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.

Medication Options for Delirium in Palliative Care

When managing delirium in palliative care patients, it is important to consider the appropriate medication options. For a patient experiencing symptoms of delirium, such as confusion and agitation, the National Institute for Health and Care Excellence (NICE) recommends the use of haloperidol. The initial dose should be 0.5-1.0 mg at night and every two hours as needed, with the option to increase the dose in 0.5-1.0 mg increments up to a maximum of 10 mg per day (or 5 mg per day for elderly patients).

While benzodiazepines may be used for delirium management, temazepam and diazepam are not recommended by NICE. Instead, lorazepam would be the preferred benzodiazepine option. Zopiclone, a hypnotic used for insomnia, is not indicated for delirium treatment in palliative care.

It is important to consider the patient’s ability to take medication orally and the availability of a syringe driver when selecting a medication option. Administering subcutaneous medication may delay the management of delirium if the patient is still able to take medication orally.

Causes of Pathological Fractures in the Elderly

Pathological fractures are fractures that occur due to weakened bones caused by underlying medical conditions. While any type of bone tumour can cause pathological fractures, the majority of cases in the elderly are due to metastatic carcinomas. This is because as people age, their risk of developing cancer increases. Multiple myeloma, a type of cancer that affects the bone marrow, is also common in the elderly and has a high incidence of pathological fractures. Lymphoma, although uncommon, can also cause pathological fractures.

It is important to keep this information in mind when evaluating elderly patients who present with musculoskeletal problems such as shoulder or back pain. A thorough medical history and physical examination can help identify the underlying cause of the fracture and guide appropriate treatment. By understanding the common causes of pathological fractures in the elderly, healthcare providers can provide better care and improve patient outcomes.

Managing Symptoms in Patients with Metastatic Cancer: Considerations for Prescribing Anti-Inflammatory Medications

When managing symptoms in patients with metastatic cancer, it is important to consider the potential side effects of medications. For example, if a patient has angina, prescribing an anti-inflammatory medication should take into account their cardiac risk to avoid thrombotic complications that could cause additional pain and suffering.

Cyclo-oxygenase-2 selective inhibitors (COX-2 inhibitors) carry an increased risk of myocardial infarction and stroke and should only be used over non-steroidal anti-inflammatory drugs (NSAIDs) if specifically indicated. However, even among NSAIDs, there is variation in terms of thrombotic risk. Diclofenac at 150 mg daily and high dose ibuprofen at 2.4 g daily are linked with an increased thrombotic risk, while naproxen 1 g daily and lower doses of ibuprofen (=<1.2 g daily) have not been shown to be associated with an increased risk of myocardial infarction. Therefore, when prescribing anti-inflammatory medications for patients with metastatic cancer, it is important to consider their individual cardiovascular risk and choose the medication with the best safety profile. The lowest effective dose of NSAID should be prescribed for the shortest period of time to control symptoms, and the need for long-term treatment should be reviewed periodically.

Treatment Options for Persistent Hiccups

Persistent hiccups can be troublesome for some patients and are often difficult to treat. However, there are several simple manoeuvres that can be tried, such as sipping cold water, breath-holding, and the Valsalva manoeuvre. If hiccups are due to gastric distention, an antacid may help. If these options fail, metoclopramide or domperidone are usually the next treatment options. Baclofen, nifedipine, and chlorpromazine are third-line options that can be tried if the hiccups persist. Haloperidol may also be effective and better tolerated than chlorpromazine. In this case, trying an antacid and antiflatulent preparation is a suitable first-line option as the symptoms are of recent onset and no pharmacotherapy has been tried so far.

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.

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.

Ethical Considerations in End-of-Life Care

End-of-life care can present complex ethical dilemmas for healthcare professionals. Here are some important considerations:

– Advanced Requests: Patients can make advanced requests for treatments they fear may be denied to them. While these requests cannot bind future decisions, they must be given weight by decision-makers if the patient has lost capacity.
– Religious Beliefs: A doctor cannot withdraw from providing care because their religious beliefs conflict with a patient’s refusal of treatment. However, if their beliefs conflict with a decision about overall benefit, arrangements must be made for another doctor to take over.
– Decision-Making: Patients with capacity may devolve decision-making to their doctor if they find it distressing. However, they still need basic information to give consent to any proposed treatment.
– Starting and Withdrawing Treatment: Emotional distress should not override clinical judgement when deciding whether to start or withdraw treatment.
– Withholding Information: Information about a terminal prognosis should not be withheld unless giving it would likely cause the patient serious harm. Serious harm means more than just upsetting the patient or causing them to refuse treatment.

Overall, ethical considerations in end-of-life care require a delicate balance between respecting patient autonomy and ensuring that decisions are made in the patient’s best interests.

Managing Hypercalcemia in Palliative Care: Admission, Treatment, and Diet Recommendations

Hypercalcemia, a rise in serum calcium levels, can cause a range of symptoms including weakness, anorexia, nausea, and constipation. Severe cases can lead to delirium, seizures, and coma. While some patients may not experience symptoms, hypercalcemia can be an emergency in palliative care. In cases where treatment is not appropriate, fluid replacement and bisphosphonates can alleviate distressing symptoms. However, symptomatic or moderate to severe hypercalcemia requires immediate admission to a hospital or hospice for management with intravenous fluids and bisphosphonates. A low calcium diet is unnecessary, and good hydration is the first-line treatment for mild asymptomatic hypercalcemia. Thiazide diuretics should be avoided as they can exacerbate hypercalcemia, as can lack of mobility.

Causes of Delirium and Terminal Restlessness in End-of-Life Care

Delirium and terminal restlessness are common occurrences in end-of-life care, and there are many different causes that can contribute to these symptoms. Some causes can be easily reversed, while others cannot.

Medications, such as opioids, anti-epileptic drugs, steroids, and anxiolytics, are just a few examples of medications that can cause delirium. Overuse or underuse of medications can also worsen delirium. Additionally, untreated physical pain or discomfort, dehydration, anoxia, anaemia, infections and fevers, brain tumours or swelling, urinary retention, constipation or faecal impaction, fear, anxiety, emotional turmoil, cancer treatments, and metabolic disturbances can all contribute to delirium and terminal restlessness.

To alleviate the distress of terminal confusion and restlessness, haloperidol is often given. This medication has little sedative effect and can help manage these symptoms.

Managing Dry Mouth in Palliative Care

Dry mouth is a common issue in palliative care, with various factors contributing to its development. If oral thrush is present, it should be treated accordingly. However, if there is no infective cause, simple measures such as good mouth care, chewing sugar-free gum, sucking ice cubes, or using artificial saliva can be effective. It is also important to review the patient’s medication, as certain drugs can cause dry mouth as a side effect, including opioids, antiemetics, and antimuscarinic drugs.

