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Version 5.3
PLAB 1 Keys is for PLAB-1 and UKMLA-AKT (Based on the New MLA Content-Map)

Corrected, Updated, Lighter

With the Most Recent Recalls and the UK Guidelines

ATTENTION: This file will be updated online on our website frequently!
(example: Version 2.7 is more recent than Version 2.6, and so on)

Key Pain ladder (Analgesia Ladder)

1

1) Simple analgesia → Paracetamol, NSAIDs, Aspirin.

2) Weak opiates → Codeine, Tramadol, Dihydrocodeine.
3) Strong opiates → Morphine, Fentanyl patches, Diamorphine, Oxycodone.

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Key If bowel obstruction occurs due to advanced malignancy or as a

2 complication of chemotherapy, conservative treatment is not an
option as in most cases it fails.

So, → Palliative colostomy can help alleviate the symptoms.

However, NGT can be used as an initial step to decompress the

stomach especially if the obstruction has caused vomiting of fecal
matters.

Key A palliative care patient with End-stage lung cancer that metastasized to bone
3 presents with worsening cough, SOB, pleuritic chest pain. X-Ray chest shows
Pleural Effusion. What is the best management to relieve his symptoms?

→ Pleural Aspiration.

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Pleural effusion

√ Pleural aspiration the best single management for relieve of pleural effusion
even if in palliative care patients (even if in their last hours).
√ However, if the patient is extremely ill, stopped talking or drinking, cannot
walk, or unconscious, he would not be fit for x-ray and pleural aspiration. In
this case, we would consider morphine to help with his SOB. But in general,
pleural aspiration is the management.

Key ◙ If an outpatient who is on Oral Morphine develops Side Effects (e.g.

4 drowsiness, Nausea, Vomiting)

→ Shift to Oral Oxycodone. √

√ Oxycodone is double the potency of the morphine but with fewer side
effects.

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√ Remember, we should not go back on the pain ladder, we either go

forwards, ↑ dose, replace to a stronger option or add-on. (No Backward on
the ladder).

Key ◙ The First-line Anti-emetic for nausea and vomiting 2ry to (increased
5 intracranial pressure) is → Cyclizine.

◙ Example,
A patient with glioblastoma presents with nausea and vomiting.
→ Cyclizine

√ Glioblastoma (intracranial tumour) → (↑ ICP) → N., V.

√ Remember that (Dexamethasone) can also help relieve the increased

intracranial pressure by shrinking the edema around the tumour and thus
relieve the nausea and other symptoms.

Key An end stage mandible cancer patient with bone metastasis presents with
6 Hypercalcemia (Ca++ >2.6)

It is written on her records (do not resuscitate = DNR).

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What should be done?

DNR = do not perform CPR (Cardiopulmonary Resuscitation), not treatment!

So, we shall treat this hypercalcemia

1) Initial → IV fluids (+)

2) Then → IV Bisphosphonate (e.g. IV Zoledronic acid “Zoledronate” or

Alendronate)

The question might mention some features of hypercalcemia such as:

• Neuro → lethargy, Confusion, Depression.
• GIT → Constipation, Nausea, Vomiting
• Renal → polyuria (increased urination), Polydipsia (Thirst).
• CVS → ECG: Short QT interval.

The stem may also mention that IV fluid (e.g. IV crystalloid) has been given,
thus, the next step would be

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→ IV Bisphosphonate (IV Zoledronic acid).

Key If a patient is in a hospice for palliative care develops severe bleeding (eg,
7 hematemesis), what should be done?

→ Administer subcutaneous Midazolam and Morphine.

√ Patients in hospice for palliative care should be offered a (rest in peace)

death. i.e., peaceful death. The aim is not to shorten or prolong their lives, but
to try to provide a more comfortable last hours of life while dying.

Massive bleeding in a palliative patient → Give SC midazolam and morphine

These medications help manage pain and anxiety, ensuring the patient
remains comfortable during severe episodes such as massive bleeding.
This approach aligns with the principles of palliative care, aiming to provide a
dignified and peaceful death for patients in their final stages of life.

Key Very Important Collection

8

♠Bone pain due to bone metastasis → Radiotherapy. (1st line)

If failed → Bisphosphonate + NSAIDs (eg, Naproxen) (2nd line)

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Need more pain control? → Opioid (eg, morphine, oxycodone). Or vice versa.

• Q1: if the pain is acute and developed after radiotherapy, give

→ Oral morphine sulphate. Imp √.

• Q2: A man with bone metastasis is on paracetamol, and immediate and

prolonged release oxycodone (opioid). There is still pain, what to add on?
→ NSAIDs eg, Naproxen. Imp √.
(All asked previously, be careful).

♠Neuropathic pain

→ Gabapentin, Amitriptyline, Pregabalin, Duloxetine

Anyone could be the correct answer (imp √).

♠Trigeminal neuralgia → Carbamazepine = (Anticonvulsant).

Key Patient on Morphine develops side effects (e.g. drowsiness, nausea)

9

→ Replace morphine by oxycodone

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*Fentanyl patches have a slow onset of action; therefore, they should be

avoided in a patient who is still in pain at the presentation time.

Key A patient who had undergone radical prostatectomy due to prostate cancer
10 last year has now developed severe thigh pain that sometimes radiates to
back. He is on morphine but still in pain.

→ Radiotherapy (bone metastasis).

√ The gold standard for bone metastasis is (MRI), followed by (Bone

Scintigraphy).

Remember:

The commonest Origins of Bone Metastasis

(commonly affects Spine, then pelvis, then ribs, then skull and long bones)

In Males ♂ → PROSTATE then Lung.

In Females ♀ → BREAST then Lung.

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Key In patient on oral morphine who are still in pain and need to take additional
11 dose PRN (Breakthrough) to achieve pain relief:

We need to calculate The Main Dose + The Breakthrough Dose

◙ The main dose:

(sum all amounts of morphine that is already being received by a patient in 24
hours to achieve his relief) then (divide it by 2 – so you can give it twice a day
as a main dose).

◙ The breakthrough dose (= the additional dose).

Take 1/6 (the total daily dose given PRN 4 hourly)
(i.e. the total main dose ÷ 6)
Or
10% of the total daily dose given PRN 4 hourly

Example (1)

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A patient with bone metastasis on oral morphine needs to take 60 mg

twice a day + 20 mg each 4 hours to relieve her bone pain. What should be
the new regimen for analgesia?

◘ Let’s first calculate the total dose in 24 hours

60 twice a day = 120
20 mg 4 hourly = 20 mg X 6 times a day = 120

So, the total dose is 120 + 120 = 240

◘ Now, for the new Main dose, divide the total by 2

The main dose → 240 ÷ 2 = (120 mg Twice a day)

◘ Now for the breakthrough (additional dose)

The total dose ÷ 6 → 240 ÷ 6 = 40 PRN 4 hourly

◙ So, the answer → 120 mg twice a day + 40 mg PRN 4 hourly

For the breakthrough dose, it is also valid to take 10% of the total dose
(instead of 1/6)
10% of the 240 mg = 24 mg

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→ 120 twice a day + 24 PRN (possible also)

Note, PRN = Per need = As needed.

Example (2)
A female patient with multiple myeloma has severe back pain. She is on
morphine 30 mg twice a day. She sometimes takes additional 3 to 4 doses to
control her pain. The palliative team decided to raise her dose by third (1/3).
What should be the new regimen.

♦ Her current total dose is 30 twice a day = 30 X 2 = 60 mg.

♦ The team will increase it by 1/3

So, the third of the 60 is 20.

So, the new main total dose will be (60 + 20 = 80 mg).

80 mg to be taken twice a day → 40 mg twice a day.

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♦ Regarding the breakthrough (additional PRN dose)

1/6 of the total dose

1/6 of 80 = (80 ÷ 6 = around 13)

So, the breakthrough (additional dose) will be

13 mg 4 hourly (6 times a day as needed).

→ 40 mg twice a day + (10 to 15 mg up to 6 times a day as needed).

Please note that the breakthrough dose is now commonly given as 10% of the
total main dose instead of 1/6. So, if you find in the options 8 mg 6 times as
needed, this could be a valid answer. (you won’t find both)!

The breakthrough dose for this example is either one of the following:

◙ 10% of the total dose = 80 ÷ 10 = 8 mg 4 hourly (6 times) as needed. Or:

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◙ 1/6 of the total dose = 80 ÷ 6 = 13 mg (i.e. 10 to 15) 4 hourly (6 times) as

needed

Example (3)
A patient with advanced cancer takes 10 mg Oramorph (oral solution of
morphine sulphate 10mg/5ml) every 4 hours to control his pain. His GP
decided to give him the same dose of morphine sulphate as a modified
release tablet. What will be dose and frequency?

