Palliative and end of life care for PLAB 1

A 71 year old man with metastatic prostate cancer is in the last days of life at home. He is drowsy and no longer able to swallow. He has been taking modified-release oral morphine 60 mg twice daily with good pain control. The district nurse asks for a syringe driver to be set up. What is the SINGLE most likely diagnosis?

1. Hypercalcaemia of malignancy Confusion, thirst, constipation and drowsiness from high calcium caused by cancer, reversible with fluids and a bone-protecting drug, and worth treating even in advanced disease. Here, loss of the oral route on 120 mg of oral morphine daily points elsewhere.
2. End of life care/symptoms of terminal illness correct Correct. A decline that cannot be reversed in advanced cancer that has spread, now that he can no longer swallow. The task is keeping his symptoms controlled without a break, not running tests.
3. Delirium Sudden confusion that comes and goes, with poor attention, and even at the end of life it must be checked for causes that can be fixed, such as pain, a full bladder, constipation or drugs. But loss of the oral route on 120 mg of oral morphine daily does not point to it.
4. Opioid toxicity Drowsiness with jerky muscle twitches, pinpoint pupils and vivid dreams, often when the kidneys start to fail. It does not fit loss of the oral route on 120 mg of oral morphine daily.
5. Spinal cord compression Back pain with leg weakness and a change in bladder control, an emergency even with advanced cancer, because the outcome depends on treating it before the legs become paralysed. That does not match loss of the oral route on 120 mg of oral morphine daily.

The point: Oral morphine to morphine given under the skin: DIVIDE BY TWO. His 120 mg a day by mouth becomes 60 mg under the skin over 24 hours. The breakthrough dose is one sixth of the 24-hour under-the-skin dose, so 10 mg. Getting this conversion wrong in either direction, doubling the dose or halving it, is one of the most serious mistakes in palliative prescribing.

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

A 71 year old man with metastatic prostate cancer is in the last days of life at home. He is drowsy and no longer able to swallow. He has been taking modified-release oral morphine 60 mg twice daily with good pain control. The district nurse asks for a syringe driver to be set up. What is the SINGLE most appropriate initial investigation?

1. Serum calcium High calcium is reversible and correcting it can bring back weeks of good function, so it is worth checking even in advanced disease. But loss of the oral route on 120 mg of oral morphine daily does not point to it.
2. Renal function Falling kidney function lets morphine breakdown products build up and cause toxicity, which changes the drug used rather than just the dose. It does not fit loss of the oral route on 120 mg of oral morphine daily.
3. No investigation; treat symptoms and review correct Correct. He is dying and the cause is already known. Blood tests and scans would not change anything that is going to be done, and taking them would cost him comfort in the hours he has left.
4. Bladder scan For a full bladder as a cause of restlessness, which is common, easily missed and can be fixed straight away. Here, loss of the oral route on 120 mg of oral morphine daily points elsewhere.
5. Urgent MRI whole spine For suspected spinal cord compression from cancer spread, within 24 hours, because the ability to move the legs is only saved if it is treated before it is lost. That does not match loss of the oral route on 120 mg of oral morphine daily.

The point: Oral morphine to morphine given under the skin: DIVIDE BY TWO. His 120 mg a day by mouth becomes 60 mg under the skin over 24 hours. The breakthrough dose is one sixth of the 24-hour under-the-skin dose, so 10 mg. Getting this conversion wrong in either direction, doubling the dose or halving it, is one of the most serious mistakes in palliative prescribing.

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

A 71 year old man with metastatic prostate cancer is in the last days of life at home. He is drowsy and no longer able to swallow. He has been taking modified-release oral morphine 60 mg twice daily with good pain control. The district nurse asks for a syringe driver to be set up. What is the SINGLE most appropriate immediate management?

1. Naloxone For genuine slowed breathing from too much opioid, but it must be given in tiny doses, built up slowly, in a palliative patient, or it brings on severe pain and distress. That does not match loss of the oral route on 120 mg of oral morphine daily.
2. Anticipatory prescribing for the five symptoms Medicine given under the skin written up in advance so that nobody has to wait for a prescription at three in the morning. But loss of the oral route on 120 mg of oral morphine daily does not point to it.
3. Hyoscine butylbromide For noisy breathing from secretions. It does not clear secretions already there, so it works best given early, and repositioning the patient helps just as much as the drug. Here, loss of the oral route on 120 mg of oral morphine daily points elsewhere.
4. Subcutaneous midazolam For restlessness and distress at the end of life, once causes that can be fixed have been looked for. It does not fit loss of the oral route on 120 mg of oral morphine daily.
5. Subcutaneous morphine via syringe driver correct Correct. 120 mg of oral morphine over 24 hours converts to 60 mg under the skin over 24 hours, divide by two, because morphine given under the skin skips the liver's first pass and is twice as strong. Prescribe 10 mg under the skin as needed for breakthrough pain, which is one sixth of the 24-hour dose, and write up the other four medicines in advance at the same time.

The point: Oral morphine to morphine given under the skin: DIVIDE BY TWO. His 120 mg a day by mouth becomes 60 mg under the skin over 24 hours. The breakthrough dose is one sixth of the 24-hour under-the-skin dose, so 10 mg. Getting this conversion wrong in either direction, doubling the dose or halving it, is one of the most serious mistakes in palliative prescribing.

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