In cases where the patient experiences symptoms of retrosternal discomfort and dysphagia, it may suggest candidal oesophagitis with more extensive disease than what is visible in the mouth. In such cases, oral miconazole gel and oral nystatin suspension may not be enough, and systemic treatment with oral fluconazole is necessary. Therefore, managing dry mouth in palliative care requires a comprehensive approach that considers the underlying causes and appropriate treatment options.

Codeine can be converted to morphine by dividing its dosage by 10.

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.

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.

A death should be referred to the coroner if the person who died was not visited by a medical practitioner during their final illness, if the cause of death is unknown, if the death was violent or unnatural, if the death was sudden and unexplained, if a medical certificate is not available, if the person who died wasn’t seen by the doctor who signed the medical certificate within 28 days before death or after they died, if the death occurred during an operation or before the person came out of anaesthetic, or if the medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning.

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.

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.

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.

Recognizing Late Stage Dementia and the Importance of Advance Care Planning

Late stage dementia is characterized by a decline in physical and cognitive abilities, making it difficult for individuals to perform activities of daily living without assistance. Indicators of late stage dementia include urinary and fecal incontinence, inability to walk without assistance, and a lack of meaningful conversation. A Barthel score of less than three is also a sign of late stage dementia. Other signs include weight loss, urinary tract infections, severe pressure sores, recurrent fever, reduced oral intake, and aspiration pneumonia.

It is important to note that a Mini-Mental State examination score of less than 10 indicates severe dementia, but not necessarily that the patient is in decline towards death. However, it is crucial to discuss with dementia patients while they still have mental capacity how they would like the later stages of their care managed. Advance care planning can help ensure that their wishes are respected and that they receive the appropriate care and support during this difficult time.

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.

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.

Several drugs are incompatible with cyclizine when used in syringe drivers.

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%.

Antiemetics in Palliative Care

A variety of antiemetics are used in palliative care to treat nausea and vomiting. However, the underlying cause of the symptoms should be determined to guide which particular treatment is most appropriate. For patients with co-existent vertigo, an antiemetic with antihistamine properties such as cyclizine is most suitable as it also has actions against vertigo, motion sickness, and labyrinthine disorders.

Nausea and vomiting caused by drugs or toxins and metabolic factors like hypercalcaemia may respond best to haloperidol or levomepromazine. Metoclopramide, a prokinetic, can be useful in treating symptoms due to gastric stasis. On the other hand, ondansetron, a 5-HT3 antagonist, acts at the chemoreceptor trigger zone in the brain and is used as a treatment for emetogenic chemotherapy.

In summary, the appropriate antiemetic for palliative care patients depends on the underlying cause of their nausea and vomiting. Healthcare professionals should consider the patient’s individual needs and symptoms when selecting the most suitable treatment.

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.

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.

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 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.

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.

Beta-blockers and Anxiety Symptoms

Beta-blockers are effective in managing the autonomic symptoms of anxiety, such as tremors and palpitations. However, they are not likely to alleviate the psychological symptoms of anxiety. While beta-blockers may help with physical symptoms, other approaches may be necessary to address the emotional and cognitive aspects of anxiety. Therefore, it is important to consider a comprehensive treatment plan that includes therapy, medication, and lifestyle changes to manage anxiety effectively.

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.

Treatment Options for Seizures in Palliative Care

In palliative care, patients may experience seizures which can be distressing for both the patient and their family. To prevent further fits and provide symptom palliation, treatment is necessary. However, the method of administration must be considered as the patient may already be receiving medication via a syringe driver. Oral preparations may not be absorbed adequately, and phenytoin is not the medication of choice in this setting. Benzodiazepines can provide palliation of anxiety, restlessness, and breathlessness, as well as treat seizures. However, intramuscular and rectal administration of medication can be uncomfortable for the patient.

Midazolam is the benzodiazepine antiepileptic of choice for use as a continuous subcutaneous infusion. It is typically administered at initial doses of 20-40 mg over 24 hours. Lorazepam and diazepam also have their roles in palliative care, but they may be preferable in different situations, especially if delivery is by an alternative route to subcutaneous infusion and as required use is indicated for more infrequent symptoms. Overall, the choice of treatment for seizures in palliative care should be carefully considered to ensure the patient’s comfort and well-being.

Anastrozole Side Effects According to BNF

The British National Formulary (BNF) is often used as a reference for setting questions in the AKT exam. One of the topics that may be tested is the side effects of medications. The BNF categorizes side effects based on their frequency, ranging from very common to very rare. Anastrozole is a medication used in the adjuvant treatment of oestrogen-receptor-positive early invasive breast cancer in postmenopausal women. However, it is contraindicated for premenopausal treatment. According to the BNF, bone fractures are common or very common side effects of Anastrozole. On the other hand, vasculitis and angioedema are very rare side effects. Notably, interstitial nephritis and interstitial pneumonitis are not listed as side effects.

Opioid Equivalencies: Understanding Dosage Comparisons

When it comes to managing pain, patients may need to use different routes of administration as their disease progresses. This is where opioid equivalencies come into play. By considering 24 hour dose equivalencies, healthcare professionals can make accurate comparisons between different opioids.

For example, modified-release oral morphine 30 mg BD is equivalent to 60 mg of oral morphine over 24 hours. To convert subcutaneous diamorphine to oral morphine, simply multiply by 3. Therefore, 10 mg (subcutaneously via syringe driver over 24 hours) × 3 = 30 mg of oral morphine over a 24 hour period.

Immediate-release morphine 10 mg QDS is equivalent to 40 mg over a 24 hour period. Oxycodone is twice as strong as oral morphine salts for the equivalent dose, so 10 mg BD of oral oxycodone is equivalent to 40 mg oral morphine over 24 hours.

Transdermal fentanyl patches have equivalencies to oral morphine listed in the BNF for ease of reference. A fentanyl ’12’ patch is equivalent to 30 mg of oral morphine salt a day. Overall, understanding opioid equivalencies is crucial for effective pain management.

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.

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.

Understanding the Risk Factors for Developing Breast Cancer

Breast cancer is a prevalent disease that affects 1.4% of the overall population. However, the risk of developing breast cancer increases with a family history of the disease. The number of affected first-degree relatives and their age at diagnosis can significantly impact the risk. For instance, having one affected first-degree relative increases the risk to 4-5%, while having two close relatives affected raises the risk to 7%.