◙ Calculate the total dose per 24 hours:

10 mg every 4 hours
→ in 24 hours: her receives 10 X 6 = 60 mg.

◙ Divide them by 2 to be given twice a day:

→ 60/2
= 30 mg BD.

Key A patient with a terminal stage prostate cancer with bone metastasis in
12 severe pain presents asking for a medication to end his life.

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√ Refer to Hospice Care (it is a place where palliative care is given to patients
with terminal illnesses and help alleviate their pain and suffering while dying.
It also involves a lot of other fields of support such as psychological, emotional
and social).

√ Euthanasia (a painless killing of a patient with a terminal disease) is a CRIME

in the UK!

Key Regarding death certificate

13

• In the 1a part of the death certificate, write the “Disease or condition

directly leading to death” clearly and specifically.

Examples
◙ Write → [Small cell carcinoma of the main right bronchus] instead of just
“Lung cancer”.

◙ Write → Inferior Myocardial Infarction

Instead of “coronary thrombus/ Cardiac arrest/ Cardiovascular event/ Acute
coronary syndrome…etc”

◙ Write → Pneumonia of the left lower lobe of the left lung

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Instead of “lung infection/ respiratory failure”

• AVOID vague terms and modes of dying such as (Respiratory distress/

Cardiac arrest/ Cardiovascular event/ Chest infections/ Cardiovascular event).

• Never use abbreviations!

• Write the date of death using (Words) NOT (Figures).

Example
◙ Write → the Fourth day of July (instead of 04/07).

Key Remember, in the analgesia ladder, we can add-on another stronger or of the
14 same potency level analgesics. However, we cannot go back on the ladder to a
weaker analgesic.

Example,
A palliative patient in a hospice for end-of-life care due to terminal non-
Hodgkin lymphoma. She has severe pain in the abdomen and chest. She is
using Fentanyl patches but still in pain. What should be done?

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→ Keep Fentanyl patch but Add SC Morphine sulphate.

√ Both are step 3 on the pain relieve ladder.

√ As the patient is dying, no need to remove the patch or replace it with
morphine.

Key Regarding Codeine Phosphate (Step 2 on the ladder).

15

√ There is nothing called (Subcutaneous) Codeine. Thus, “subcutaneous

codeine” will always be a wrong answer.

√ Oral Codeine has very high rate of side effects (nausea, vomiting,
constipation, confusion) and the young barely tolerate it. Therefore, in the
elderly, do no give Codeine!

√ Oral Codeine, if led to side effects such as nausea, can be replaced by either:
♦ Buprenorphine patch (Optimal! If given in the choices, pick it unless the
patient is currently in pain, as it takes some time to work).
Or
♦ Subcutaneous morphine.

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Example
A terminal bladder cancer patient has lower abdominal pain that is well
controlled with Oral Codeine Phosphate. However, he is nauseous, and finds
it difficult to keep taking oral medications as he is week to swallow. What
should be done?

◙ Oral codeine can be replaced by either

√ Buprenorphine patch (best option if given), or
√ Subcutaneous Morphine.
◙ Note that he cannot tolerate orally, thus any oral option is WRONG!
◙ Also, Fentanyl patch is inappropriate as it is very potent compared to his
current method of pain control. It will be an unnecessary exposure to more
opioids (Overdose).
◙ Finally, there is no Subcutaneous form of Codeine!

Key A patient with liver metastasis has Right hypochondriac pain. He is on

16 Paracetamol and Morphine sulphate. However, the pain intensity increases
sometimes. What should be added to manage his pain?

√ Liver pain is due to stretching of the liver capsule during enlargement (liver
has no nerve fibres).

√ Capsular pain responds well to → NSAIDs (eg, Ibuprofen/ Naproxen).

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√ Note, adding on Codeine is wrong. The patient is already on a stronger

opioid (Morphine), we do not get back on the pain ladder.

So, the answer is → Ibuprofen or Naproxen (capsular pain responds well to

NSAIDs).

Very Important:
• If the patient is already susceptible to thrombotic risk or GI bleeding, in case
he uses NSAIDs (eg, if the patient is already on Aspirin, Rivaroxaban),
→ DO NOT give NSAIDs to control liver pain due to metastasis.
• Instead, give → Dexamethasone (It is also useful in relieving the sharp
stabbing liver pain that results due to liver capsule stretched due to cancer).

Key √ Remember, we should not go back on the pain ladder, we either go

17 forwards, ↑ dose, replace to a stronger option or add-on. (No Backward on
the ladder).

Example,
A prostate cancer with bone metastasis patient has very severe back pain
that is no longer controlled by Codeine and Naproxen (NSAIDs). What should
be done?

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→ Replace Codeine (step 2) with Oral Morphine (step 3)

♦ Do not pick dihydrocodeine or tramadol (same step on the ladder), move

up on the ladder!
♦ Also, do not pick (Oxycodone) as it might cause an opioid overdose (it is the
double potency of morphine).
♠ We shall try Morphine first before oxycodone while climbing up the ladder.
♠ If morphine results in intolerable side effects such as nausea and vomiting,
we might then try oxycodone as cleared previous (it has more potent and with
less side effects).

Key Anticipatory Medications

18
(Every single word is important!)

♠ These are “just in case” medications that are allowed to be given to a

palliative patient during his/ her last days in life (ie, end-of-life care).

♠ They are typically given SUBCUTANEOUSLY! “Important”

♠ They are aimed at making the death more comfortable, and hence, they
cover the following main possible complaints in a dying individual:

◘ Pain and Breathlessness → SC Morphine.

◘ Nausea and Vomiting (eg, end-stage bowel obstruction in palliative patient)

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→ SC Haloperidol or SC Cyclizine.

◘ Anxiety, Delirium, Agitation → SC Midazolam.

◘ Noisy/ Excessive Respiratory Secretions (Death Rattles)

→ SC Hyoscine Butylbromide or SC Glycopyrronium.

Glycopyrronium and hyoscine are anticholinergic medications, typically given

subcutaneously. They reduce the excessive respiratory secretions by blocking the
action of acetylcholine and therefore reduce the discomfort and risk of aspiration.

Important Notes (Recently Asked):

• If a lung cancer patient is active, moving around, able to eat and drink,
vitally stable in general (ie, not in their last days of life) and developed
wheezes and breathlessness → Give Nebulized Salbutamol (Bronchodilators),
NOT SC Morphine even if the patient is having lung cancer and is under
Palliative register.
• SC Morphine is the choice if the patient is dying, to help them die in peace.
Eg, if the same lung cancer patient with end-stage cancer, has dyspnea and
wheezes, not eating or drinking, not active, his vitals are deteriorated, go for
SC morphine in such a case (End-of-life care).

Quick Scenarios:

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◙ An elderly man with severe dementia has developed excessive

respiratory secretions that cause noisy breathing, discomfort, rhonchi:

→ Subcutaneous hyoscine or glycopyrronium.

◙ An elderly man with advanced colorectal cancer is suspected to have

bowel obstruction. He has nausea and vomiting. He refuses any kind of
surgery or invasive procedures:

→ Subcutaneous cyclizine or haloperidol.

◙ An elderly man with advanced lung cancer who is unable to eat, drink,
move freely. His vitals are deteriorating. He has dyspnea and wheezes:

→ Subcutaneous morphine.

◙ An elderly man with advanced lung cancer who is able to eat, drink,
move freely. His vitals are within normal. He has dyspnea and wheezes:

→ Nebulised salbutamol (bronchodilators).

Key ♠ Intractable Hiccup due to liver cancer → Metoclopramide. Others:

19
Domperidone, Nifedipine. “Useful for peripheral hiccups”
(Peripheral hiccup due to diaphragmatic irritation by liver metastasis “irritates
phrenic nerve” → hiccup).
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♠If Metoclopramide, Domperidone, Nifedipine are not given within the

options, pick

→ Chlorpromazine. “useful for central hiccups e.g., brain tumor, or if liver

cancer but metoclopramide, domperidone, or nifedipine are tried but failed or
if they are not given in the options in case of liver cancer.”

Key Very Important: Anti-emetics for Nausea and Vomiting

20

◙ Anti-emetic in renal failure/ Hypercalcemia (metabolic cause) or Drug or Toxin

induced vomiting
→ Haloperidol. (1st line)

◙ However, if there is associated Parkinson’s disease, Haloperidol is

contraindicated! Instead of Haloperidol, we use instead:
→ Levomepromazine. (2nd line).
If not in the options, pick → Cyclizine.

