The patient has acute renal failure likely caused by an obstructive nephropathy from a pelvic tumor and dehydration. She is experiencing bony, visceral, and neuropathic pain exacerbated by hypercalcemia. NSAIDs and gabapentin are not recommended, and opioids are the preferred treatment. Morphine is effective but can cause toxicity in renal failure due to accumulation of morphine-6-glucuronide. Fentanyl is a synthetic opioid that is unaffected by renal impairment but can only be given parenterally. Transdermal fentanyl is not appropriate for acute pain.

Diagnosis of Brain Stem Death

Brain stem death occurs when the brain stem is so severely damaged that it can no longer control cardiac and respiratory functions. This can result in the heart stopping soon after. However, with artificial support, an individual may continue to live for a period of time. To avoid futile interventions, it is important to accurately diagnose brain stem death and sensitively manage the patient’s family.

The Royal College of Physicians published a code of practice for the diagnosis of brain stem death in 1998. The diagnosis involves the absence of all brain stem reflexes, which must be assessed by two medical practitioners, one of whom must be a consultant. Members of the transplant team are not allowed to participate in the diagnosis. The time between assessments is determined by clinical judgement, but one week is considered excessive. Death is pronounced after the second set of tests, but the legal time of death is recorded as the time of the first set of tests revealing brain stem death.

Choosing the Right Antiemetic

In selecting an antiemetic, it is crucial to consider the underlying cause of the nausea. Antiemetics have different modes of action and target specific receptors, making them suitable for certain clinical situations. Metoclopramide is a prokinetic that targets dopamine and serotonin receptors, making it effective for delayed gastric emptying and post-chemotherapy nausea. Haloperidol, on the other hand, is most effective for toxin or metabolic-induced nausea as it targets dopamine receptors. Levomepromazine is a broad-spectrum antiemetic that antagonizes dopamine, serotonin, histamine, and cholinergic receptors, but it can cause severe postural hypotension and sedation, making it more appropriate for terminal care.

Cyclizine is the most appropriate first-line agent for the patient in this case, given the possibility of brain metastases. Cyclizine targets dopamine and cholinergic receptors and is widely accepted as the best antiemetic for nausea associated with cerebral disease. While dexamethasone may become an appropriate management option if the patient is later diagnosed with brain metastases, the focus of this case is on the acute management of vomiting, making cyclizine a more appropriate initial treatment.

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.

Mental Capacity and Communication

The Mental Capacity Act 2005 outlines four conditions that must be met for a person to retain capacity to make decisions. These include relevant information, retaining that information, using it to make a decision, and communicating that decision. However, if a person is unable to communicate their decision, efforts should be made to enable them to do so before concluding that they lack capacity. Being deaf does not necessarily interfere with capacity, as alternative communication methods can be used. Patients are entitled to change their minds and make unwise decisions without lacking capacity. The Mini-Mental State Examination (MMSE) is not a reliable indicator of capacity, as there is no reproducible link between MMSE score and capacity. these factors is crucial in ensuring that individuals are able to make informed decisions and have their rights respected.

Fentanyl as an Effective Treatment for Breakthrough Pain in Renal Failure Patients

Fentanyl is a potent pain medication that selectively activates µ receptors in the body. While it is not very effective when taken orally due to extensive first-pass metabolism, it can be administered through lozenges for buccal absorption, resulting in a rapid onset of action within five minutes. This makes it an ideal choice for patients experiencing breakthrough pain, particularly those with renal failure, as fentanyl is primarily metabolized in the liver and has inactive metabolites.

In contrast, other pain medications such as morphine sulfate, methadone, and oxycodone have a longer onset of action and may not be as effective for sudden pain. Additionally, these drugs can accumulate in patients with renal impairment, leading to unpredictable and potentially severe side effects. Diamorphine, which has a rapid onset of action, may be suitable for breakthrough pain in patients with normal renal function.

Overall, fentanyl’s unique pharmacokinetics and effectiveness in treating breakthrough pain make it a valuable option for patients with renal failure.

Treatment for Anticipatory Vomiting in Chemotherapy Patients

Chemotherapy-induced nausea and vomiting can be treated with various drugs. However, modern palliative chemotherapy for breast cancer is less likely to cause severe nausea and vomiting. In the case of a patient experiencing anticipatory vomiting, which is likely caused by anxiety about chemotherapy, treating them with a benzodiazepine as an anxiolytic and antiemetic would be the most effective approach.