Women with BRCA1 mutation have a 40% carrier risk of developing carcinoma, while those with BRCA2 have a 25% risk. Additionally, women who have had many ovulations, early menarche, and nullipara are more likely to develop breast cancer. However, the use of the combined oral contraceptive pill is associated with a reduced risk of developing the disease.

In summary, understanding the risk factors for developing breast cancer is crucial in taking preventive measures and seeking early diagnosis and treatment.

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.

Drug Dose Calculations

Calculating drug doses can be a challenging task, especially when it comes to converting between different medications and routes of administration. One common question in medical exams involves calculating the appropriate dose of a medication for a patient.

To answer this question correctly, there are several steps to follow. Firstly, the total oral dose of morphine must be converted to diamorphine. Then, the breakthrough dose of subcutaneous diamorphine must be calculated, not the oral morphine dose.

To calculate the 24-hour dose of diamorphine for a patient, the total daily dose of oral morphine should be divided by 3. For example, if a patient is taking 90 mg of oral morphine over 24 hours, this is equivalent to 30 mg of diamorphine over 24 hours by syringe driver.

According to the BNF, the subcutaneous dose for breakthrough pain should be between one sixth and one tenth of the 24-hour dose. Therefore, for this patient, the correct breakthrough dose of subcutaneous diamorphine would be between 3 mg and 5 mg.

It is important to note that drug dose calculations are a common area of weakness in medical exams. Examiners often include questions on this topic, and it is essential for healthcare professionals to have a good understanding of how to calculate drug doses accurately.

Converting Oral Morphine to SC Diamorphine: A Guide

When converting oral Morphine to SC Diamorphine, it is important to remember that the 24-hour total SC Diamorphine dose required will be approximately one-third of the 24-hour total oral Morphine dose. This means that the ratio of Morphine PO to Diamorphine SC is 3:1.

For example, if a patient is taking MST SR 60 mg bd, which is a total of 120 mg/24 hrs PO, the 24-hour total Diamorphine SC dose required will be 120/3 = 40 mg. It is crucial to double-check the direction of your conversion to avoid calculation errors.

Prescribing medication can be a complex process, and it is important to take the necessary precautions to ensure accuracy and patient safety. By following this guide, healthcare professionals can confidently convert oral Morphine to SC Diamorphine with ease.

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.

Hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide can be used to treat respiratory secretions and bowel colic with syringe drivers.

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%.

As the patient was not examined by a physician during the final 28 days of their illness, it is necessary to report their death.

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.

Interpreting Blood Test Results in Palliative Care Patients

When interpreting blood test results in palliative care patients, it is important to consider the context and urgency of each abnormal result. In this case, the serum calcium level is the most concerning, as it is significantly elevated and could indicate symptomatic hypercalcaemia. Immediate admission to a hospital or hospice is recommended, along with intravenous fluid replacement and bisphosphonate treatment. The alkaline phosphatase level is also elevated, but further investigation is needed to determine the source. The slightly low potassium level can be monitored with routine testing, while the slight hyponatraemia may be normal for the patient or repeated non-urgently. A slightly elevated urea level may indicate mild dehydration or renal impairment, but is not significant enough to require emergency treatment. Overall, careful consideration of each abnormal result is necessary in order to provide appropriate care for palliative care patients.

Understanding the Five Stages of Grief: Insights from Dr. Elisabeth Kübler-Ross

Dr. Elisabeth Kübler-Ross is known for her pioneering work in supporting and counseling individuals experiencing personal trauma, grief, and grieving, particularly in relation to death and dying. Her ideas, particularly the five stages of grief model, have been widely used to help people cope with emotional upheavals resulting from various life events.

The first stage is denial, which involves a conscious or unconscious refusal to accept the reality of the situation. This can be a defense mechanism that some people use to cope with traumatic changes. However, denial can also hinder the healing process if it is not addressed.

The second stage is anger, which can manifest in different ways. People may direct their anger towards themselves or others, especially those close to them. It is important to understand that anger is a natural response to grief and to remain non-judgmental when dealing with someone who is upset.

The third stage is bargaining, which often involves attempting to make deals with a higher power or trying to negotiate a better outcome. However, this rarely provides a sustainable solution for grief.

The fourth stage is depression, which can include feelings of sadness, regret, fear, and uncertainty. It is a sign that the person is beginning to accept the reality of the situation.

The final stage is acceptance, which varies depending on the individual’s circumstances. It is an indication that the person has achieved some emotional detachment and objectivity. People who are dying may enter this stage long before their loved ones, and they must go through their own unique stages of grief.

While Kübler-Ross’s concepts were developed through extensive interviews with dying patients, some have criticized her one-size-fits-all approach as being too simplistic. Not everyone will experience all of these stages, and they may not occur in a specific order. Nonetheless, understanding these stages can provide valuable insights into the grieving process and help individuals cope with emotional upheavals resulting from various life events.

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.

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.

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.

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 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.

Treatment Options for Neuropathic Pain

Neuropathic pain is often described as burning or shooting pain and can be difficult to manage with traditional painkillers. However, there are several treatment options available.

Tricyclic antidepressants like amitriptyline are commonly used and can be started at a low dose of 10-25 mg at night, with the option to increase up to 75 mg under specialist advice. Other nerve painkillers like gabapentin, pregabalin, and carbamazepine may also be effective.

If a tumour is compressing a nerve, dexamethasone may be useful to reduce tumour oedema. Nerve blocks can also be an option for localized pain. However, NSAIDs like ibuprofen are not effective for neuropathic pain.

Opioids like tramadol and oxycodone can be used with some success, but they only have a partial effect on neuropathic symptoms. Immediate release morphine is not preferable to amitriptyline, and regular medication is more appropriate.

Lidocaine plasters can be useful for post-herpetic neuralgia, but they are not a first-line therapy for neuropathic pain. Finally, oxybutinin can be helpful in treating bladder spasm.

In summary, there are several treatment options available for neuropathic pain, and it may take some trial and error to find the most effective one for each individual patient.

Common Oral Conditions in Myelosuppressed Patients

Myelosuppressed patients, particularly those undergoing cancer treatment, are at a high risk of developing oral complications. One of the most common conditions is oral mucositis, which can occur in up to 70% of patients undergoing stem cell transplantation. This painful condition is caused by a combination of factors, including chemotherapy or radiotherapy damage, the oral environment, myelosuppression, and genetic predisposition. Symptoms include burning, erythema, and ulcerations in the mouth, which can impact the patient’s nutritional status and require supportive treatment with oral hygiene, mucosal-coating agents, and analgesia.