◙ Anti-emetic in case of ↑ ICP (e.g., intracerebral tumour) or vomiting due to

bowel obstruction
→ Cyclizine.

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◙ Anti-emetic in case of “delayed gastric emptying e.g., peritoneal metastasis

causing partial bowel obstruction”:
→ Metoclopramide “a prokinetic”.

(Never use Haloperidol with Parkinson’s)!

◙ Anti-emetic due to Chemotherapy, Radiotherapy

→ Ondansetron. √

◙ Anti-emetics in Hyperemesis gravidarum (after giving IV fluids):

√ 1st line: “zine” family e.g. Cyclizine, Promethazine

√ 2nd line: IV Metoclopramide, Ondansetron

√ 3rd line: Steroids

◙ Vertigo (e.g., Meniere’s/ BPPV/ Vestibular neuritis)

→ Buccal Prochlorperazine.

Key Regarding Valid Prescription

21

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◙ The quantity of any controlled drug (e.g. Morphine) must strictly be

written in both Words and Figures!

e.g.
Morphine 10 mg modified release capsules
Supply 62 (sixty-two) capsules
Take one capsule twice a day

If the words (sixty-two) are not written → the prescription will be legally
rejected by a pharmacist!

So, the (Quantity) not the (strength) of the controlled-drug is what matters
the most!

Others

√ The doctor’s (signature) must be handwritten but the prescription itself

does not have to be handwritten.

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√ The age and date of birth of patient are better written but not legally
required unless if < 12 YO.

Key Liver cancer + Hiccups.

22

Give → Metoclopramide

Key A patient with gastric ulcer needs analgesics. He is on paracetamol and is

23 allergic to diclofenac (NSAIDs). What should be given next?

→ Tramadol. (2nd step on the analgesia ladder + Safe in Gastric ulcers).

Pain ladder (Analgesia Ladder)

Simple analgesia → Paracetamol, NSAIDs, Aspirin.

Weak opiates → Codeine, Tramadol, Dihydrocodeine.
Strong opiates → Morphine, Fentanyl patches, Diamorphine, Oxycodone

Key A patient with a terminal stage prostate cancer with bone metastasis in
24 severe pain presents asking for a medication to end his life.

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√ Refer to Hospice Care (it is a place where palliative care is given to patients
with terminal illnesses and help alleviate their pain and suffering while dying.
It also involves a lot of other fields of support such as psychological, emotional
and social).

√ Euthanasia (a painless killing of a patient with a terminal disease) is a CRIME

in the UK!

Key A patient who had undergone radical prostatectomy due to prostate cancer
25 last year has now developed severe thigh pain that sometimes radiates to
back. He is on morphine but still in pain.

→ Radiotherapy (bone metastasis).

√ The gold standard for bone metastasis is (MRI), followed by (Bone

Scintigraphy).

The commonest Origins of Bone Metastasis

(commonly Spine, then pelvis, then ribs, then skull and long bones)

In Males ♂ → PROSTATE then Lung.

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In Females ♀ → BREAST then Lung.

♠ Bone pain due to metastasis → Radiotherapy.

Others → NSAIDs, Opioids.
♠ Neuropathic pain → Gabapentin, Amitriptyline, Pregabalin, Duloxetine.

Key ◙ An elderly with metastatic colorectal carcinoma presents with

26 colicky abdominal pain, vomiting of fecal content. O/E, the
abdomen is distended with high-pitched bowel sound.

The most appropriate management to relieve his symptoms

→ NGT “Nasogastric tube”.

NGT is used in palliative patients if:

√ vomiting of fecal contents, or:
√ Persistent vomiting that does not respond to anti-emetics (e.g. cyclizine).

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Key ◙ An elderly female with end-stage breast cancer admitted 5 days

27 ago for abdominal pain. She has not opened her bowel nor eaten
anything for the last few days. She cannot take her oral medication
as she finds it difficult to swallow. She lacks capacity. Her daughter
is concerned about her mother’s oral intake.

The appropriate action → encourage small sips of water and mouth care.

This patient is dying. The palliative care objection here is to ensure a peaceful
and comfortable death. Mouth care and being moisture is what matters here
as she is already in her last days.

Key ◘ Noisy Respiratory Secretions and gurgling sounds in a late cancer patient
28

→ Subcutaneous Hyoscine Butylbromide. Or Glycopyrronium (Not orally!)

They are antimuscarinic.

Another correct answer → Glycopyrronium Bromide Subcutaneously.

Another correct answer → Antimuscarinic = Anticholinergic.

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Key ◙ A cancer patient on paracetamol and codeine. However, his pain is still
29 uncontrolled. What to do?

→ Shift to morphine

We never go back in the pain ladder.

Key A Colorectal cancer patient is visited at home by palliative care team. He

30 takes codeine to manage his abdominal pain. However, he does not want
oral medications as he finds it difficult to swallow. He has not taken codeine
for the last 2 days and thus he is in pain now. What should be given instead?

→ Subcutaneous Morphine.

◙ SC is preferred over IV in Palliative Care patients.

◙ Do not give patches (e.g. Buprenorphine patch) if the patient is currently in
pain as these patches need some time to start working.

Key 60-year-old man with metastasized bladder cancer on SR morphine.

31

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Pain is not controlled and thus the dose was increased. He also Had to
increase oral morphine too. However, the pain is still not controlled.

A. Add NSAID
B. change to SC morphine
C. change to hydromorphine
D. fentanyl patch
E. Change morphine to oxycodone

√ Oxycodone is double the potency of the morphine but with fewer side
effects.

√ Remember, we should not go back on the pain ladder, we either go

forwards, ↑ dose, replace to a stronger option or add-on. (No Backward on
the ladder).

√ Fentanyl patches have a slow onset of action; therefore, they should be

avoided in a patient who is still in pain.

Key A 52-year-old female with metastatic breast cancer to the lungs with dry
32 cough. Cough not responsive to linctus. Responded minimally to codeine for
7 days. What is the most appropriate management?

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A Nebulized normal saline

B Nebulized local anaesthetic agent
C Oral Morphine
D Oral antibiotics
E Oral steroids

√ As the cough has responded “minimally” to codeine which is a “weak

opiate”, it is likely to respond better to a strong opiate “oral morphine”.
√ Morphine inhibits the central cough reflex.

Key An elderly woman with breast Ca and cerebral metastasis presents to A and
33 E Complaining of headache and intractable vomiting. Most appropriate
medication to prescribe?

A. Dexamethasone
B. Haloperidol
C. Metoclopramide
D. Promethazine

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♦ In intracranial tumour

→ Give high does dexamethasone “initially” to shrink the mass and edema
and therefore alleviate the headache and the other symptoms.

♦ Note, if GCS is ≤ 8, we give “Mannitol” as it has a very rapid action.

Otherwise, we start with corticosteroids (high dose dexamethasone is
preferred).

♦ In Intracranial Hemorrhage with Very Low GCS and Neurological deficit (e.g.
Unequal Pupils)
→ Urgent Craniotomy

Key An old man with metastasis from Cancer Bronchus. Investigations:

34 hypercalcemia, others normal. What’s the appropriate initial treatment?

a) 0.9% NaCl “Normal Saline”

b) Bisphosphonates
c) Calcitonin
d) Dexamethasone

The initial step to correct hypercalcemia → IV Normal Saline.

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The next step would be Bisphosphonate.

Key A 68-year-old man with upper abdominal pain. Has colon cancer which has
35 metastasized to the liver. He refuses morphine because of previous bowel
obstruction and constipation. Paracetamol has minimal effect on pain. Liver
enzymes are deranged. What pain relief should be prescribed?

a) Naproxen
b) Codeine
Amitriptyline
d) Gabapentin

Liver metastasis → Capsular pain (Responds well to NSAIDs such as Ibuprofen

and Naproxen).

♠ Capsular pain (liver) → NSAIDs (e.g. Ibuprofen/ Naproxen ).

Key A question about Hiccups due to Liver metastasis. Most appropriate

36 management?

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A. Metoclopramide
B. Haloperidol

♠ Intractable hiccup due to liver metastasis → Metoclopramide

Key Patient with advanced ovarian carcinoma with gaseous distension and
37 intermittent pain. The most DEFINITIVE Rx?