Anticipatory vomiting is a common issue among chemotherapy patients, and it can be challenging to manage. It is often caused by anxiety and fear associated with the treatment. In such cases, treating the underlying anxiety can help alleviate the vomiting. Benzodiazepines are a class of drugs that are commonly used as anxiolytics and antiemetics. They work by reducing anxiety and calming the patient, which can help prevent anticipatory vomiting.

In conclusion, when dealing with anticipatory vomiting in chemotherapy patients, it is essential to address the underlying anxiety. Treating the patient with a benzodiazepine as an anxiolytic and antiemetic can be an effective approach to managing this issue. It is important to note that this treatment should only be administered under the supervision of a healthcare professional.

Management of Neuropathic Pain in Tumor Patients

Neuropathic pain is a common symptom in tumor patients, and it can be challenging to manage. In this case, the patient is experiencing pain possibly due to tumor involvement of the T4 vertebra. The pain is not responsive to opioids, so increasing the MST or introducing a weak opioid like tramadol would not be appropriate. NSAIDs are effective for pain caused by bony metastases, but not for neuropathic pain like this. Prescribing more than one opioid simultaneously is generally not recommended, and there is no indication for an increase in opioid dose in this scenario.

The best next step in this patient’s pain management would be to add a neuropathic agent. The NICE guidelines recommend starting with a low dose of amitriptyline or pregabalin, which can be titrated up to minimize side effects. Amitriptyline 10 mg is the first-line recommendation, with pregabalin as an alternative. It is important to note that tramadol is only recommended as an initial opioid and not as an additional opioid in the WHO analgesic ladder. Therefore, it is crucial to follow the appropriate guidelines and tailor the treatment plan to the patient’s specific needs.

Optimizing Pain Management for a Patient with Liver Metastases: Medication Adjustments

When managing pain in a patient with liver metastases, it is important to consider the underlying cause of the pain and adjust medication accordingly. In this case, the patient is likely experiencing capsular pain and would benefit from the addition of dexamethasone as an adjuvant analgesic. Up-titration of analgesia is also necessary, with the next step being a weak opiate such as codeine. Alfentanil is not needed in this case, as the patient has normal renal function. Morphine via continuous subcutaneous infusion may be a good option if there are issues with oral medication absorption, but since the patient’s vomiting and diarrhea have resolved, up-titration of oral analgesia is a better choice. Tramadol as a weak opiate PRN is not likely to be effective and is more emetogenic than codeine. While reducing the paracetamol dose is appropriate in patients with impaired liver function, the patient’s liver function tests are only slightly out of range and controlling her pain is a higher priority. Adding naproxen, a non-steroidal anti-inflammatory drug, is not as appropriate as introducing opiates and dexamethasone for capsular pain. Overall, optimizing pain management for this patient requires careful consideration of the underlying cause of pain and appropriate medication adjustments.

Acute Dystonic Reaction: Symptoms, Causes, and Management

An acute dystonic reaction is characterized by involuntary muscle contractions that can affect various parts of the body, such as the tongue, face, neck, and eyes. This condition can be triggered by certain medications, particularly neuroleptics, antiemetics, and antidepressants. It usually occurs within a few days of starting a new drug and can be accompanied by symptoms such as facial grimacing, difficulty speaking, and oculogyric crisis. However, the patient’s mental status and vital signs are typically normal.

To manage an acute dystonic reaction, the first step is to discontinue the causative medication. Then, medications such as benztropine or diphenhydramine can be given to block cholinergic receptors in the striatum, which may help to restore the balance between cholinergic and dopaminergic activity and alleviate the dystonia. Benzodiazepines may also be useful in some cases. Overall, prompt recognition and treatment of an acute dystonic reaction can prevent complications and improve the patient’s outcome.

Pain Management in Renal Failure

The management of pain in patients with renal failure can be challenging due to the accumulation of toxic metabolites from commonly used strong analgesics. Morphine, diamorphine, and oxycodone are among the drugs that should be used with extreme caution in these situations. However, fentanyl is a safer option as it is not renally excreted. Fentanyl lozenges have a rapid onset of action and are useful for breakthrough pain, while transdermal fentanyl has a prolonged duration of action.

