QuestionSBA
QuestionChoice
Gabapentin is a medication that can effectively relieve neuropathic pain when combined with other pain medications. However, the dosage of gabapentin must be gradually increased to avoid side effects, so it may not be a suitable choice for a patient who needs rapid pain relief.
62066
d
High dose gabapentin
QuestionChoice
Morphine is a common opioid medication, but its active by-products can build up in the body when the kidneys are not functioning properly, which increases the risk of harmful neuroexcitatory effects if the medication is rapidly increased in dosage. Moreover, it is contraindicated in chronic kidney disease.
62064
b
Morphine
QuestionChoice
Oxycodone is a powerful opioid medication preferred in palliative care patients with severe renal impairment. It is often the **preferred opioid for treating cancer-related pain in patients with chronic kidney disease**. When managing end-of-life care for renal failure or disease patients, oxycodone 1.25 – 2.5 mg is prescribed to alleviate pain. However, it is important to exercise caution as there is a higher potential for opioid toxicity. Therefore, increasing the dosing intervals with the lowest possible dose is necessary to ensure safety.
62063
a
Oxycodone
QuestionChoice
Codeine is contraindicated in patients with kidney failure. Therefore, it is not the best choice in this scenario.
62067
e
Codeine
QuestionChoice
A transdermal fentanyl patch is an effective pain medication for patients who are already taking opioids regularly. It does not produce any active by-products that can accumulate in the body and cause problems in patients with end-stage kidney disease. However, it should only be used in patients who are already tolerant to opioids.
62065
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Transdermal fentanyl patch
QuestionComment
Oxycodone is NOT recommended for end-stage renal failure, only in mild-moderate CKD. In end-stage/severe CKD, analgesics such as fentanyl, alfentanil and buprenorphine should be used.
25625
QuestionComment
Agreed
28565
User
subscriber
Werk the Ward Round
User
subscriber
Amnesia Defibrillator
QuestionComment
Acetaminophen?? Why don't you go the whole way and call it Tylenol
28957
User
subscriber
Supine Kinase
Concept
Chapter
# Summary

Medications in end-of-life care focus on alleviating distressing symptoms in patients nearing death. A holistic approach is vital, considering physical, emotional, and social aspects of symptoms, often involving a multidisciplinary team. For pain management, the WHO pain ladder guides pharmacological strategies, with morphine as the primary strong opioid. Specific treatments for other symptoms depend on the underlying cause and it is important to consider reversible causes and non-pharmacological measures.



# Definition

Medications used in end of life care aim to relieve distressing symptoms which may appear in the last days, weeks, or months of life. They are commonly prescribed as 'anticipatory' or 'just in case' medications for a patient known to be nearing the end of life.


They can be administered:


- Orally - if the patient is safely able to swallow
- Subcutaneously - via single dose or continuous syringe pump
- Transdermally - especially for stable symptoms and if available
- Intramuscularly - less common
- Intravenously - less common, but may be helpful if a patient already has access

## A note on holistic care

In palliative care, and in medicine, it is important to consider all symptoms in context. There are many different aspects to symptoms. These include the physical cause, the patient's beliefs about their illness and symptoms, social contributors and impacts, their emotional and behavioural responses. Holistic assessment and management are crucial, which is why the multidisciplinary team is so important. 

For example, a patient may have been prescribed very effective analgesia but is unable to administer medicines themselves. They may also have a very strong emotional response to pain or believe that they deserve their symptoms. They may benefit from a package of care or financial support for terminal illness which a social worker could help with, or an occupational therapist to help with activities of daily living. Counselling may give the patient a space to explore their feelings around their symptoms and their illness, while spiritual support could alleviate some existential distress. These additional interventions work alongside pharmacological therapy to optimise a person's quality of life through their illness.

This chapter focuses on medications for symptoms towards the end of life, but it is crucial to remember that each patient has a different combination of needs which requires an individual assessment and management plan, often with input from a range of health and social care professionals.

# Pain


Initial pharmacological management of pain should follow the WHO pain ladder. Once patients have reached the top of this ladder (requiring regular strong opioids), careful optimisation is necessary to ensure the right level of pain relief while minimising side effects.

- Morphine is the first-line strong opioid analgesic. This can be given as a modified release or immediate release form. 
- Generally, patients would have a regular 'background' dose based on their 24-hour requirements, plus a PRN dose available for **breakthrough pain.** PRN doses are usually 1/6-1/10 of the 24 hour dose. Analgesia requirements should be reviewed regularly, for example every 24 hours.
- Alternatives to morphine may be necessary for patients with poor renal function. These include oxycodone, alfentanyl or buprenorphine.
- When prescribing opioid analgesia consider co-prescribing a regular laxative and an as-required anti-emetic. Monitor for signs of opioid toxicity (respiratory depression, sedation, myoclonus) and switch to alternatives or dose reduce as necessary.

When switching analgesia, it is helpful to convert the dose first to oral morphine before converting to the desired medication. Please note that different routes also have different equivalent doses, so it is always safest to check guidelines.


The following table shows dose equivalents of 10mg oral morphine


| Analgesic/Route | Dose | Conversion Factor |
| ----------------------------- | ------- | ----------------- |
| Codeine/tramadol/dihydrocodeine oral | 100mg | x10 |
| Diamorphine IM/IV/Subcut | 3mg | x3.3 |
| Morphine IM/IV/Subcut | 5mg | x2 |
| Oxycodone oral\* | 5mg\* | x2\* |
| Oxycodone Subcut\* | 2.5mg\* | x4\* |
| Alfentanil Subcut | 0.3mg | x30 |


*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. If in doubt, always opt for the lower dose and titrate up.