Other oral conditions that may affect myelosuppressed patients include herpes zoster infection, candidiasis, herpes simplex infection, and Stevens-Johnson syndrome. Candidiasis is the most frequent oral infection in myelosuppressed patients, presenting as white patches on the gums, tongue, and inside the mouth. Herpes simplex virus 1 (HSV-1) is another common viral infection that causes ulcers on the lips. Herpes zoster infection can involve the mouth and skin, while Stevens-Johnson syndrome is a potentially fatal skin reaction caused by drugs, presenting with macules, target lesions, and bullae affecting the skin and mucosal surfaces.

In conclusion, myelosuppressed patients are at a high risk of developing various oral complications, which can impact their quality of life and require supportive treatment. It is important for healthcare providers to be aware of these conditions and provide appropriate management to improve patient outcomes.

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.

Management of a Patient at Risk of Neutropenia with a NEWS2 Score of 5

When managing a patient at risk of neutropenia with a NEWS2 score of 5, it is important to arrange emergency admission for assessment in secondary care to establish whether any supportive treatment is required. The NEWS2 score is a tool developed by the Royal College of Physicians that considers a patient’s vital signs and level of consciousness to improve the detection and response to clinical deterioration in adult patients.

If the patient’s NEWS2 score aggregate is <4, they may be treated in the community with oral antibiotics such as doxycycline 100 mg once a day for seven days. However, if the patient's NEWS2 score is 5, urgent review in secondary care is necessary. In this case, prescribing 500 mg amoxicillin orally twice a day for seven days may be appropriate. While advice from the local Oncology Unit may be beneficial in cases of a raised temperature, stable patients with a NEWS2 score of 5 require urgent review and should not delay seeking medical attention. Self-care and antipyretics may be appropriate for immunocompetent patients with a low risk of sepsis indicated by a NEWS2 score <3.

Syringe Driver Compatibility Guide

When using a syringe driver, it is important to know which drugs are compatible with each other to avoid any adverse reactions. For diamorphine, the following drugs are compatible: cyclizine, dexamethasone, haloperidol, hyoscine, metoclopramide, octreotide, midazolam, and ondansetron. However, phenobarbital, diclofenac, and ketamine should be administered with a separate syringe driver. It is also important to note that diazepam, chlorpromazine, and prochlorperazine are not suitable for subcutaneous usage. By following this compatibility guide, healthcare professionals can ensure safe and effective administration of medication through a syringe driver.

Choosing the Right Drug for Syringe Drivers: Considerations and Precautions

When it comes to selecting a drug for syringe drivers, diamorphine is often preferred due to its low volume. However, it’s important to note that diamorphine is about three times more potent than oral morphine, so careful dose conversion is necessary.

For those considering fentanyl patches, it’s important to keep in mind that it takes 24 hours for the drug to reach steady state. Finally, if using MST, it’s a twice-daily sustained-release preparation.

Overall, selecting the right drug for syringe drivers requires careful consideration and attention to detail to ensure safe and effective pain management.

Superior Vena Caval Obstruction (SVCO)

Superior Vena Caval Obstruction (SVCO) is a condition where there is a blockage of blood flow in the superior vena cava. This can be caused by external compression or thrombosis within the vein. The most common cause of SVCO is malignancy, with lung cancer and lymphoma being the most frequent culprits. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

Typical features of SVCO include facial and upper body oedema, facial plethora, venous distention, and increased shortness of breath. Impaired venous return can cause dizziness and even syncopal attacks. Headache due to pressure effect is also seen.

Prompt recognition of SVCO on clinical grounds is crucial, and immediate referral for specialist assessment is necessary. If there is any stridor or laryngeal oedema, SVCO becomes a medical emergency.

Treatment for SVCO typically involves steroids and radiotherapy, with chemotherapy and stent insertion being indicated in some cases. Although dexamethasone may be given as an acute treatment, it is not the best answer for this patient, who needs to be referred immediately for inpatient treatment and monitoring.

In summary, SVCO is a serious condition that requires prompt recognition and referral for specialist assessment. Treatment options include steroids, radiotherapy, chemotherapy, and stent insertion, depending on the underlying cause.

To convert this patient’s daily dose of oral morphine to a more tolerable route, the dose should be divided by two. The ratio of oral to parenterally administered morphine is 2:1, meaning that subcutaneous or intravenous doses are half that of the oral dose. However, it is important to note that there has been no change in the patient’s condition or nature of pain, so switching to a different class of pain relief would not be appropriate. Transdermal patches may not be suitable for this patient as they are typically used for those with stable levels of pain and should not be given to opioid-naïve patients. A subcutaneous dose of 60 mg/24 hours is equivalent to 120 mg of oral morphine and would be an appropriate option. It is important to address the patient’s difficulty in taking their pain relief as the cause of their pain, rather than an increase in their pain requirements.

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.

Managing Nausea and Vomiting in Palliative Care: Medications to Consider

Nausea and vomiting are common symptoms in palliative care, and can be caused by a variety of factors such as drug toxicity or metabolic disturbances. To manage these symptoms, several medications can be considered.

Haloperidol is often the first-line drug for opioid-induced nausea, renal failure, and hypercalcaemia. Metoclopramide and levomepromazine are alternative options. For nausea caused by cytotoxic therapy or radiotherapy, ondansetron can be used.

Ranitidine may be beneficial if gastric or oesophageal stasis is an issue. Cyclizine is useful for managing vagally-mediated nausea and vomiting caused by mechanical bowel obstruction, vestibular disturbance, and Intracranial disease. Dexamethasone can be added to cyclizine in scenarios where Intracranial pressure is raised.

Finally, hyoscine butylbromide can be used for managing bowel colic and excessive gastrointestinal secretions. When selecting medications, it is important to consider the underlying cause of the nausea and vomiting, as well as the patient’s individual needs and preferences.

Notifying the coroner is not legally required for this death, but it must be reported to the Local Authority Proper Officer under the Health Protection Regulations 2010.

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.

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.

Coordinating End-of-Life Care: The Importance of a Named Person

End-of-life care requires a coordinated approach to ensure that the physical, psychological, social, and spiritual needs of the patient are addressed. While decisions about a person’s care are made through multi-disciplinary discussions, there should be a named care coordinator of services. This lead professional could be anyone from a general practitioner to a specialist nurse, but their role is crucial in ensuring that best interest decisions are taken for people who lack capacity.

Early and ongoing conversations with the patient about planning their treatment and care are encouraged, and this communication should be informative, timely, and sensitive. Health professionals should support people in making choices about their preferred place of death, whether it be at home, in hospital, care home, or hospice. To support end-of-life care, practices should have a palliative care register that includes people with terminal conditions other than cancer, such as frailty, dementia, and heart failure.