Therefore, oral transmucosal fentanyl citrate is the best choice for patients with renal failure who require analgesia for short, isolated periods. It is important to consider the patient’s renal function when selecting an appropriate analgesic to avoid further complications. By choosing the right medication, patients with renal failure can receive effective pain relief without risking further harm to their kidneys.

During a catastrophic, terminal haemorrhage, it may be necessary to administer a large dose of midazolam (10mg) as part of crisis management to alleviate distress. To help mask the color of the blood and absorb it, red or green towels or blankets should be readily available.

Adrenaline is not typically used in cases of terminal haemorrhage, as it is reserved for specific circumstances of major haemorrhage. Morphine can be used to manage pain and breathlessness in palliative care, but it is not typically used in terminal haemorrhages. Terlipressin may be used for major haemorrhage, particularly in cases of gastrointestinal bleeding, but it is not appropriate for terminal haemorrhages.

Given that the patient is on the end-of-life pathway and surgical intervention is not an option, seeking a vascular surgery opinion at this time would not be appropriate.

Managing Agitation and Confusion in Palliative Care

When managing agitation and confusion in palliative care, it is important to identify and treat any underlying causes such as hypercalcaemia, infection, urinary retention, or medication. If these specific treatments fail, medications such as haloperidol, chlorpromazine, or levomepromazine may be used as first-line options. In the terminal phase of the illness, midazolam is the preferred medication for managing agitation or restlessness. It is important to note that the use of these medications should be carefully monitored and adjusted as needed to ensure the best possible symptom management for the patient. Proper management of agitation and confusion can greatly improve the quality of life for patients in palliative care.

When it comes to end of life care, it is important to discuss treatment options with the patient as early as possible. However, if this is not possible, any previous discussions or forms filled out by the patient can be used as a guide. In the case of resuscitation decisions, it is important to ask for permission from the patient’s relatives if death is expected. The healthcare professional should explain the reasons for the decision and consult with the relatives to ensure the patient’s best interests are being considered.If a decision is made not to resuscitate, any treatments that may prolong life should also be discontinued. However, if there are treatments that can improve the patient’s condition and allow them to return home or to a hospice, these should be considered.It is important to note that while relatives have the right to be consulted, the healthcare professional is only obligated to act in the patient’s best interests. Additionally, decisions about resuscitation can be reviewed and reassessed at a later date, especially if there is a change in the patient’s condition.

Blood Transfusion in Palliative Medicine

In palliative medicine, the decision to offer blood transfusion is based on individual patient needs rather than strict guidelines. The main reason for giving blood in the hospice setting is for symptom control, which can range from fatigue and anorexia to shortness of breath and angina. Patients with chronic anemia and low hemoglobin levels may not receive transfusions if they are relatively asymptomatic. The presence of postural hypotension may or may not be an indication for transfusion, depending on the patient’s symptoms. In cases of major bleeding, blood transfusion may not be appropriate, and the focus should be on staying with the patient and providing comfort measures. Despite a short prognosis, blood transfusion can play an important role in symptom control and should not be discounted.

To determine the appropriate amount of fentanyl for a patient on a complex opiate analgesia regimen, the total daily dose of morphine salt must be calculated. In this case, the patient’s intake was 140mg of morphine from MST 70 mg BD and 50-60mg of morphine from Oramorph 10mg PRN, resulting in a total daily intake of 190-200 mg of morphine salt. To avoid opiate toxicity, the recommended course of action is to start the patient on a fentanyl 75 patch, which is equivalent to 180mg of daily morphine salt intake, and supplement with PRN Oramorph solution as needed.

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

Treatment and Management of Spinal Cord Compression

Spinal cord compression is a serious condition that requires prompt treatment and management. Dexamethasone is a commonly used medication for this condition and can be administered via any available route. However, there is no significant advantage to giving it intravenously over orally. Patients with MSCC should be offered 16 mg of dexamethasone as soon as possible after assessment, except for those with a significant suspicion of lymphoma. The possibility of spinal surgery does not affect the prescribing of corticosteroids in this situation.

