All of the mentioned medications are antiemetics that can be used to treat nausea. However, cyclizine would be the most appropriate choice as it also possesses anti-histamine properties, which can help alleviate symptoms of vertigo. Ondansetron is a specific 5HT3 antagonist that is particularly effective for patients undergoing cytotoxic treatment. Domperidone acts on the chemoreceptor trigger zone and is also highly beneficial for patients receiving cytotoxic treatment. Metoclopramide directly affects the gastrointestinal tract and is a useful anti-emetic for individuals with gastro-duodenal, hepatic, and biliary diseases. Haloperidol may be considered in end-of-life care situations where other medications have not yielded successful results.

According to NICE, hyoscine butylbromide is recommended as the initial medication for managing nausea and vomiting in individuals with obstructive bowel disorders who are in the last days of life. NICE provides guidance on how to handle these symptoms in the final days of life, which includes assessing the potential causes of nausea and vomiting in the dying person. This may involve considering factors such as certain medications, recent chemotherapy or radiotherapy, psychological causes, biochemical causes like hypercalcemia, raised intracranial pressure, gastrointestinal motility disorder, ileus, or bowel obstruction.

It is important to discuss the available options for treating nausea and vomiting with the dying person and their loved ones. Non-pharmacological methods should also be considered when managing these symptoms in someone in the last days of life. When selecting medications for nausea and vomiting, factors such as the likely cause and reversibility of the symptoms, potential side effects (including sedation), other symptoms the person may be experiencing, and the desired balancing of effects when managing other symptoms should be taken into account. Additionally, compatibility and potential drug interactions with other medications the person is taking should be considered.

For individuals in the last days of life with obstructive bowel disorders who have nausea or vomiting, hyoscine butylbromide is recommended as the first-line pharmacological treatment. If the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide, octreotide may be considered as an alternative option.

For more information, refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

Here are some recommendations from NICE on how to manage breathlessness in the final days of life:

1. First, it is important to identify and treat any reversible causes of breathlessness in the person who is dying. This could include conditions like pulmonary edema or pleural effusion.

2. Non-pharmacological methods can also be considered for managing breathlessness in these individuals. It is not necessary to automatically start oxygen therapy for breathlessness. Oxygen should only be offered to those who are known or suspected to have low oxygen levels causing symptoms.

3. Breathlessness can be managed using medications such as opioids or benzodiazepines. These can be used individually or in combination, depending on the needs of the person.

For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

There is no indication for an independent psychiatric evaluation of this patient. However, it is important to clearly document in his medical records that you have assessed his mental capacity and determined that he is capable of making decisions. It would not be appropriate in this case to refer him to a specialist against his wishes or to breach confidentiality by discussing his illness with his family or next of kin. According to the guidelines set by the General Medical Council (GMC), it is necessary to document the fact that the patient has declined relevant information. It is also important to avoid pressuring the patient to change their mind in these circumstances.

For further information, please refer to the GMC guidelines on treatment and care towards the end of life: good practice in decision making.

When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.

For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.

When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.

In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.

For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140

An advanced decision is a legally binding document that allows individuals to express their preferences for end-of-life care in advance. It serves as a means of communication between patients, healthcare professionals, and family members, ensuring that the patient’s wishes are understood and respected. In situations where a patient becomes unable to make informed decisions about their care due to the progression of their illness, an advanced directive can help prevent any confusion or disagreements.

According to the General Medical Council (GMC), if there is a significant difference of opinion within the healthcare team or between the team and the patient’s loved ones regarding the patient’s care, it is advisable to seek advice or a second opinion from a colleague who has relevant expertise. In this particular case, it would be wise to consult a palliative care specialist to help resolve the disagreement between yourself and the patient’s wife.

For more information, you can refer to the GMC guidelines on treatment and care towards the end of life, which provide guidance on good practice in decision making.

Here are some suggestions for managing breathlessness in the final days of life, as provided by NICE:

1. It is important to identify and treat any reversible causes of breathlessness in the dying person, such as pulmonary edema or pleural effusion.

2. Non-pharmacological methods can be considered for managing breathlessness in someone nearing the end of life. It is not recommended to start oxygen therapy as a routine measure. Oxygen should only be offered to individuals who are known or suspected to have symptomatic hypoxemia.

3. Breathlessness can be managed using different medications, including opioids, benzodiazepines, or a combination of both.

For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

This patient’s symptoms are consistent with a diagnosis of oesophageal candidiasis, which is commonly seen in patients undergoing treatment for haematopoietic or lymphatic malignancies.

The classic combination of symptoms associated with oesophageal candidiasis includes dysphagia, odynophagia, and retrosternal pain. This infection can be life-threatening and often requires hospital admission.

The recommended treatment for oesophageal candidiasis is as follows:

– First-line treatment involves taking oral fluconazole at a daily dose of 200-400 mg.
– If the patient is unable to tolerate oral treatment, intravenous fluconazole can be used instead.
– Second-line treatment options include oral itraconazole, oral posaconazole, or intravenous or oral voriconazole.

It is important to seek medical attention promptly for oesophageal candidiasis, as timely treatment is crucial in managing this potentially serious infection.

When dealing with a terminally ill patient who is still lucid and alert and able to drink oral fluids, it is sensible to encourage them to take frequent sips of fluids to maintain hydration and alleviate symptoms of a dry mouth. According to NICE guidelines, it is important to support the dying person in their desire to drink if they are capable and willing. However, it is crucial to assess any difficulties they may have with swallowing or the risk of aspiration. It is recommended to have a discussion with the dying person and those involved in their care to weigh the risks and benefits of continuing to drink.

In addition, it is essential to provide regular care for the dying person’s mouth and lips, including managing dry mouth if necessary. This can involve assisting with teeth or denture cleaning if desired, as well as offering frequent sips of fluid. It is also encouraged to involve important individuals in the dying person’s life in providing mouth and lip care or giving drinks, if they are willing. Necessary aids should be provided, and guidance on safe drink administration should be given.

The hydration status of the dying person should be assessed on a daily basis, and the potential need for clinically assisted hydration should be reviewed while respecting the person’s wishes and preferences. It is important to discuss the risks and benefits of clinically assisted hydration with the dying person and their loved ones. It should be noted that while clinically assisted hydration may relieve distressing symptoms related to dehydration, it may also cause other problems. The impact on life extension or the dying process is uncertain whether hydration is provided or not.

Before initiating clinically assisted hydration, any concerns raised by the dying person or their loved ones should be addressed. An individualized approach should be taken into account, considering factors such as the person’s expressed preferences, cultural or religious beliefs, level of consciousness, swallowing difficulties, thirst level, risk of pulmonary edema, and the possibility of temporary recovery.

If the person exhibits distressing symptoms or signs associated with dehydration, such as thirst or delirium, and oral hydration is insufficient, a therapeutic trial of clinically assisted hydration may be considered. Monitoring for changes in symptoms or signs of dehydration, as well as any evidence of benefit or harm, should be conducted at least every 12 hours for those receiving clinically assisted hydration. If there are signs of clinical benefit, the hydration should be continued. However, if there are indications of potential harm, such as fluid overload, or if the person no longer desires it, the clinically assisted hydration should be stopped.

When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.

For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.

When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.

In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.

For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140