Individualized care plans should be produced with the patient involved in the process, and the plan should be recognized in all care settings. Coordinating end-of-life care is essential to ensure that the patient’s needs are met, and having a named person to oversee this process is crucial.

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.

Drugs that can cause hypercalcaemia

Bendroflumethiazide is a type of thiazide diuretic that is commonly known to cause hypercalcaemia. This condition is characterized by high levels of calcium in the blood, which can lead to various health problems. Aside from bendroflumethiazide, other drugs that may cause hypercalcaemia include lithium, teriparatide, and with theophylline toxicity. It is important to be aware of the potential side effects of these medications and to consult with a healthcare professional if any symptoms of hypercalcaemia arise. Proper monitoring and management of this condition can help prevent complications and ensure optimal health outcomes.

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.

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.

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.

Controlled drugs are medications that have the potential for abuse and are regulated by the 2001 Misuse of Drugs Regulations act. The act divides these drugs into five categories or schedules, each with its own rules on prescribing, supply, possession, and record keeping. When prescribing a controlled drug, certain information must be present on the prescription, including the patient’s name and address, the form and strength of the medication, the total quantity or number of dosage units to be supplied, the dose, and the prescriber’s name, signature, address, and current date.

Schedule 1 drugs, such as cannabis and lysergide, have no recognized medical use and are strictly prohibited. Schedule 2 drugs, including diamorphine, morphine, pethidine, amphetamine, and cocaine, have recognized medical uses but are highly addictive and subject to strict regulations. Schedule 3 drugs, such as barbiturates, buprenorphine, midazolam, temazepam, tramadol, gabapentin, and pregabalin, have a lower potential for abuse but are still subject to regulation. Schedule 4 drugs are divided into two parts, with part 1 including benzodiazepines (except midazolam and temazepam) and zolpidem, zopiclone, and part 2 including androgenic and anabolic steroids, hCG, and somatropin. Schedule 5 drugs, such as codeine, pholcodine, and Oramorph 10 mg/5ml, have a low potential for abuse and are exempt from most controlled drug requirements.

Prescriptions for controlled drugs in schedules 2, 3, and 4 are valid for 28 days and must include all required information. Pharmacists are generally not allowed to dispense these medications unless all information is present, but they may amend the prescription if it specifies the total quantity only in words or figures or contains minor typographical errors. Safe custody requirements apply to schedules 2 and 3 drugs, but not to schedule 4 drugs. The BNF marks schedule 2 and 3 drugs with the abbreviation CD.

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

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.

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.

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.

Differential Diagnosis for a Patient with Pancytopenia and Splenomegaly

A patient presents with pallor, tiredness, and breathlessness, along with pancytopenia and splenomegaly. The most likely cause is a myelodysplastic disorder, specifically primary myelofibrosis, which results in scarring of the bone marrow and loss of bone marrow function. This disorder has a median survival of around five and a half years and can cause progressive symptoms. The splenomegaly is due to extramedullary haemopoiesis.

Other potential causes, such as bowel cancer, prostate cancer, and metastatic oesophageal carcinoma, are less likely due to the absence of relevant symptoms or metastasis to the bone. Chemotherapy-related bone marrow suppression is also unlikely as the patient is not receiving any active treatment.

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.

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.

Divide the dosage of tramadol by 10 to obtain the equivalent dosage of morphine.

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.

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.

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.

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.

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.

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.

Managing Foul Odors in Palliative Care

In palliative care, managing foul odors is an important aspect of providing comfort to patients. One approach is to use metronidazole, which can improve smells caused by anaerobic organisms that infect fungating tumors. Another option is to use charcoal dressings, which absorb malodorous substances. It is recommended to familiarize oneself with the British National Formulary (BNF) section on prescribing in palliative care, as it contains valuable information that is often tested in exams. By utilizing these strategies, healthcare providers can help alleviate unpleasant odors and improve the quality of life for their patients.

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.

Hypercalcaemia in Palliative Care Patients

Hypercalcaemia is a common life-threatening metabolic disorder in cancer patients, particularly in those with myeloma and breast, renal, lung, and thyroid cancers. The severity of symptoms doesn’t always correlate with the degree of hypercalcaemia but often reflects the rapidity of onset. In palliative care patients, hypercalcaemia is a medical emergency that requires immediate attention.

Intravenous fluid replacement and intravenous bisphosphonates are the treatments of choice for hypercalcaemia in patients with a reasonable short-term prognosis who are willing to undergo treatment. It is important to note that hypercalcaemia can result from renal failure, so a urea level test may be useful. However, isolated acute kidney injury doesn’t explain the symptoms and may lead to a missed diagnosis.

A high serum alkaline phosphatase level is usually present in patients with bony metastases, but it would not be the most useful test in isolation. Although anaemia may be present in some patients, it doesn’t fit with the acute clinical symptoms, and a haemoglobin level test would not provide useful diagnostic information.

Thirst and polyuria may suggest diabetes, but the clinical history makes hypercalcaemia a more likely diagnosis. Therefore, it is crucial to consider hypercalcaemia as a potential cause of acute symptoms in palliative care patients.

If the underlying cause is stated, it is acceptable to use a type of organ failure in 1a. However, section 2 should be used to record Type 2 diabetes mellitus as it doesn’t lead to essential hypertension.

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.

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%.

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.

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.

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.

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.

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.

Managing Pain in Palliative Care: Medication Recommendations

When it comes to managing pain in palliative care, there are several medication options available. For neuropathic pain, amitriptyline is recommended as a starting dose of 10-25 mg at night, with the option to increase after three to seven days. Tricyclic antidepressants can also be used alongside standard analgesics for mixed pain.

Liquid oral morphine can be added as needed, with a starting dose of 5 ml and no more than a dose every two hours. If the patient requires further morphine, titrating the dose with liquid morphine is recommended.

While non-steroidal anti-inflammatory agents like naproxen can be used for pain management, they are not first-line for neuropathic pain. Sedating benzodiazepines like diazepam are not recommended for neuropathic pain, but may be used for sleeping problems or anxiety.

Overall, a combination of medication options may be necessary to effectively manage pain in palliative care.

Assessing Nausea and Vomiting in Palliative Care: Possible Causes and Treatment Options

When assessing nausea and vomiting in palliative care, it is important to seek a reversible cause. If none is found, a specific diagnosis should be made. One possible cause is anxiety, which can present with nausea in waves and anticipatory vomiting that may be relieved by distraction. Benzodiazepines or levomepromazine can be used for medication. Other causes include gastric stasis, gastric outflow obstruction, small stomach syndrome, oesophageal blockage, bowel obstruction, raised intracranial pressure, movement-related nausea, vestibular issues, drugs, metabolic issues, and carcinomatosis. It is important to consider all possible causes and choose appropriate treatment options accordingly.