Spinal stabilisation surgery should be urgently considered for patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability, as well as those with mechanical pain resistant to conventional analgesia, even if they have been completely paralysed for more than 24 hours. Preoperative radiotherapy is not recommended, but postoperative fractionated radiotherapy can be offered to patients with a satisfactory outcome once the wound has healed.

Patients with MSCC should be assessed at least once a day for changes in bowel and bladder function. Bladder dysfunction should be managed with a urinary catheter on free drainage, although this should not be performed automatically on all MSCC patients. Overall, prompt treatment and management are crucial for patients with spinal cord compression to improve their outcomes and quality of life.

Converting Oral Oxycodone Dose to Subcutaneous Syringe Driver

Oxycodone is a potent opioid that is stronger than morphine when taken orally. However, due to its higher cost, it should only be used for patients who cannot tolerate morphine. To convert an oral dose of oxycodone to a 24-hour subcutaneous syringe driver, you must first calculate the total daily oral dose. For example, if a patient takes 30 mg of oxycodone twice a day, the total daily oral dose would be 60 mg.

To convert this to a 24-hour subcutaneous route, you need to divide the total daily oral dose by two. In this case, dividing 60 mg by two would give you a subcutaneous dose of 30 mg. This conversion is important for patients who are unable to take medication orally and require a different route of administration. By how to convert oral doses to subcutaneous doses, healthcare professionals can ensure that patients receive the appropriate amount of medication for their pain management needs.

Management of Constipation in Palliative Care Patients

Constipation is a common problem in patients with advanced cancer, especially those taking opioid medication, with reduced oral intake and mobility. Lactulose, an osmotic laxative, is usually avoided in palliative care due to its side effects such as abdominal cramps and excessive flatulence. Fentanyl, a less constipating opioid, is not the best option in this situation as it would be too high a dose for the patient. Co-danthramer, a combination of danthron and poloxamer 188, is a popular choice for constipation in palliative care but should not be given to incontinent patients. Bulk-forming agents like ispaghula husk are generally unpalatable and can worsen constipation when taken with inadequate fluids. Polyethylene glycol (Movicol) is the best choice in this scenario as it is an osmotic laxative that helps retain water in the gut and is generally well-tolerated. It has been shown to be more effective than lactulose in managing chronic constipation. In summary, the management of constipation in palliative care patients requires careful consideration of the patient’s condition and medication regimen to choose the most appropriate laxative.

This man is suffering from advanced hepatocellular carcinoma and is experiencing distressing hiccups. As there are no indications of gastro-oesophageal reflux, a proton pump inhibitor trial is unlikely to be effective. In cases of hepatic or cerebral cancer, a trial of dexamethasone may provide some relief and is therefore recommended as the next course of action, given that previous attempts with a prokinetic and typical antipsychotic have not been successful. Baclofen and levomepromazine have limited evidence of effectiveness, and subcutaneous midazolam should only be used as a last resort. It is worth noting that the British National Formulary has a helpful section on prescribing in palliative care situations, which suggests the use of antacids or nifedipine in addition to the aforementioned options.

Palliative Care Prescribing for Hiccups

Hiccups can be a distressing symptom for patients receiving palliative care. In cases where hiccups are intractable, medication may be necessary to manage the symptom. Chlorpromazine is a licensed medication for the treatment of intractable hiccups and is commonly used in palliative care settings. Haloperidol and gabapentin are also medications that can be used to manage hiccups. Additionally, dexamethasone may be prescribed, particularly if there are hepatic lesions present. It is important for healthcare providers to assess the individual needs of each patient and determine the most appropriate medication for managing their hiccups. By effectively managing this symptom, patients can experience improved comfort and quality of life during their palliative care journey.

Palliative Care and Breathlessness Management

Breathlessness is a common issue in palliative care, not limited to patients with lung cancer. The management of breathlessness involves the use of opioids, other medications, physiotherapy, and psychological support. Opioids are highly effective in reducing the sensation of breathlessness by decreasing inappropriate respiratory drive. When used correctly, opioids rarely cause respiratory depression.

Psychological support and physiotherapy are useful adjuncts to medications, but they require time and may not be immediately helpful in cases of distress unless breathing techniques have been taught. Benzodiazepines are also effective agents, but they are typically used as a second-line treatment after opioids.

