are rare or very rare, while renal failure is not listed as a side effect in the BNF, although haematuria can occur less commonly. Therefore, clinicians are advised to consider periodic liver function tests for patients undergoing bicalutamide treatment. The RCGP may set questions based on the BNF for the AKT, testing candidates’ knowledge of less well-known medication side effects.

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.

Considerations for Drug Delivery in Palliative Care

Drug delivery is a crucial aspect to consider in palliative care, as patients may have difficulties with certain formulations or preparations. For instance, some patients may have trouble swallowing medication due to dysphagia, while others may be intolerant to specific preparations. In such cases, transdermal fentanyl and buprenorphine can be used as alternatives.

However, it’s important to note that transdermal preparations may not be suitable for patients who require treatment for acute pain or those with variable pain relief needs. This is because the route of administration affects the pharmacokinetics, resulting in a delay in achieving a steady state.

When switching from oral morphine preparations to transdermal fentanyl, the British National Formulary (BNF) provides a section on equivalent doses. For example, 60 mg daily of oral morphine equates to the fentanyl ’25’ patch. However, if the opioid problem is hyperalgesia, it’s recommended to cut the dose of the new opioid by one quarter to one half of the equivalent dose.

It’s essential to consult the palliative care section in the BNF for further details on other dose equivalencies. Fentanyl patches should be applied every 72 hours, and patients may require extra analgesia for up to 24 hours after the patch is started due to its slow onset of action. Doses of the patch can be adjusted at 72-hour intervals.

If a patient is taking a long-acting 12-hourly morphine, the patch should be applied when the last dose is given. On the other hand, if a patient is taking a short-acting morphine, it should be continued four hourly for the first 12 hours of patch use. By considering these drug delivery factors, healthcare professionals can provide effective pain relief for patients in palliative care.

Managing Constipation in Palliative Care

Constipation is a common problem in palliative care, often caused by the use of opioid analgesics. To prevent constipation, laxatives should be co-prescribed with opioids. A combination of a faecal softener and a peristaltic stimulant, such as co-danthramer, is ideal. Alternatively, a stool softener like docusate sodium can be combined with a stimulant laxative like a senna preparation. PRN suppositories are not recommended for regular use. Lactulose can be used in combination with senna, but some sources advise against it due to its side effects. Methylnaltrexone bromide is indicated for opioid-induced constipation in terminally ill patients who do not respond to other laxatives. Prucalopride is not a palliative care medication and is only licensed for treating chronic constipation in women who have not found relief from other laxatives and lifestyle changes.

In summary, managing constipation in palliative care requires a combination of preventative measures and appropriate medication. Co-prescribing laxatives with opioids is essential, and a combination of a faecal softener and a peristaltic stimulant is ideal. Methylnaltrexone bromide can be used in terminally ill patients who do not respond to other laxatives. Prucalopride is not a palliative care medication and is only licensed for treating chronic constipation in women who have not found relief from other laxatives and lifestyle changes.

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.

Managing Haemoptysis in Terminal Lung Cancer Patients

Haemoptysis is a common symptom experienced by 20-30% of patients with lung cancer, with 3% experiencing massive haemoptysis as a terminal event. The management of haemoptysis in terminal lung cancer patients depends on the volume of blood loss, its cause, and prognosis.

For massive haemoptysis, intramuscular or intravenous morphine and midazolam are indicated, and the use of dark-coloured towels can mask blood. For smaller, self-limiting haemorrhage, tranexamic acid 1 g three times a day can often be effective.

In this scenario, there is no information to suggest a cause other than tumour progression, so tranexamic acid is the correct answer. It would be reasonable to try tranexamic acid first before considering radiotherapy.

In the secondary care setting, protamine is given intravenously as a reversal agent to heparin, should this be required. However, it is not usually used in the community.

Overall, managing haemoptysis in terminal lung cancer patients requires careful consideration of the individual’s situation and needs.

Drug Calculation Learning Point

When it comes to drug calculations, it’s important to be careful and avoid getting caught out. One common scenario is converting a patient from oral medication to a subcutaneous infusion as their disease progresses. However, it’s also important to be able to take patients off a syringe driver and back on to oral medication. In this case, the total daily dose of diamorphine via syringe driver is one-third of the total oral dose of morphine. It’s easy to get the calculation the wrong way around, so it’s crucial to be familiar with this learning point.

For example, if a patient is having 30 mg of diamorphine over 24 hours, the total 24-hour oral dose of morphine would be 30 mg x 3 = 90 mg oral morphine. This is a common area of weakness in the AKT exam, and examiners have highlighted it as an area of poor performance. Therefore, it’s essential to practice this calculation repeatedly during revision time to ensure a thorough understanding of the concept.