A. Hyoscine Butylbromide
B. SC morphine
C. Palliative stoma
D. NG tube

If bowel obstruction occurs due to advanced malignancy or as a

complication of chemotherapy, conservative treatment is not an option
as in most cases it fails. So, the answer for this question is C. Palliative
colostomy.

However, if the patient is vomiting fecal contents, to relieve the symptoms,

initially insert NGT.

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Key An immunocompromised elderly patient with previous history of PE and MI.

38 Taking Medications for COPD for 10 years. Complained of breathlessness
and Coughing. Pneumonia is diagnosed and died after few hours. X-ray
showed Multiple patchy Opacities. What will be filled in the 1a part of the
death certificate?

A. COPD
B. Pneumonia
C. Lung Failure
D. Chest Infections.

Regarding death certificate

• In the 1a part of the death certificate, write the “Disease or condition

directly leading to death” clearly and specifically.

Examples
◙ Write → [Small cell carcinoma of the main right bronchus] instead of just
“Lung cancer”.

◙ Write → Inferior Myocardial Infarction

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Instead of “coronary thrombus/ Cardiac arrest/ Cardiovascular event/ Acute

coronary syndrome…etc”

◙ Write → Pneumonia of the left lower lobe

Instead of “lung infection/ respiratory failure”

• AVOID vague terms and modes of dying such as (Respiratory distress/

Cardiac arrest/ Cardiovascular event/ Chest infections/ Cardiovascular event).

Key For the bed-ridden very elderly patients who still have mental
39 capacity, if they develop a disease (e.g. Pneumonia), we need to:

→ Discuss their wishes on the management plan, whether they prefer to be

treated at home or in hospital.

Key An elderly woman with metastatic breast cancer being under the
40 palliative care team. She needs 60 mg oral morphine twice a day to
control her pain. However, she now has difficulty in swallowing and
thus will be shifted to subcutaneous morphine. What should be the
dose?

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→ 60 mg subcutaneous morphine over 24 hours.

◙ From [Oral morphine to Subcutaneous morphine] → (÷ 2)

◙ From [Oral morphine to Subcutaneous diamorphine] → (÷ 3)
◙ From [Oral tramadol to IV morphine] → (÷ 20)

√ Remember, palliative patients are preferred to receive Subcutaneous

medications rather than IV or IM.

√ She takes 60 mg oral morphine twice a day (i.e. 120 mg over 24

hours).

√ To shift to SC morphine, divide the 24-hour dose by 2 and give it over

24 hours.

√ This means 120/2 = 60 mg over 24 hours.

Key ◙ Anti-emetic in case of ↑ ICP (e.g. intracerebral tumour) or vomiting due to bowel
41 obstruction
→ Cyclizine.

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◙ Anti-emetic in case of “delayed gastric emptying” e.g. peritoneal metastasis

causing partial bowel obstruction:
→ Metoclopramide “a prokinetic”. Also: domperidone.

Key An old patient with a terminal stage cancer cannot sleep because of anxiety.
42 What to give?

→ Benzodiazepines (e.g. Lorazepam).

• Benzodiazepine can cause addiction; however, this is not a concern in this
late stage cancer.
• An added benefit of lorazepam here is that it can be given sublingually in
case he develops difficulty in swallowing due to weakness.

Key Catastrophic bleeding in palliative care (at end of life care):

43
→ administer 10 mg SC midazolam “for anxiety” and
10 mg SC morphine sulphate “for pain if required”.

Remember, the palliative care primary goal is not to prolong life neither to
shorten it, but to ensure the patient is comfortable during his last days.

Key Breathlessness (dyspnea) in palliative patients who can tolerate orally can
44 be dealt with by giving the patient opioids e.g., → Oral morphine. √

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√ Be careful, nebulized salbutamol would be appropriate if there is additional

wheeze and the dyspnea is thought to be due to partial airway obstruction
from the tumour.

√ So, in palliative patients who have (eg, terminal stage lung cancer, chronic
heart failure) and present with breathlessness, consider low doses of oral
morphine as it will decrease the perception of breathlessness without causing
significant respiratory distress.

Key ◙ In palliative patients with bowel obstruction (e.g., nausea, vomiting,

45 constipation, abdominal pain)

Give → Subcutaneous hyoscine butylbromide (Antimuscarinic).

◙ The most DEFINITIVE Rx

→ Palliative stoma

◙ If the patient is vomiting fecal content, initially

→ NGT to relieve symptoms
“All asked previously”

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Key Legal prescription requirements

46

◙ For Prescription only medicine (POM):

√ Patient’s name and address. “asked recently”.
√ Patient’s age and date of birth “only required for children < 12 YO”.
√ Date.
√ Prescriber’s address.
√ For handwritten “paper” prescription e.g., handwritten FP10 form
→ Prescriber’s handwritten signature. “asked recently”.
√ For electronic signature → Prescriber’s electronic signature.

◙ For most controlled drugs e.g., diamorphine hydrochloride (heroin),

oxycodone hydrochloride, gabapentin, midazolam:
√ All the above-mentioned requirements +
√ Prescriber’s address “must be within the UK”.
√ Dose (e.g., 20 mg twice a day).
√ Form (e.g., tablets, capsules, injections).
√ Strength.
√ Quantity in both words and figures (e.g., 10 (ten) mg).

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•• Important note: *recently asked*

Oramorph (oral morphine sulphate 10mg/5ml) classed as scheduled 5
controlled drugs. Thus, quantity in both words and figures is NOT a
requirement!

In other words, Schedule 5 controlled drugs such as Oramorph → no need for

the quantity to be written in both figures and words.

Key ◘ Noisy Respiratory Secretions and gurgling sounds in a palliative patient:

47

→ Subcutaneous Hyoscine Butylbromide. (Not orally!)

It is an antimuscarinic.

Another correct answer → Glycopyrronium Bromide Subcutaneously.

Another correct answer → Antimuscarinic = Anticholinergic. Recently asked.

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Key ♠Bone pain due to bone metastasis → Radiotherapy. (1st line)

48
If failed → Bisphosphonate + NSAIDs (eg, Naproxen) (2nd line)
Need more pain control? → Opioid (eg, morphine, oxycodone). Or vice versa.

• Q1: if the pain is acute and developed after radiotherapy, give

→ Oral morphine sulphate. Imp √.

• Q2: A man with bone metastasis is on paracetamol, and immediate and

prolonged release oxycodone (opioid). There is still pain, what to add on?
→ NSAIDs eg, Naproxen. Imp √.

Key ♠ Intractable Hiccup due to liver cancer → Metoclopramide. Others:

49
Domperidone, Nifedipine. “useful for peripheral hiccups”
(Peripheral hiccup due to diaphragmatic irritation by liver metastasis “irritates
phrenic nerve” → hiccup).

♠If Metoclopramide, Domperidone, Nifedipine are not given within the

options, pick

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→ Chlorpromazine. “useful for central hiccups e.g., brain tumor, or if liver

cancer but metoclopramide, domperidone, or nifedipine are tried but failed or
if they are not given in the options in case of liver cancer.”

Key A patient with Hx of bronchogenic cancer developed low-grade

50 fever and halitosis (bad mouth breath). His CT scan shows large
right upper lobe cavitary lesion. The most appropriate
management?

→ Antibiotics.

Fever + Cavity in lung on top of cancer

→ suspect cavitation lung cancer ± necrosis and bacterial infection
→ antibiotics would benefit this patient.

(This halitosis is not due to oral lesion where oral mouth wash would benefit
him, it is due to a systemic lesion, which is the cavitary lesion and infection).

Key A 50 YO man with non-Hodgkin’s lymphoma with bone metastasis

51 is admitted to the hospice complaining of a week of:

Uncontrolled abdominal and back pain, Nausea, vomiting and

constipation.
He is on the maximum doses of codeine phosphate.

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What is the single most appropriate action?

A) Start a buprenorphine patch and stop codeine phosphate.

B) Start subcutaneous haloperidol once a day.
C) Start subcutaneous cyclizine.
D) Start intravenous morphine sulphate and stop codeine phosphate.
E) Start subcutaneous morphine sulphate in a syringe driver and stop
codeine phosphate.

Answer:

• Option (A) is wrong: buprenorphine patch needs 2-3 days in order to start
becoming effective and control the pain. Thus, it is not suitable because the
patient is already in pain “not stable”.

• Option (B) and (C) are wrong: haloperidol and cyclizine may stop the
vomiting. However, they would not control and relieve the pain. Also, note
that his complaints of nausea, vomiting and constipation are mostly because
he is on codeine phosphate “side effects” and when we stop it, these
symptoms might disappear.

