Symptom control & end of life flashcards
18 high-yield MRCP Part 1 cards from the Intellect Medicos Geriatrics & Palliative Care course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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A palliative patient becomes agitated and confused. Name three reversible causes to look for before giving sedatives.
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Any three of: hypercalcaemia, infection, urinary retention, drugs (e.g. opioid toxicity), constipation.
Why? Treating the cause can settle agitation without sedation.
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What is the first-line drug for agitation and confusion (delirium) in palliative care?
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Haloperidol.
Why? It treats delirium without heavy sedation. Levomepromazine or chlorpromazine are alternatives.
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Which drug is used for terminal agitation (restlessness in the last days of life)?
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Midazolam, given SC or by syringe driver.
Why? It is a short-acting benzodiazepine that sedates and relieves distress when the cause cannot be reversed.
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Name two drugs used for noisy respiratory secretions ("death rattle") at the end of life.
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Any two of: hyoscine butylbromide, hyoscine hydrobromide, glycopyrronium bromide, atropine.
Why? These antimuscarinics reduce new secretion production but do not clear secretions already present. They can take up to 12 hours to work (NICE NG31).
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Which antimuscarinic for respiratory secretions crosses the blood–brain barrier and may cause sedation or confusion?
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Hyoscine hydrobromide.
Why? It is a tertiary amine and enters the CNS. Hyoscine butylbromide and glycopyrronium are quaternary and do not.
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Besides drugs, what are the two key steps for terminal respiratory secretions?
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Explain to the family (it is often more distressing for them than for the patient) and avoid excess IV fluids.
Why? Extra fluid increases secretions; repositioning also helps.
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Which drug is licensed in the UK for intractable hiccups?
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Chlorpromazine.
Why? Other options: haloperidol, metoclopramide, baclofen, gabapentin, nifedipine.
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Which drug is added for hiccups caused by hepatic or cerebral metastases?
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Dexamethasone.
Why? It reduces tumour oedema that irritates the diaphragm/phrenic pathway (liver) or the brainstem.
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What is the classification of senna, and of docusate sodium, as laxatives?
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Senna is a stimulant laxative; docusate is mainly a stool softener (it also has a weak stimulant action).
Why? For opioid constipation the BNF advises a regular stimulant laxative first, adding an osmotic laxative (e.g. macrogol) if it is not enough.
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Which two drugs are used for breathlessness in the last days of life?
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Morphine (opioid) and midazolam (for associated anxiety).
Why? Opioids reduce the sensation of breathlessness; a benzodiazepine helps when anxiety drives it.
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Name three indications for a syringe driver in palliative care.
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Any three of: unable to swallow (dysphagia), persistent nausea/vomiting, bowel obstruction, coma/reduced consciousness, last days of life.
Why? It gives a continuous subcutaneous infusion, so drugs keep working when the oral route fails.
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Syringe drivers now used in UK palliative care (e.g. the T34) have their infusion rate set in ______.
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ml per hour
Why? The older Graseby drivers were set by syringe length: MS16A in mm per hour and MS26 in mm per 24 hours. Mixing them up caused serious dosing errors, so they were phased out after a 2010 NPSA alert.
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Name a syringe-driver drug for each of: pain, agitation, nausea and secretions.
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Pain: morphine/diamorphine. Agitation: midazolam. Nausea: haloperidol or cyclizine. Secretions: hyoscine butylbromide or glycopyrronium.
Why? These are the standard anticipatory and syringe-driver drugs at the end of life.
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For which five symptoms should anticipatory ("just in case") medicines be prescribed in the last days of life?
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Pain, breathlessness, nausea and vomiting, anxiety/agitation/delirium, and noisy respiratory secretions.
Why? Prescribing in advance means relief is available immediately when the oral route is lost.
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Which antiemetic is first-line for nausea caused by drugs or metabolic upset (e.g. opioids, hypercalcaemia, renal failure)?
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Haloperidol.
Why? These causes act on the chemoreceptor trigger zone, where haloperidol blocks D2 receptors.
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Which antiemetic is first-line for nausea from gastric stasis (e.g. squashed stomach from hepatomegaly)?
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Metoclopramide.
Why? It is a prokinetic: D2 antagonist plus 5-HT4 agonist that speeds gastric emptying.
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Which antiemetic is preferred for nausea from raised intracranial pressure?
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Cyclizine (with dexamethasone to reduce cerebral oedema).
Why? Cyclizine is an H1 antihistamine (with antimuscarinic action) that acts on the vomiting centre.
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Which broad-spectrum, sedating antiemetic is used second-line when nausea persists in palliative care?
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Levomepromazine.
Why? This phenothiazine blocks several receptors (D2, H1, 5-HT2, muscarinic); at higher doses it is also used for terminal agitation.