Treatment Options for Pruritus in Palliative Care Patients

The National Institute for Health and Care Excellence (NICE) recommends treating the underlying cause of pruritus if possible. However, in palliative care patients, symptom management is the primary focus. For widespread pruritus, sedating antihistamines like hydroxyzine or chlorphenamine may be used. Gamma-aminobutyric (GABA) drugs like gabapentin and pregabalin may also be considered, but consultation with a specialist is recommended. Topical calamine lotion has limited evidence for effectiveness and is not recommended by NICE. Hydralazine, a vasodilator antihypertensive drug, has no indication for use in pruritus and is not appropriate for palliative care patients.

When switching from one strong opioid to another, the most common switch is from oral morphine sulphate to subcutaneous diamorphine or morphine. Diamorphine is more soluble and easier to administer in higher doses, but morphine is preferred in most cases. The potency ratio of parenteral diamorphine to oral morphine is 3:1, while the subcutaneous dose of morphine is one third to one half of the oral dose. Most centres divide the oral dose by two and re-titrate as necessary.

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.

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.

Managing Opioid-Induced Constipation in Palliative Care

Opioid-induced constipation is a common problem in palliative care. The main treatment involves the use of oral laxatives, with senna being the recommended initial choice due to its ability to stimulate peristalsis. The dosage should be titrated up to achieve comfortable defecation without colic, and higher doses may be necessary in palliative care. If colic is a problem, a reduction in senna dosage and the addition of an osmotic or surface-wetting laxative may be necessary. Increasing fluid and dietary fiber intake can also help, but it is more important to ensure that patients have food and drink they enjoy. Bulk-forming laxatives like ispaghula may be unpalatable and cause intestinal obstruction if not taken with enough water. If laxatives are insufficient, a pro-kinetic agent like metoclopramide may be added, but should not be used if the patient has colic.

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.

Different Clinical Scales and Their Uses

There are various clinical scales used in healthcare to assess different aspects of a patient’s condition. Here are some examples:

Waterlow Scale: This scale is used to estimate the risk of pressure sores in patients. It helps determine the level of nursing care required and the type of mattress that may be needed.

Barthel Scale: This scale measures a patient’s ability to perform activities of daily living and provides an overall estimate of disability.

Glasgow-Imrie Scale: This scale is used to evaluate the severity of acute pancreatitis.

Modified Rankin Score: This scale assesses disability associated with neurological impairment.

Ranson’s Criteria: This scale is used to evaluate the risk of mortality in patients with acute pancreatitis.

Each of these scales serves a specific purpose in healthcare and helps healthcare professionals make informed decisions about patient care.

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.

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.

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.

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.

Managing Medication Side Effects in Palliative Care

Medication side effects are a crucial consideration in palliative care. When a patient experiences pruritus without an obvious clinical reason, drug side effects must be taken into account. Morphine, for example, is known to cause itching in some patients by stimulating histamine release. In such cases, switching to an alternative opioid preparation that is less likely to stimulate pruritus, such as oxycodone, may be appropriate.

There are other options available to treat pruritus in certain circumstances. Cetirizine, an antihistamine, can be used as an anti-pruritic. Cholestyramine is useful in treating pruritus due to obstructive jaundice by binding and forming an insoluble complex with bile salts. Anti-inflammatory drugs like ibuprofen have been shown to be effective in some cases of pruritus, as they act on prostaglandins that play a role in its development. Additionally, odansetron has been used to treat pruritus due to its action as a 5-hydroxytrytamine antagonist, as 5-hydroxytryptamine has been shown to be involved in the mechanism of pruritus. By carefully considering medication side effects and choosing appropriate treatments, healthcare providers can help manage symptoms and improve quality of life for 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.

Understanding Different Types of Grief and Trauma Reactions

Grief and trauma can manifest in various ways, and it is essential to differentiate between different types of reactions to provide appropriate support and treatment. Complicated grief is a type of grief that persists in its intensity, hindering a person’s ability to engage in normal activities and causing feelings of shame or guilt. This type of grief can last for an extended period, and the person may struggle to accept the death, leading to isolation and loneliness. On the other hand, post-traumatic stress disorder (PTSD) can result from a distressing event, causing intrusive symptoms such as vivid and distressing memories or flashbacks. Normal grief reactions follow the Kubler Ross model, with stages of denial, anger, bargaining, depression, and acceptance. However, if the intense feelings of grief persist, it may indicate complicated grief. Major depressive disorder (MDD) shares some symptoms with complicated grief, but the context of the loss is crucial in distinguishing between the two. Acute stress reaction is a transient disorder that develops in response to exceptional physical and mental stress, subsiding within hours or days, and is not indicated in this case. Understanding these different types of grief and trauma reactions can help in providing appropriate support and treatment to those who need it.

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.

Treatment Options for Seizures in Palliative Care Patients

Seizures are a common occurrence in palliative care patients, often caused by brain tumors or biochemical imbalances. Advance care planning is crucial to prevent unwanted hospital admissions. Here are some treatment options:

1. Intravenous Lorazepam: Administer 4 mg by slow injection if resuscitation equipment is available.

2. Midazolam or Diazepam: Buccal or subcutaneous administration of 10 mg midazolam or 10 mg rectal solution or per stoma of diazepam is recommended as first-line treatment. If seizure activity persists, the dose can be repeated once after 10-20 minutes.

3. Intravenous Phenytoin: 15 mg/kg (maximum total dose 1 g) can be used for refractory seizures, but requires a filter and cardiac monitoring.

4. Intramuscular Diamorphine: This is not a suitable treatment for seizure activity.

5. Intramuscular Diazepam: Diazepam is a reasonable first-line treatment, but the 10 mg dose should be administered per rectum (or via a stoma if appropriate), and not intramuscularly.

6. Intramuscular Phenobarbital: Phenobarbital 100-200 mg intramuscularly would only be used for a protracted seizure not responding to first-line treatment, under specialist supervision.

Formal advance directives are the preferred option for patients. It should be noted that lasting power of attorney arrangements do not cover decisions related to life-sustaining treatments unless they are explicitly stated.

The Mental Capacity Act was introduced in 2007 and applies to adults over the age of 16. It outlines who can make decisions on behalf of a patient who becomes incapacitated, such as after a stroke. Mental capacity includes the ability to make decisions about daily life, healthcare, and finances. The Act is based on five key principles, including assuming a person has capacity unless proven otherwise, taking all possible steps to help a person make decisions, and making decisions in the person’s best interests.