• Option (D) is wrong: IV drugs are not favoured in palliative patients.

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• Option E is right: SC morphine can control the pain and even if the patient
needs a higher dose, it is easy to increase the dose as the onset of action is
rapid “around and hour”. SC is preferred over IV in palliative patients.

Note that oral morphine sulphate modified release can also be used as long as
the patient tolerate orally and not vomiting. If no, we can change it to SC
morphine. However, this is not among the options.

Key A 64 yr old man with multiple myeloma presenting with agitation and
52
confusion. He forgets his daughter’s name. Serum calcium: 3.4 (Normal 2.1-
2.6). He was given IV 0.9% saline infusion; however, his calcium is still high.
What is the next most appropriate management?

→ IV pamidronate.

• Remember, hypercalcemia can cause agitation and confusion.

Other important features: polyuria, polydipsia, low moods, confusion…etc).

• The initial management of hypercalcemia → IV fluids normal saline.

• Then → Bisphosphonates (e.g., alendronate, pamidronate IV infusion).

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“Note: this is a palliative care patient who is having agitation. He could benefit
from SC midazolam. However, the reason for his agitation here is known and
treatable. Thus, we treat the root. Nonetheless, in general, SC midazolam is
useful to relieve the agitation and restlessness in palliative care patients in
general if there is no apparent and correctable cause of their agitation”.

Key Agitation and restlessness in a palliative patient

53
→ Give Subcutaneous Midazolam.

Haloperidol is another useful option. It should also be given subcutaneously in

palliative care patients. So, if haloperidol orally or IV is in the options, it is wrong.

Key Artificial Nutrition

54

First: Enteral Feeding (NGT VS PEG)

NGT = Nasogastric tube
PEG = Percutaneous Endoscopic Gastrostomy.

◙ Short-Term feeding
→ NGT “Nasogastric Tube”.
- Usually used first, unless if long-term feeding is required (see below).
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- Example: a few days after stroke (recent stroke), and the patient has
started to get swallowing difficulties. We start with NGT feeding as his
swallowing might improve with time. So, we feed him via NGT slowly and
refer him to SALT (Speech and Language Therapist) who will assess and
encourage his swallowing. If no improvement after a few weeks → PEG.

◙ Long-Term feeding

→ PEG “Percutaneous Endoscopic Gastrostomy feeding tube”.

- It is surgery to insert a flexible tube through the abdomen into the

stomach. Thus, the patient has to be fit for sedation and surgery.

- Example (1): A patient with an old stroke (months) and no improvement

of dysphagia or swallowing, and he becomes thin (losing weight). This
patient needs a long-term feeding method (PEG).

- Example (2): A patient with motor neuron disease (MND) with

“progressive” difficulty of swallowing. We know that MND is a chronic
degenerative progressive disease. So, we do not expect improvement, but
deterioration. Therefore, a long-term feeding would be required (i.e., PEG).
The examples are important and were asked in previous exams

Important Medical Ethics Points:

√ The next of kin (e.g., wife, brother, parents) do not have the legal authority
to decide even if the patient lacks metal capacity.

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√ If the patient who is now lacking mental capacity has an advance directive
that states that he does not want to receive a specific intervention such as
artificial feeding, doctors should follow his advance directive.

◙ Advance Directive = a living well

A legal document in which a patient writes the treatments/ the procedures
that he/she does not want to receive if they become unable to make
decisions.

Second: Total Parenteral Nutrition (TPN)

Example :
A patient is booked for total gastrectomy due to non-metastatic gastric
cancer. He is in hospital as his surgery will be done in a few days. He vomits
every single meal and cannot tolerate feeding due to gastric cancer (outlet-
block). He is malnourished and has lost 18 Kg in the last month. What is the
most appropriate feeding method before the surgery?

• The best pre-operative feeding for him

→ Total parenteral nutrition (TPN) “A temporary method until surgery”.
NGT and PEG deliver nutrition to his stomach. Thus, they are not suitable as
he has gastric outlet obstruction. Any nutrition directed to his stomach would
not pass down to small intestine.

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• The post-operative method for him would be

→ Jejunostomy feeding tube (J-tube).
This is a plastic tube that would be inserted (during the gastrectomy surgery)
through the skin of the abdomen into the jejunum so that that patient would
be able to have enteral feeding after surgery.
He would not have a stomach and thus he would need a feeding tube directly
to his small intestine (jejunum).

Key
After PEG is inserted, one-off leaks may occur.
55
As long as there are no signs of infection
→ Reassure and continue enteral feeding.
The stoma will most likely shrink in a few days, and fit well around the tube.

Key Collection of important points in case of advanced colon cancer that causes
56 bowel obstruction: “All were asked previously”

◙ Anti-emetic in nausea and vomiting due to bowel obstruction

→ Cyclizine.

(Note: neither senna nor phosphate enema are helpful in a palliative patient with
bowel obstruction, they won’t relieve the obstruction or the constipation. Thus,
symptomatic relief of vomiting and nausea by giving cyclizine is appropriate).

◙ Anti-emetic in nausea and vomiting due to bowel obstruction due to end-stage

colorectal cancer + Hx of Parkinson’s disease + Cyclizine has failed

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→ SUBCUTANEOUS Levomepromazine.

◙ In palliative patients with bowel obstruction (e.g., nausea, vomiting,

constipation, abdominal pain)

→ Subcutaneous hyoscine butylbromide (Antimuscarinic) is also appropriate.

◙ The most DEFINITIVE Rx

→ Palliative stoma (palliative colostomy).

◙ If the patient is vomiting fecal content, initially

→ Nasogastric tube (NGT) to relieve symptoms

Key An old patient is in hospice for renal cell carcinoma with abdominal wall
57 metastasis. He is on 200 mg slow-release morphine (twice a day) +
immediate-release morphine (every 4 hrs). However, he is still in pain. What
to do?
→ Replace slow-release morphine by SC morphine in a syringe driver.

Key Management of Bone Pain due to Bone Metastasis

58
1] Radiotherapy (1st line).

2] If failed → 2nd-line → Bisphosphonate + NSAIDs (eg, Naproxen).

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3] Still pain? → add on Opioids (eg, morphine, oxycodone or alfentanil).

Note: if the patient is already on step 2 and needs more pain control, go for
step 3. If he has jumped to step 3 (opioids) and still needs more pain control,
add on the step 2 (NSAIDs eg, Naproxen).

Note: √ If he is already on opioids, we cannot add another opioid eg,

alfentanil, morphine, oxycodone. (But, we can change between them).
√ Instead, pick another line of managing bone pain due to bone metastasis →
Radiotherapy, NSAIDs, Bisphosphonate.

Note: Gabapentin, amitriptyline and pregabalin are used to manage

neuropathic pain and are not useful for bone pain due to metastasis.

Key An elderly man with terminal prostate cancer is brought by her carer to the
59 emergency department as he recently became more confused than usual. He
is on end-of-life care and has no relatives or advance directive. His carer says
that the patient fell and hit his head 2 days ago. CT scan of the head shows
intracranial hemorrhage. His GCS score is 8. He looks cachexic. He is agitated
and is moaning in pain. What is the most appropriate management?

→ Administer subcutaneous Midazolam.

• He is receiving end of life care. Mannitol, Intubation or burr hole surgery

may prolong her life for a few days.
However, the primary goal of end-of-life care is to provide dignified and
peaceful death (eg, by relieving any pain, agitation and anxiety).

→ Administer 10 mg SC midazolam (for anxiety and agitation) +

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10 mg SC morphine sulphate (for pain if required).

• Remember, the palliative care primary goal is not to prolong life neither to
shorten it, but to ensure the patient is comfortable during his last days.

Key • Palliative team should not try to prolong their palliative patients’ lives as this
60 would prolong their suffering. Also, they should not try to shorten their lives or
lead to their death (Euthanasia is prohibited and illegal in the UK).
• The aim of palliative care register is to make patients comfortable at the last
hours of their lives.
• Example
An elderly man with lung cancer and metastasis who is bed-bound and unable
to do his daily activities had fallen on his head and developed intracranial
hemorrhage.
→ Give anxiety treatment (sedation) eg, → Midazolam.
(Midazolam can be given subcutaneously).

Key ◙ In lung cancer patients:

61 → lung cavitations → necrosis → colonisation of anaerobic bacteria → foul-gases
→ bad mouth breath (halitosis).

◙ In palliative care patients with lung cancer, the treatment of halitosis is:
• Antibiotics (eg, metronidazole to reduce the anaerobic bacteria).
• Antiseptic mouthwash (to kill anaerobic bacteria).