Liquid oral morphine is the preferred medication for managing breathlessness in palliative care. Oxygen has a limited role in breathlessness management unless the patient is hypoxic. It may be necessary when patients become psychologically dependent on supplementary oxygen. Steroids have little to no role in the management of breathlessness.

In summary, the management of breathlessness in palliative care involves a combination of medications, psychological support, and physiotherapy. Opioids, particularly liquid oral morphine, are highly effective in reducing the sensation of breathlessness. Oxygen and benzodiazepines may also be used, but their roles are limited. Steroids are not typically used in the management of breathlessness.

Diagnosis of Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is the most likely diagnosis based on the information provided in the scenario. The classic tetrad of altered mental state, muscle rigidity, hyperthermia, and autonomic instability, along with other neurological abnormalities such as tremor, dysphagia, chorea, and dysarthria, point towards NMS. The patient’s raised white cell count and creatinine kinase also support this diagnosis. It is possible that the recent use of antiemetic medication such as levomepromazine or haloperidol triggered the syndrome.

It is important to differentiate NMS from serotonin syndrome, which presents with shivering, hyperreflexia, myoclonus, and ataxia, along with diarrhea, nausea, and vomiting. Hyperthermia and muscle rigidity tend to be less severe in serotonin syndrome, and elevations in white cell count and creatinine kinase are less marked. Malignant hyperthermia, which occurs following exposure to certain anesthetic agents, is not likely in this case.

Although MDMA toxicity is a possibility, it is less likely given the patient’s demographic. Rigidity is uncommon in MDMA toxicity, although hyperthermia and rhabdomyolysis can occur. Meningitis is also a differential diagnosis to consider, but the recent change in medication, widespread muscle rigidity, and accompanying raised creatine kinase make NMS the most likely diagnosis.

Refeeding Syndrome in Palliative Care Patients

Artificial feeding is becoming more common in palliative medicine, especially in patients with neurodegenerative conditions. However, it is important to be aware of refeeding syndrome, which can occur in malnourished patients receiving artificial nutrition. Refeeding syndrome is caused by shifts in fluid and electrolytes and can lead to serious complications such as cardiac arrhythmias, pulmonary edema, seizures, and even death. Patients are typically monitored with regular blood tests to check for low levels of potassium, magnesium, and phosphate, which are characteristic of refeeding syndrome.

To identify patients at high risk of developing refeeding syndrome, NICE guidelines on Nutrition support in adults (CG32) recommend looking for a BMI < 16 kg/m2, little or no nutritional intake for > 10 days, and unintentional weight loss greater than 15% within the last three to six months. It is important to be aware of refeeding syndrome in palliative care patients, as many of them may have experienced a period of reduced nutritional intake prior to receiving artificial feeding. By monitoring for and managing refeeding syndrome, healthcare professionals can help ensure the safety and well-being of their patients.

Emergency Treatment for Anaphylaxis

Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate emergency treatment. Even if the patient is an inpatient at a hospice with metastatic bowel cancer, it is still crucial to treat anaphylaxis as an emergency. The symptoms of anaphylaxis can include difficulty breathing, swelling of the face and throat, and a sudden drop in blood pressure.

The guidelines for emergency treatment of anaphylactic reactions recommend using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) method to assess the patient’s condition. After completing the initial assessment, it is essential to call for help and lie the patient flat. The first-line treatment for anaphylaxis is adrenaline (1:1000) 500 micrograms IM. This medication should be given as soon as possible to help reverse the symptoms of anaphylaxis.

Once the initial steps have been taken, high flow oxygen, IV fluids, hydrocortisone, and chlorphenamine can be given to help manage the patient’s symptoms. It is crucial to note that the dose and concentration of adrenaline used for anaphylaxis treatment should not be confused with that given during adult life support (adrenaline (1:10000) 1mg IV). By following these guidelines, healthcare professionals can provide prompt and effective treatment for patients experiencing anaphylaxis.