To assess whether a person lacks capacity, the Act provides a clear test that is decision-specific and time-specific. A person can only be considered unable to make a particular decision if they have an impairment or disturbance in the functioning of the mind or brain and are unable to understand, retain, use, or communicate information relevant to the decision. The Act also emphasizes that no individual can be labeled incapable based on their age, appearance, or any medical condition.

When assessing what is in someone’s best interests, the Act considers factors such as the likelihood of regaining capacity, the person’s wishes and beliefs, and the views of other relevant people. The Act also allows for the appointment of an attorney through a Lasting Power of Attorney (LPA) to act on behalf of a person who loses capacity. The LPA can cover property and financial affairs as well as health and welfare decisions, including life-sustaining treatment. Advance decisions can also be made by individuals with capacity to specify treatments they would not want if they lost capacity. These decisions must be written, signed, and witnessed if they refuse life-sustaining treatment.

Treatment options for oesophageal spasm

This patient is suffering from oesophageal cancer and is experiencing odynophagia and dysphagia. A clinical diagnosis of oesophageal spasm has been made. There are several treatment options available depending on the underlying cause of the symptoms.

Dexamethasone is useful if the dysphagia is due to tumour enlargement and physical blockage is causing dysphagia. Fluconazole is used to treat oesophagitis caused by candidal infection. Omeprazole is a proton pump inhibitor that can be helpful if symptoms of gastro-oesophageal reflux disease are present. Pamidronate is a bisphosphonate that is administered intravenously to treat bone pain and hypercalcaemia.

Nifedipine can work well in cases like this due to its action of relaxing smooth muscle and can help treat the painful spasm that is underlying the symptoms. It is important to identify the underlying cause of the oesophageal spasm to determine the most effective treatment option. With proper treatment, the patient can experience relief from their symptoms and improve their quality of life.

Managing Palliative Care Symptoms with Subcutaneous Medications

To support anticipatory prescribing and access to palliative care medications for patients in the dying phase, ‘just-in-case’ boxes are produced in many areas. These boxes include subcutaneous medication for pain, nausea/vomiting, secretions, and agitation, along with syringes and water for injection. Proactive management of symptom control for patients is a key component of the Gold Standards Framework.

When a patient experiences symptoms for the first time, giving subcutaneous stat doses over 24 hours is useful to assess their needs and guide the amount required in a subsequent continuous syringe driver. This approach is particularly helpful for opioid-naïve patients with intermittent pain, as it allows for a period of assessment to guide a starting dose.

While a buprenorphine patch may be useful earlier in the course of illness, it has a relatively slow onset of action and is difficult to titrate to match rapidly changing pain. Non-steroidal anti-inflammatory drugs like diclofenac are unlikely to be used for a sudden increase in pain or breakthrough pain that may occur in the last days of life.

Levomepromazine is a common choice of antiemetic for end-of-life care and will likely be in the patient’s ‘just-in-case’ box. However, it is not the treatment of choice for pain. Overall, subcutaneous medications are an important tool for managing palliative care symptoms and improving the quality of life for patients in the dying phase.

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.

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.

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.

Managing Cancer-Related Fatigue: Practical Advice and Guidance

Cancer-related fatigue is a common symptom experienced by many patients undergoing treatment. While the causes are not fully understood, there are practical steps that can be taken to manage this debilitating condition.

One important factor is maintaining a good level of physical activity. This can help reduce symptoms of fatigue, boost appetite, provide more energy, and improve sleep quality. However, it’s important to strike a healthy balance between activity and rest.

While support groups can be helpful for some patients, it’s important to note that speaking to others about fatigue may worsen symptoms for some. It’s important to find what works best for each individual.

Short-term sedative sleeping tablets are not recommended for managing fatigue. Instead, establishing a sleep routine and practicing good sleep hygiene can be more effective.

Psychological support can also be beneficial for some patients. Many hospitals offer access to counsellors or staff specially trained to provide emotional support to people affected by cancer. Oncologists or specialist nurses can provide information about available services.

Overall, managing cancer-related fatigue requires a multifaceted approach that takes into account individual needs and preferences. By following practical advice and guidance, patients can improve their quality of life and better cope with the challenges of cancer treatment.

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.

Treatment Options for Capillary Bleeding

In cases of capillary bleeding, there are several treatment options available. Oral tranexamic acid is one option that can be used to treat this type of bleeding. It is recommended to continue its use for an additional week after the bleeding has stopped. Topical options include gauze soaked in tranexamic acid 100 mg/mL or adrenaline solution 1 mg/mL (1 in 1000), which can be applied directly to the affected area.

It is important to note that intramuscular adrenaline has no role in treating localised capillary bleeding. Topical metronidazole is used in treating malodorous fungating tumours, but it is not effective in stopping bleeding. Oral steroids have numerous effects, but they would not halt bleeding. However, oral vitamin K may be useful when bleeding is due to prolonged clotting in liver disease.

In summary, when dealing with capillary bleeding, it is important to consider the appropriate treatment options and use them accordingly. Oral tranexamic acid and topical solutions such as gauze soaked in tranexamic acid or adrenaline solution can be effective in stopping bleeding, while other options such as intramuscular adrenaline and topical metronidazole are not recommended for this purpose.

Understanding Multiple Myeloma

Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is characterized by the presence of abnormal plasma cells that produce an excess of monoclonal antibodies, also known as paraproteins. Here are some key diagnostic markers and symptoms of multiple myeloma:

– Bence Jones protein is a reliable diagnostic marker.
– Bone pain is common, usually in the back, but not in the skull.
– White blood cell count is usually normal or low, with a classic leucoerythroblastic anemia.
– Paraprotein may be absent in 20% of cases, but there are light chains in the urine.
– Serum calcium can be normal or raised, and both ESR (usually) and CRP (nearly always) are raised.
– IL6 is a key myeloma growth cytokine. Serum IL6 is raised in active myelomatosis and it primarily controls CRP production. A rise in IL6 is mirrored by a rise in CRP.
– Bone lesions are lytic.

It is important to note that multiple myeloma can present differently in each individual, and a proper diagnosis requires a thorough evaluation by a healthcare professional. If you are experiencing any symptoms or have concerns about multiple myeloma, please consult with your doctor.

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.

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.