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◙ In short: Rx of halitosis in these cases?

→ Treat the underlying source (eg, use antibiotics).
If not given in the options, pick → antiseptic mouthwash.

Key End-stage colorectal cancer

62 + Partial bowel obstruction

(Nausea, Vomiting, Abdominal distension and pain)

Subcutaneous Cyclizine has FAILED to relieve symptoms
Has Parkinson’s disease

→ Subcutaneous levomepromazine.

(Subcutaneous route is preferred in palliative patients

+ Levomepromazine is good for Parkinson’s patients with vomiting).

Key • When liver is enlarged (eg, due to tumor, or metastasis), painful right upper
63 abdomen may occur.

• This pain is not in the liver itself as the liver does not have any nerve fibres that
sense pain. The pain is in the capsule that surrounds liver.

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Remember:
• For liver pain (right upper abdominal pain) eg, liver metastasis:
→ NSAIDs eg, Naproxen, Ibuprofen.

Example: A palliative patient with a Hx of colorectal cancer is on paracetamol

and immediate and modified release oxycodone. He presents with right upper
abdominal pain and elevated liver enzymes. What to add on for pain?
→ Naproxen (ie, NSAIDs). This is most likely liver metastasis.

Key Scenarios on Pain Management in Palliative Patient

64

Scenario (1)
A 70-year-old palliative patient with end-stage renal carcinoma can no longer
tolerate taking his prolonged-release morphine orally as he feels too weak to
swallow. He is now having increasing back pain. His laboratory results show:
Low serum albumin: 14 g/L (35-50)
Slightly elevated serum urea and creatinine.
eGFR 20 (>90).

What is the most appropriate medication (in a syringe driver) of the following to
switch his oral morphine tablets to?

A) Oral morphine sulphate liquid.

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B) Oral codeine.
C) Subcutaneous paracetamol.
D) Subcutaneous non-steroidal anti-inflammatory drugs.
E) Subcutaneous alfentanil.

Answer → (E) Subcutaneous alfentanil.

• Since he cannot tolerate orally, both options A and B are wrong. Also, the
preferred rout for palliative patients is subcutaneous.

• Paracetamol and NSAIDs could be too weak to manage his pain at this point.

• More importantly, when eGFR is low (<60), it is more appropriate to use

opioids such as oxycodone, morphine, alfentanil.

→ The best answer here is → (E) Subcutaneous alfentanil (which is an opioid).

Scenario (2)
A 71-year-old palliative patient with advanced prostate cancer can no longer get
benefit of morphine as his significant pain is fluctuating in intensity, which
requires more flexible dosing. His eGFR is 20 (>90).
What is the most appropriate medication of the following to switch his
morphine to?
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A) Oral oxycodone.
B) Alfentanil patch.
C) Fentanyl patch.
D) Subcutaneous diamorphine.
E) Subcutaneous alfentanil.

Answer → (E) Subcutaneous alfentanil.

√ The best medication for fluctuating pain is → subcutaneous alfentanil. This is

because of its rapid onset and short duration of action, which suits the patient’s
fluctuating levels of pain.
√ In addition, it is a safer option in patients with renal impairment (as in this
patient). This is because it is metabolised in the liver.
√ What about alfentanil patch? → There is no patch form for alfentanil. Also,
patches in general are not suitable for fluctuating pain as they release
medication steadily, which makes it less flexible for managing fluctuating pain.

Key The Management of Hypercalcemia [in General] Includes:

65
• First line → Rehydration (IV fluids). [In palliative patients: SC fluids].
• Second line → Bisphosphonates (eg, alendronate, zoledronate, pamidronate).

However:
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In palliative patients with end-stage metastasised cancer who are bed-bound,

have POOR quality of life, and require FULL support with their daily activities, it
could be better to have NO FURTHER TREATMENT other than SC fluids if they
develop hypercalcemia (eg, prostate cancer metastasised to bone).

√ Patients in hospice for palliative care should be offered a (rest in peace)

death. i.e., peaceful death. The aim is not to shorten or prolong their lives, but
to try to provide a more comfortable last hours of life while dying.

Key Important Note (Recently Asked):

66
• If a lung cancer patient is active, moving around, able to eat and drink,
vitally stable in general (ie, not their last days of life) and developed wheezes
and breathlessness → Give Nebulized Salbutamol (Bronchodilators), NOT SC
Morphine even if the patient is having lung cancer and is under Palliative
register.
• SC Morphine is the choice if the patient is dying, to help them die in peace.
Eg, if the same lung cancer patient with end-stage cancer, has dyspnea and
wheezes, not eating or drinking, not active, his vitals are deteriorated, go for
SC morphine in such a case (End-of-life care).

Key Managing Liver Pain due to Liver Metastasis/Cancer

67
√ Liver capsule pain results when the cancer stretches the tissues surrounding
the liver. So, the pain is due to capsule being stretched → Sharp stabbing right
upper quadrant pain. (Note: liver itself has no nerve fibres).

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√ Liver capsular pain responds well to → NSAIDs (eg, Ibuprofen/ Naproxen).

Very Important:
• If the patient is already susceptible to thrombotic risk or GI bleeding, in case
he uses NSAIDs (eg, if the patient is already on Aspirin, Rivaroxaban),
→ DO NOT give NSAIDs to control liver pain due to metastasis.
• Instead, give → Dexamethasone (It is also useful in relieving the sharp
stabbing liver pain that results due to liver capsule stretched due to cancer).

So, be aware that both NSAIDs and Dexamethasone are helpful in relieving
liver capsule pain in patients with liver cancer/metastasis.
Pick Dexamethasone if the patient is at a risk of GI bleeding, as NSAIDs is
contraindicated. Otherwise, go for NSAIDs (eg, Naproxen/Ibuprofen).

Key Important Anti-emetics in Parkinson’s Patients

68
• Cyclizine. (It can also be given SC if severely ill patient).
• Levomepromazine. (It can also be given subcutaneously. This antiemetic is useful
particularly if the cause of vomiting is metabolic).
Other useful antiemetics in Parkinson → Domperidone (oral only), Ondansetron.

√ In Parkinson’s disease, avoid → Haloperidol + May Cause Parkinson’s (ie,

Metoclopramide, Cinnarizine, Prochlorperazine).

These medications block D2 (dopamine) receptors. Thus, contraindicated.

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Key To convert from oral morphine to injectable morphine

69
→ Calculate the total oral morphine dose in 24 hours.
→ Then divide it by 2.
(Oral morphine has half the potency of injectable morphine).

Example:
If a patient is on 60 mg oral morphine twice a day and wants subcutaneous
morphine:

60 mg twice a day = 120 mg in 24 hours. (don’t miss out -twice a day-)!

120/2 = 60

So, he would be given 60 mg subcutaneous morphine.

Remember: in palliative care patients, subcutaneous route is preferred.

Side Important Note:

For morphine sulphate capsules prescription to be given by a pharmacist, the
doctor must write the quantity of morphine in words and figures (as it is a
controlled; schedule 2 medication).

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Key Terminal Respiratory Secretions (= Death Rattles/ Noisy Breathing)

70
• In palliative care patients with excessive respiratory secretions that causes
discomfort and rhonchi

→ Glycopyrronium or Hyoscine (typically given subcutaneously).

√ Glycopyrronium and hyoscine are anticholinergic medications, typically

given subcutaneously. They reduce the excessive respiratory secretions by
blocking the action of acetylcholine and therefore reduce the discomfort and
risk of aspiration.
√ Rhonchi are low-pitched cutaneous rattling respiratory sounds that are
often associated with airway obstruction or the presence of secretions/
mucus in the larger airways.

Key Constipation in Palliative Care Patients

71

◙ For most cases of chronic constipation in palliative patients

→ Macrogol (osmotic laxatives). (each sachet is dissolved in half a glass of
water).

◙ For opioid-induced constipation

• → Senna (could be given tablets or syrup based on the ability to swallow).
• Another option → Bisacodyl (per-rectal suppository).
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√ Both senna and bisacodyl are (stimulant laxatives).

√ Senna is preferred in those who can swallow (either syrup or tablets)
because it is easier to use regularly.
√ Bisacodyl suppository has a faster onset of action but because it is a
suppository, it is less preferred.
√ Avoid senna and bisacodyl (stimulant laxatives) in bowel obstruction.

Example:
A frail elderly woman with metastatic lung cancer is under palliative care and
taking oral opioids consistently to manage her pain. She developed constipation
with infrequent passage of soft stool. She can swallow liquids but not tablets.
There are no signs of bowel obstruction, but there is mild abdominal discomfort.
What is the most appropriate medication to manage her constipation?