Haloperidol as the First Choice Antiemetic for Opiate Induced Nausea in Palliative Care

Haloperidol is the preferred antiemetic for opiate induced nausea in the palliative care setting due to its central dopamine antagonist properties. The chemoreceptor trigger zone (CTZ) is rich in dopaminergic receptors, and opioid related nausea is believed to be primarily caused by dopamine pathways in the CTZ. While domperidone and metoclopramide also have central antidopaminergic activity, they are less effective than haloperidol, as much of their antiemetic action is due to their peripheral effects on the gut. Levomepromazine and cyclizine can also be used for opiate induced nausea, but they are not as effective as haloperidol. Levomepromazine has several mechanisms of action, while cyclizine’s effectiveness is limited. Therefore, haloperidol is the correct choice for opiate induced nausea in palliative care.

Hypercalcaemia is a serious metabolic disorder associated with malignancy, with 10% of cancer patients developing it. The most common cancers associated with hypercalcaemia are breast cancer, lung cancer, renal cell carcinoma, and myeloma. The disorder is caused by osteolytic metastases, tumour secretion of parathyroid hormone-related protein, and tumour production of calcitriol. Treatment involves intravenous fluid rehydration and bisphosphonate administration.

When converting from oral morphine to s/c diamorphine, it is important to use the correct conversion factor to avoid under-dosing or over-dosing the patient. The recommended conversion factor is approximately one third of the mg dose of oral morphine.

For a patient requiring 120 mg of oral morphine per day, the correct dose of s/c diamorphine would be 40 mg. Choosing a dose of 20 mg risks under-dosing and inadequate pain relief, while doses of 70 mg and 90 mg risk over-dosing and respiratory depression. A dose of 110 mg is nearly three times the required dose and could lead to respiratory arrest due to opiate overdose.

Therefore, it is crucial to carefully calculate and choose the correct dose of s/c diamorphine when converting from oral morphine.

According to the BNF, the patient should receive a breakthrough dose of morphine 30 minutes before transfer, instead of 1 hour before, as it should last for the transfer back. The appropriate dose for a breakthrough is 1/6th of the patient’s total daily dose, which is 10mg. Therefore, 15mg is too high for this patient. Even though the pain is temporary, it should still be managed to ensure the patient’s comfort and quality of life.

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.

Choosing the Right Analgesic for Colicky Pain

When it comes to treating colicky pain, an antispasmodic agent is the most appropriate choice. Mebeverine is a commonly used antispasmodic, but it is only available in oral preparations and cannot be administered through a subcutaneous syringe driver. Instead, hyoscine butylbromide (Buscopan) is an excellent choice of analgesic for bowel obstruction as it can be given subcutaneously. While opioid analgesics like diamorphine and alfentanil may be beneficial in colicky pain, an antispasmodic should be the first line of treatment. Dexamethasone is sometimes used to reverse intestinal obstruction due to a tumor, but it should not be given over 24 hours in a syringe driver due to its potentially excitatory side effects. Instead, it can be given as one or two subcutaneous injections per day, preferably in the morning. Choosing the right analgesic for colicky pain is crucial in providing effective pain relief for patients.

Treatment of Agitation in Terminally Ill Patients

Agitation is a common symptom in terminally ill patients and requires prompt management. Antipsychotics, such as haloperidol or levomepromazine, are preferred for delirium and can be administered orally or subcutaneously. Benzodiazepines are preferred in patients with alcohol withdrawal, Parkinson’s disease, and dementia with lewy bodies. Depot haloperidol should not be used as it is slow-acting. Aggressive measures such as intubation and mechanical ventilation should only be taken after discussion of treatment goals with the family. Sublingual lorazepam is not the drug of choice for agitation in terminally ill patients. Prompt and appropriate management of agitation can improve the quality of life for terminally ill patients.

Liver Capsule Pain in Metastatic Disease

The patient’s history suggests that the pain they are experiencing is due to liver capsule pain caused by metastatic disease. The liver is surrounded by a collagenous capsule, and any swelling caused by metastases can stretch this capsule, leading to pain. However, liver capsule pain is not typically responsive to opioids, so increasing morphine dosage would not be the best option. Similarly, anti-inflammatory drugs like ibuprofen are effective for muscular or bony pain but may not be the best choice for liver capsule pain. Additionally, the pain does not appear to be neuropathic in nature, so starting a neuropathic agent like gabapentin would not be the correct next step in managing the patient’s pain. the nature of liver capsule pain in metastatic disease is crucial for effective pain management.