People at the end of life for MRCGP AKT

A 71-year-old man with lung cancer that has spread takes modified-release morphine 30 mg twice daily. His pain is controlled, but he asks for something for breakthrough pain. Which is the most appropriate breakthrough dose of immediate-release oral morphine?

1. 60 mg Wrong. That is his whole daily dose in a single dose and would be dangerous.
2. 20 mg Wrong. That is one third of his daily dose, about double the usual breakthrough amount.
3. 10 mg correct Correct. The breakthrough dose is one sixth of the total daily dose. His total is 60 mg, so 60 divided by 6 is 10 mg when needed.
4. 30 mg Wrong. That is half his daily dose in one go. It risks drowsiness and slowed breathing.
5. 5 mg Wrong. That is one twelfth of his daily dose. It is likely to be too small, and he may decide morphine does not work for him.

The point: Breakthrough dose = one sixth of the total 24-hour morphine dose. If he needs three or more breakthrough doses a day, increase the regular dose. Always prescribe a laxative alongside strong opioids.

Source: NICE CG140: Palliative care for adults: strong opioids for pain relief NICE · tier 1, national regulator or guidance

A 66-year-old woman has advanced ovarian cancer. She takes modified-release morphine 20 mg twice daily for pain and has done so for three weeks. She feels full after a few mouthfuls and has hiccups. Sometimes she brings up a large amount of undigested food, and the nausea then eases. Her abdomen is soft with no colicky pain, and her bowels open normally. Her liver edge is felt 8 cm below the ribs. Her corrected calcium is 2.4 mmol/L (2.2 to 2.6). According to the BNF, which is the most appropriate antiemetic?

1. Metoclopramide correct Correct. Early fullness, hiccups and vomiting of large amounts of food that relieves the nausea point to slow stomach emptying (gastric stasis), here from a big liver pressing on the stomach. Metoclopramide speeds up stomach emptying. She has no colic or blockage.
2. Haloperidol Wrong. Haloperidol acts on the brain's vomiting trigger zone. It suits chemical causes such as high calcium, kidney failure or a recent opioid start. Her calcium is normal and her morphine dose is steady.
3. Hyoscine butylbromide Wrong. It relaxes gut muscle and is used for colic from bowel obstruction. It slows the gut and would make stomach emptying worse. She has no colic.
4. Ondansetron Wrong. Ondansetron blocks 5-HT3 receptors and is mainly used for nausea from chemotherapy or radiotherapy. It causes constipation and does not speed stomach emptying.
5. Cyclizine Wrong. Cyclizine blocks histamine and muscarinic receptors and slows the gut. It suits raised pressure inside the skull or a vestibular cause. It would work against stomach emptying here.

The point: Choose the antiemetic by the cause of the nausea, as the BNF palliative care guidance sets out. Slow stomach emptying: metoclopramide. Chemical causes such as opioids, high calcium or kidney failure: haloperidol. Raised intracranial pressure, vestibular causes or bowel obstruction: cyclizine. Do not give metoclopramide and cyclizine together because they oppose each other. Avoid metoclopramide if the bowel is completely blocked.

Source: BNF: Metoclopramide hydrochloride British National Formulary · tier 3, national formulary

A 77-year-old man with lung cancer that has spread is in the last days of life at home. He is breathless at rest and looks frightened. His oxygen saturation is 95% on air. The GP finds no sign of fluid on the lungs or a pleural effusion. He is drowsy and can no longer swallow tablets. He takes no regular opioid. His wife has opened the window and tried a handheld fan, with little effect. According to current national guidance, which is the most appropriate next step?

1. Subcutaneous furosemide Wrong. Furosemide helps when pulmonary oedema (fluid on the lungs) is the cause, and NICE says to treat such causes. The GP has found no sign of it.
2. Oxygen at 2 L/min by nasal cannula Wrong. Oxygen is not given routinely for breathlessness in the last days of life. It is only for people with known or suspected symptomatic low oxygen levels. His saturation is 95%.
3. Subcutaneous morphine at the lowest effective dose correct Correct. NICE says to consider an opioid, a benzodiazepine, or both, for breathlessness in the last days of life. He cannot swallow, so the subcutaneous route is used. Start low because he is opioid-naive, then titrate.
4. Subcutaneous hyoscine butylbromide Wrong. This dries noisy chest secretions or eases bowel colic. He has no rattle and no colic, so it will not help his breathlessness.
5. Nebulised salbutamol Wrong. Salbutamol helps if there is wheeze from airway narrowing. His breathlessness comes from advanced cancer, and the stem gives no sign of wheeze.

The point: In the last days of life, look for and treat reversible causes of breathlessness first, such as pulmonary oedema or a pleural effusion. Use non-drug measures like a fan. Do not start oxygen routinely. Offer it only if symptomatic hypoxaemia is known or suspected. NICE NG31 says consider an opioid or a benzodiazepine, or both. Start at the lowest effective dose and review at least daily.

Source: NICE NG31: Care of dying adults in the last days of life NICE · tier 1, national regulator or guidance