→ Senna syrup (ie: Stimulant Laxatives).

√ Those who are taking strong opioids should be prescribed regular laxatives.

√ Although senna is generally used for short-term, in palliative patients, senna

can be used regularly.

√ For opioid-induced constipation → Senna or Bisacodyl. Since the patient can

drink liquids and needs regular laxatives → Senna “syrup” is preferred.

Key Management of Opioid-Induced Constipation in Palliative Care

72
• Constipation caused by opioids (eg, oxycodone) in a palliative patient
→ Senna (stimulant laxative).

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In palliative care, managing constipation caused by opioid use, such as

oxycodone, is crucial. The preferred approach involves using stimulant
laxatives like senna to enhance bowel motility.
Other measures, including adequate hydration and stool softeners, can
support effective bowel management.

Key
73 Managing Fluctuating Pain in Renal Impairment (Summarised)
• Subcutaneous Alfentanil: √

o Ideal for fluctuating pain due to rapid onset and short duration.
o Safer for renal impairment as it is metabolised in the liver.

• Alfentanil Patch:

o No patch form available for Alfentanil; that one is Fentanyl.

o Patches generally unsuitable for fluctuating pain due to steady release.

• Fentanyl Patch:

o Suitable for stable, chronic pain.

o Not ideal for fluctuating pain due to continuous release.

In short: The best choice for fluctuating pain in a patient with renal
impairment is → Alfentanil Subcutaneous (not patch, and not fentanyl).
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Key
74 Palliative Medications and Their Indications

Morphine sulphate:

• Indicated for pain and breathlessness relief.

Haloperidol:

• Used as an antiemetic and for treating restlessness and confusion.

• Preferred for nausea due to opioid use or metabolic causes.

Levomepromazine:

• Broad spectrum antiemetic, pain relief, and for restlessness and

confusion.
• Suitable for refractory nausea when other antiemetics fail.
• Preferred for vomiting in patients with Parkinson's disease due to its low
risk of exacerbating symptoms.

Cyclizine:

• Antiemetic especially useful for intracranial causes of nausea and

vomiting.
• Effective for motion sickness and raised intracranial pressure.

Octreotide:
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• Used for nausea and vomiting in patients with bowel obstruction.

• Beneficial in managing symptoms of gastrointestinal obstruction.

Metoclopramide:

• Indicated for nausea and vomiting in patients with delayed gastric

emptying.
• Enhances gastric motility, useful in gastroparesis.

Domperidone:

• Similar to metoclopramide, used for nausea and vomiting with delayed

gastric emptying.
• Less likely to cause central nervous system side effects.

Ondansetron:

• Effective for nausea and vomiting associated with chemotherapy or

radiotherapy.
• Preferred for severe, refractory nausea due to cancer treatment.

Midazolam:

• Used for agitation and restlessness, especially in distressing catastrophic

bleeds.
• Provides sedation and anxiolysis.

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Lorazepam:

• Indicated for agitation and restlessness.

• Useful for anxiety and terminal agitation.

Glycopyrronium:

• Manages excessive respiratory secretions at end of life (e.g., death

rattles, noisy breathing).
• Preferred for patients where anticholinergic side effects need to be
minimized.

Hyoscine butylbromide:

• Used for excessive respiratory secretions at end of life, bowel

obstruction, and intestinal colic.
• Reduces both GI and bronchial secretions.

Hyoscine hydrobromide:

• Similar to hyoscine butylbromide for managing respiratory secretions at

end of life.

Dexamethasone:

• Used for vomiting or headaches with raised intracranial pressure and as

an appetite stimulant.
• Beneficial for reducing inflammation and cerebral edema.

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Antiemetic Comparison in Palliative Care:

• Haloperidol: Preferred for nausea due to opioid use or metabolic causes.

Contraindicated in Parkinson’s disease.
• Levomepromazine: Suitable for refractory nausea when other antiemetics
fail. Preferred for vomiting in patients with Parkinson's disease due to its
low risk of exacerbating symptoms.
• Cyclizine: Effective for motion sickness and nausea from raised intracranial
pressure.
• Octreotide: Best for managing nausea and vomiting in bowel obstruction.
• Metoclopramide: Ideal for nausea with delayed gastric emptying or
gastroparesis.
• Domperidone: Similar to metoclopramide, with fewer central nervous
system side effects.
• Ondansetron: Preferred for severe, refractory nausea due to
chemotherapy or radiotherapy.

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Key Revision (Important Scenarios) for Palliative Care Chapter

75
(1)

A 68-year-old man with advanced oesophageal cancer is receiving palliative care.

He has developed progressive shortness of breath over the last few days. A chest
X-ray shows a large left-sided pleural effusion. Despite being on regular oral
morphine, he reports little relief from his breathlessness and appears anxious.
He is in the terminal phase of his illness with a life expectancy of only a few
weeks. What is the most appropriate next step in his management?

A) Subcutaneous glycopyrronium.

B) Increase the dose of oral morphine.

C) Pleural aspiration.

D) Switch to oral oxycodone.

E) Subcutaneous midazolam.

Answer:

In this scenario, the patient's breathlessness is primarily caused by the large

pleural effusion. While oral morphine is helpful for relieving general dyspnoea, it

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does not address the mechanical issue of the pleural effusion, which is
contributing to his respiratory distress.

The most appropriate next step is pleural aspiration (Option C), as it directly
addresses the underlying cause of his breathlessness by draining the fluid from
the pleural space. This procedure can provide rapid and significant relief from
symptoms, improving the patient’s quality of life during the terminal phase of
his illness.

• Increasing the dose of oral morphine (Option B) may help with general
discomfort or pain but would not specifically address the pleural effusion
causing the breathlessness.
• Subcutaneous midazolam (Option E) could be used for anxiety and agitation,
but it is not the primary treatment for breathlessness caused by an effusion.
• Subcutaneous glycopyrronium (Option A) is used for managing secretions but
would not relieve the mechanical cause of breathlessness due to the pleural
effusion.
• Switching to oral oxycodone (Option D) would not offer a substantial benefit
over oral morphine in this case.

In short:

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• Pleural aspiration provides immediate relief by removing the fluid causing the
respiratory distress.
• It targets the root cause of the breathlessness (the pleural effusion) and
significantly improves the patient's quality of life.
• Oral morphine may reduce general discomfort but does not resolve the
mechanical issue of fluid in the pleural space. Therefore, aspiration is the best
option in such cases where weeks of life remain.

(2)

A 65-year-old woman with a history of breast cancer, currently receiving

palliative care, presents with confusion, lethargy, and worsening fatigue. She has
not been eating well for several days. On examination, she is tachycardic with a
heart rate of 110 beats per minute, appears dehydrated, and is mildly confused.
Blood results reveal the following:

Calcium: 3.4 mmol/L (2.1-2.6)

Urea: 10 mmol/L (2.5-7)

Creatinine: 130 µmol/L (60-120)

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She has been given intravenous fluids for rehydration, but her symptoms persist,
and her calcium level remains elevated. Her family is concerned about her
comfort and agitation. What is the next best step in her management?

A) Subcutaneous haloperidol.

B) Oral paracetamol.

C) IV pamidronate.

D) IV prednisolone.

E) Oral calcium supplements.

Answer:

In this case, the patient is presenting with hypercalcaemia, likely related to her
history of malignancy (breast cancer). Hypercalcaemia is common in palliative
care, particularly in malignancies, and can cause symptoms like confusion,
fatigue, and dehydration, as seen in this patient.

IV pamidronate (Option C) is the correct next step because it is a

bisphosphonate that inhibits bone resorption, lowering calcium levels.
Pamidronate is commonly used in treating hypercalcaemia of malignancy,

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including in palliative care settings. While intravenous fluids are the first line of
treatment for hypercalcaemia, they may not be sufficient to control calcium
levels, and further measures like IV pamidronate are necessary to bring the
calcium down.

Haloperidol (Option A) would be appropriate for managing agitation in a patient

who is actively dying, but in this case, the patient is not in the final stage of life.
Haloperidol does not treat the underlying cause of hypercalcaemia.

Oral calcium supplements (Option E) would exacerbate hypercalcaemia and are

therefore contraindicated in this situation.

Oral paracetamol (Option B) would provide symptomatic relief for pain or

discomfort but does not address the elevated calcium.

IV prednisolone (Option D) might have some role in certain hypercalcaemic

conditions, but IV pamidronate remains the first-line treatment in malignancy-
related hypercalcaemia.