# Breathlessness

Consider non-pharmacological measures for breathlessness first. For example, sitting the patient up, opening a window or setting up a fan can all help.

Pharmacological management may involve low-dose opioids, benzodiazepines or therapeutic oxygen, and should be tailored to the patient.


# Nausea and vomiting

It is important to consider the likely cause of nausea and vomiting, as medications target different parts of the vomiting pathway. Perform a full assessment to determine the likely cause of the nausea and vomiting. Consider parenteral routes of administration - patients may have severe gastrointestinal disturbance or at least may not be able to keep down oral antiemetics long enough to be effective.

The following table shows the primary site of activity and side effects of commonly used antiemetics:

| Antiemetic | Receptor activity | Side effects & cautions | Useful for |
|---|---|---|---|
| Metoclopramide | Dopamine antagonist | Extrapyramidal symptoms, drowsiness, restlessness, diarrhoea. Do not give with antimuscarinics or in mechanical bowel obstruction | Gastric stasis, functional bowel obstruction |
| Cyclizine | Histamine, acetylcholine antagonist | Drowsiness, antimuscarinic | Raised intracranial pressure, vestibular dysfunction |
| Hyoscine | Acetylcholine antagonist | Antimuscarinic | Motion sickness |
| Haloperidol | Dopamine antagonist | Less common in palliative care doses | Chemical |
| Levomepromazine | Dopamine, histamine, acetylcholine, 5HT2 antagonist | Sedation, postural hypotension, antimuscarinic |Broad range |
| Ondansetron | 5HT3 antagonist | Constipation, arrhythmias, movement disorder | Cytotoxic-related |

- For chemically-mediated symptoms (for example medications, metabolic derangemenet), aim to treat the underlying cause. Antiemetics that may be helpful include haloperidol, metoclopramide or levomepromazine.
- For nausea and vomiting due to raised intracranial pressure, cyclizine is usually used first-line. Dexamethasone or radiotherapy may be helpful to reduce the pressure-associated symptoms.
- For patients with vestibular disturbance (for example symptoms associated with movement), cyclizine usually used first-line. Alternatives include hyoscine hydrobromide.
- For patients with bowel obstruction, seek specialist advice. If due to peristaltic failure, review medications and consider starting metoclopramide (providing there is no colic). Likewise for gastric stasis, consider metoclopramide. For patients with mechanical obstruction and/or colic, do not give metoclopramide. Exclude constipation, give cyclizine for nausea and treat colic with hyoscine butylbromide.
- If nausea and vomiting is due to compression from an abdominal or pelvic tumour, cyclizine should be used first-line.
- For anxiety-related nausea and vomiting, begin with non-pharmacological measures for anxiety, such as CBT. A benzodiazepine or levomepromazine would be first-line pharmacological options.

# Agitation

As with other symptoms, aim to manage reversible causes of agitation and possible delirium first. Consider non-pharmacological measures such as environmental modification. For patients in their last days of life, haloperidol or low-dose midazolam may be prescribed. Often, this is done as part of anticipatory prescribing.


# Respiratory tract secretions

Respiratory tract secretions often occur in the last days of life as a person becomes less able to clear their airways. They are rarely a cause of distress to the patient, but may be upsetting for family members or those close to the patient. An antimuscarinic such as hyoscine butylbromide or glycopyrronium bromide may be prescribed for noisy respiratory secretions.


# NICE guidelines


[NICE Guidance: Care of dying adults in the last days of life](https://www.nice.org.uk/guidance/ng31)

[NICE CKS: Palliative care - general issues](https://cks.nice.org.uk/topics/palliative-care-general-issues/)

[NICE CKS: Palliative care - dyspnoea](https://cks.nice.org.uk/topics/palliative-care-dyspnoea/)

[NICE CKS: Palliative care - nausea and vomiting](https://cks.nice.org.uk/topics/)

[NICE CKS: Palliative care - secretions](https://cks.nice.org.uk/topics/)

[NICE CKS: Palliative cancer care - pain](https://cks.nice.org.uk/topics/)

# References

[Pallcare.info](https://www.pallcare.info/book.php)

[BNF: Ondansetron](https://bnf.nice.org.uk/drugs/ondansetron/#drug-action)

[BNF: Nausea and labyrinth disorders](https://bnf.nice.org.uk/treatment-summaries/nausea-and-labyrinth-disorders/)

[BNF: Prescribing in palliative care](https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/)
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Oncology and Palliative Care
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Quesmed Tutorial: Oncology and Palliative Care
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SBAs in Palliative Care Prescribing
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A 60-year-old man presents to the GP with severe lower back pain for the past few days. He has a history of end-stage renal disease on haemodialysis, diabetes mellitus type 2, hypertension, and was recently diagnosed with prostate cancer. He further mentions that the pain (8/10) is severe in the lumbar region and has significant paraspinal muscle spasms. It does not radiate and denies any recent changes in bladder or bowel habits. His current medications include lisinopril, atenolol, insulin, and as needed, acetaminophen.

Physical examination is normal except for tenderness over the lumbar spine and an AV fistula in the left forearm. Vital signs are normal. A CT scan shows lytic lesions in the lumbar spine.

What is the most appropriate treatment for his pain?
a