Addressing Lack of Appetite in Palliative Care Patients

A thorough history and clinical examination are crucial in identifying the underlying cause of anorexia and lack of appetite in palliative care patients. Pain, constipation, nausea, vomiting, and dysphagia are some of the potential causes that need to be treated accordingly. However, if the primary cause is a lack of appetite, specific measures should be taken to address it.

Home care input may not be effective in improving appetite, and changing antiemetics is unnecessary if the current medication is working well. Nutritional supplements may aid in caloric intake, but addressing the lack of appetite is still the priority. Referral for PEG feeding is not appropriate if there are no physical problems preventing oral intake.

The best option to stimulate appetite and improve oral intake is a course of prednisolone or dexamethasone. These corticosteroids have been proven to increase appetite and enjoyment of food in many patients. Progestogens are also effective but are more expensive.

In conclusion, addressing the lack of appetite in palliative care patients is crucial in improving their quality of life. A thorough assessment of the underlying cause is necessary, and appropriate measures should be taken to address it. Corticosteroids such as prednisolone and dexamethasone are effective in stimulating appetite and improving oral intake.

Chlorine salicylate gel

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.

Benefits for Bereavement

When a loved one passes away, it can be a difficult time emotionally and financially. However, there are benefits available to help ease the financial burden. One such benefit is the Funeral Payment, which is a one-time payment given to the partner or parent of the deceased if they are on benefits to help pay for the funeral. Another benefit is the Bereavement Support Payment, which includes a lump sum and up to 18 monthly payments if the claimant is under the state pension age when their partner died. The amount received depends on the national insurance contributions and whether the claimant receives Child Benefit.

Additionally, there is the Widowed Parent’s Allowance, which is payable to a parent whose husband or wife has died. To be eligible, the surviving partner must be bringing up a child under 19 years of age and receiving Child Benefit. The deceased partner must have made adequate national insurance contributions, and the woman may also be eligible if she was expecting her late husband’s baby. However, divorcees and those who remarry are not eligible to claim. While GPs may not be experts on these benefits, it is important to have a basic understanding of them to provide support and guidance to patients during a difficult time.

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.

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.

Recognizing Spinal Metastases: Symptoms and Risks

Spinal metastases pose a significant risk of spinal cord compression, affecting 5-10% of all cancer patients. While all options may indicate spinal metastases, it is crucial to identify specific symptoms. Lumbar pain that worsens with movement and improves with rest is a common symptom of mechanical back pain, but other concerning features include progressive and nocturnal spinal pain. If a patient presents with symptoms suggestive of spinal metastases, doctors should consult with the local metastatic spinal cord coordinator within 24 hours to ensure prompt and appropriate management.

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.

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.

Superior Vena Cava Obstruction: A Palliative Care Emergency

Superior vena cava obstruction (SVCO) is a medical emergency that requires immediate attention in palliative care. It occurs when central venous return is impaired due to compression, obstruction, or thrombosis. Patients with SVCO often present before a definitive diagnosis of the underlying pathology is made. The most common causes of SVCO are lung cancer (70% of cases) and lymphoma (8%).

Active intervention is appropriate for patients with SVCO who are still ambulant. Hospital admission is required for assessment and possible chemotherapy/radiotherapy, stenting, or other interventions. Corticosteroids and diuretics may be used in emergency situations, but they are not appropriate as a first-line management option when there is evidence of airway compromise.

After treatment, the average survival is eight months. If a patient is bed-bound, terminal, or refusing intervention, or if no further treatment is available, symptom-control measures should be given, and nursing support should be arranged.

In conclusion, SVCO is a serious condition that requires prompt intervention in palliative care. Early diagnosis and treatment can improve outcomes and quality of life for patients.

Managing Hypercalcaemia in Palliative Care

You should urgently arrange intravenous treatment for hypercalcaemia in palliative care patients, especially when the calcium level is very high. This may indicate bone metastases or a non-metastatic effect of malignancy. As a GP, the most appropriate decision would be to admit the patient for immediate treatment.

The RCGP emphasizes that an AKT question may have several plausible answers, but the candidate’s ability to select the most appropriate one is crucial. In this case, admitting the patient for treatment is the best course of action.

Once admitted, the patient may receive intravenous 0.9% saline to increase circulating volume. Adding a loop diuretic may also help by inhibiting the tubular reabsorption of calcium. Additionally, a bisphosphonate may reduce bone turnover.

This question is part of the MRCGP examination curriculum, which requires candidates to have knowledge of various palliative care emergencies and their appropriate management. These emergencies include major haemorrhage, hypercalcaemia, superior vena caval obstruction, spinal cord compression, bone fractures, anxiety/panic, and the use of emergency drugs.

Understanding the Potency of Corticosteroids

Corticosteroids are commonly used in daily practice to manage various conditions such as asthma, COPD, inflammatory joint disease, and even in palliative care to manage cerebral edema associated with malignancy and chemotherapy-induced nausea and vomiting. However, not all corticosteroids have the same anti-inflammatory potency.

To understand the relative potencies of corticosteroids, it is important to compare their glucocorticoid effects. The British National Formulary (BNF) provides a useful table that lists equivalent anti-inflammatory doses of various corticosteroids. For example, 5 mg of prednisolone is equivalent to 6 mg of deflazacort, 750 µgrams of dexamethasone, 20 mg of hydrocortisone, and 4 mg of methylprednisolone.

Knowing the relative potencies of corticosteroids can help healthcare professionals make informed decisions when prescribing them for their patients. It is important to note that the uses of corticosteroids are vast and varied, and the appropriate choice of corticosteroid depends on the specific condition being treated.

Managing Thirst in a Dying Patient: Considerations and Options

As a patient approaches the end of life, their need for food and water decreases. However, thirst can still be a distressing symptom. When managing a dying patient’s hydration status, it is important to consider their wishes and preferences, as well as the potential risks and benefits of clinically assisted hydration. Here are some options to consider when a patient is complaining of thirst:

– Subcutaneous fluids: This can be a good option for providing symptomatic relief without overloading the patient with fluids.
– Increasing haloperidol in the syringe driver: While haloperidol can be helpful for managing nausea and vomiting, it is unlikely to improve thirst.
– Continuing mouth care and sips of water only: While this may be appropriate for some patients, it may not be enough to relieve thirst in others.
– Increasing morphine in the syringe driver: While morphine can be helpful for pain relief, it is unlikely to improve thirst.
– Inserting a nasogastric tube: If clinically assisted hydration is necessary, subcutaneous fluids are generally a more comfortable and less invasive option than a nasogastric tube.

Ultimately, the goal of managing thirst in a dying patient is to provide comfort and relief, rather than to prolong life. Each patient’s situation should be evaluated on an individual basis, with their wishes and preferences taken into account.