In short:

• The patient is not actively dying, which would otherwise necessitate focusing
on symptom control such as agitation.

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• IV pamidronate (IV bisphosphonate) is effective in lowering calcium levels but

takes time (up to 48-72 hours), and it is appropriate in this case as the
patient’s condition is not immediately terminal.
• Subcutaneous haloperidol is useful for managing agitation in patients in the
active dying phase but not for this patient, who requires treatment for the
underlying hypercalcaemia.

(3)

A 68-year-old man with a history of chronic obstructive pulmonary disease

(COPD) presents to the hospital with a three-day history of fever, worsening
breathlessness, and productive cough. He has also had reduced oral intake. On
examination, his oxygen saturation is 89% on room air, respiratory rate is 30
breaths per minute, and blood pressure is 86/60 mmHg. There are crackles
heard on auscultation, and a chest X-ray confirms consolidation suggestive of
pneumonia.

Investigations show the following:

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Haemoglobin: 140 g/L (130-180)

White cell count: 12.0 × 10^9/L (4.0-11.0)

Neutrophils: 8.0 × 10^9/L (2.5-7.5)

Platelets: 310 × 10^9/L (150-400)

Creatinine: 350 µmol/L (70-150)

eGFR: 28 mL/min (>90)

CRP: 340 mg/L (<10)

Despite receiving antibiotics and supportive care, his condition worsens, and he
passes away the following day. What should be listed in Part 1a of his death
certificate?

A) Acute kidney injury.

B) Pneumonia.

C) Sepsis.

D) Chronic obstructive pulmonary disease.

E) Respiratory failure.

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Answer:

In this scenario, the primary cause of death (1a) is → pneumonia, which directly
led to the patient’s deterioration and death. Pneumonia was the precipitating
event that caused the patient’s worsening symptoms and ultimately led to his
demise.

Pneumonia should therefore be listed in Part 1a of the death certificate, as it

was the immediate and direct cause of death.

• Acute kidney injury (AKI) is likely a consequence of the pneumonia but not
the primary cause, so it could be listed in Part 1b as a result of the
pneumonia.
• Sepsis (if present) could be listed in Part 1c, as it may have contributed to the
patient's deterioration by leading to AKI and further worsening of his
condition.
• Chronic obstructive pulmonary disease (COPD) would be placed in Part 2, as
it is a chronic underlying condition that made the patient more susceptible to
pneumonia and its complications but was not the direct cause of death.

Here’s how the death certificate should be filled:

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1a. Pneumonia.
1b. Acute kidney injury.
1c. Sepsis (if applicable).
Part 2. Chronic obstructive pulmonary disease.

• Pneumonia is listed as the direct cause of death in Part 1a, as it was the
immediate event that led to the patient’s death.
• Acute kidney injury could be listed in Part 1b, as it was a consequence of the
pneumonia.
• Sepsis (if relevant) could be listed in Part 1c as the underlying cause of the
acute kidney injury.
• COPD is placed in Part 2, as it contributed to the patient’s vulnerability but
was not part of the direct chain of events leading to death.

(4)

A 67-year-old man with a history of prostate cancer, currently receiving

palliative care, presents with worsening right leg pain, difficulty walking, and
occasional swelling around the thigh. The pain has been gradually increasing
over the last few weeks and is now severe, particularly in the femur. On

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examination, there is tenderness over the right femur, and he is unable to bear
weight on the affected leg. Imaging confirms metastasis to the right femur.
Blood tests show:

Calcium: 2.7 mmol/L (2.1-2.6)

Urea: 8 mmol/L (2.5-7)

Creatinine: 120 µmol/L (60-120)

He has been receiving pain relief, but his symptoms persist, and he is in
significant discomfort. What is the next best step in his management?

A) Oral paracetamol.

B) Subcutaneous haloperidol.

C) IV bisphosphonates.

D) Radiotherapy to the affected bone.

E) Oral calcium supplements.

Answer:

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In this scenario, the patient has bone metastasis causing severe pain and
functional impairment. The metastasis is specifically affecting the femur, leading
to symptoms such as pain and difficulty bearing weight.

The most appropriate next step is radiotherapy to the affected bone (Option D),
which is commonly used in cases of bone metastases to reduce pain, prevent
fractures, and improve mobility. Radiotherapy is effective in alleviating
symptoms and can help stabilize the bone in cases where metastasis is causing
significant structural weakness.

• Oral paracetamol (Option A) may provide mild pain relief but would not be
sufficient for managing pain caused by bone metastasis.
• Subcutaneous haloperidol (Option B) is used for managing agitation or
delirium, but it is not appropriate for treating pain caused by bone metastasis.
• IV bisphosphonates (Option C) can be helpful for managing hypercalcaemia
of malignancy or to slow bone resorption, but in this case, radiotherapy
would be more effective for acute pain relief and stabilisation of the affected
bone.
• Oral calcium supplements (Option E) would not be beneficial in this scenario
and could worsen hypercalcaemia if present.

Thus, radiotherapy to the affected bone is the most appropriate management

for symptomatic relief in this case of metastatic bone disease.

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Remember:

Management of Bone Pain due to Bone Metastasis:

1. Radiotherapy – 1st line for localized bone pain caused by metastasis.

2. If pain persists or radiotherapy is not fully effective, use the following both:

o Bisphosphonates (e.g., IV pamidronate or zoledronic acid) or Denosumab

(an alternative to bisphosphonates) are used to manage bone metastasis

pain and prevent skeletal-related events.

o NSAIDs (e.g., naproxen) can be added for their anti-inflammatory and pain-

relieving properties.

3. If there is still pain: Opioids (e.g., morphine, oxycodone, or alfentanil) are

added for stronger pain control.

Additional Notes (for reading):

• In some cases, corticosteroids (e.g., dexamethasone) can be used to reduce

inflammation and swelling around bone metastases.

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• Nerve blocks or neuropathic pain medications (e.g., gabapentin) might also be

considered if there is nerve involvement.

This approach provides a stepwise escalation of pain management, starting from

radiotherapy and advancing through bisphosphonates/NSAIDs, opioids, and other
modalities if needed.

(5)

A 75-year-old man with metastatic colon cancer presents to the hospital with
worsening nausea, vomiting, and abdominal cramping. He was recently treated
for a partial bowel obstruction and has had episodic vomiting since then. He
describes the cramping as sharp and intermittent. On examination, his abdomen
is mildly distended with active bowel sounds, and he continues to pass stool.
There is no guarding or rebound tenderness. He has been on regular oral opioids
for pain management. Which of the following is the most appropriate next step
in managing his nausea?

A) Hyoscine butylbromide.

B) Prednisolone.

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C) Cyclizine.

D) Diazepam.

E) Oral laxatives.

Answer:

In this scenario, the patient presents with nausea and vomiting likely due to his
recent history of partial bowel obstruction, a common complication in palliative
care for patients with advanced cancers. Managing these symptoms effectively
is crucial for his comfort.

The best treatment for nausea in this case is Cyclizine (Option C). Cyclizine is an
antiemetic that is commonly used to control nausea and vomiting associated
with bowel obstruction. It is particularly effective when vomiting is the
predominant symptom, as is the case here.

• Hyoscine butylbromide (Option A) would be useful if the predominant

symptom were colicky abdominal pain due to bowel spasms. While the
patient does experience some cramping, it is not the main focus of this
scenario, which centers around managing nausea.

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• Prednisolone (Option B) and diazepam (Option D) are not appropriate for

treating nausea in this context.
• Oral laxatives (Option E) could worsen the bowel obstruction and are
contraindicated in this setting.

In short:

• Cyclizine is effective for managing nausea and vomiting in cases of bowel

obstruction. It helps improve the patient's comfort by addressing the primary
symptom.
• Hyoscine butylbromide is appropriate when the main issue is colicky pain, as
it acts as an antispasmodic to relieve bowel spasm, but cyclizine is preferred
when nausea is the dominant concern.

(6)

Glycopyrronium is an antimuscarinic (also known as an anticholinergic)

medication. It works by blocking the action of acetylcholine on muscarinic
receptors, which reduces secretions in the respiratory tract and other areas. It is
commonly used subcutaneously in palliative care to manage excessive
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secretions or distressing gurgling sounds, such as in patients with terminal

respiratory conditions, and in other settings like anaesthesia and chronic
obstructive pulmonary disease (COPD) to reduce airway secretions or manage
chronic drooling.

Another valid option → SC Hyoscine Butylbromide.

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