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, and it is reversible with fluids and a bisphosphonate, worth treating even in advanced disease. Loss of the oral route on 120 mg of oral morphine daily raises it.
2. End of life care/symptoms of terminal illness correct Correct. Irreversible decline in advanced metastatic disease with loss of the oral route. The task is continuity of symptom control, not investigation.
3. Delirium Acute fluctuating confusion with inattention, and it must be assessed for reversible causes even at the end of life, pain, retention, constipation, drugs. Loss of the oral route on 120 mg of oral morphine daily makes it worth looking for.
4. Opioid toxicity Drowsiness with myoclonus, pinpoint pupils and vivid dreams, often when renal function falls. Loss of the oral route on 120 mg of oral morphine daily suggests it.
5. Spinal cord compression Back pain with leg weakness and bladder change, an emergency even in advanced malignancy, because outcome depends on treating before paralysis. Loss of the oral route on 120 mg of oral morphine daily points to it.

The point: Oral morphine to subcutaneous morphine: DIVIDE BY TWO. His 120 mg daily oral becomes 60 mg subcutaneous over 24 hours. Breakthrough is one sixth of the 24-hour subcutaneous dose, so 10 mg. Getting this conversion wrong in either direction, a doubled dose or a halved one, is one of the most consequential errors 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 Hypercalcaemia is reversible and its correction can restore weeks of good function, so it is worth checking even in advanced disease. Loss of the oral route on 120 mg of oral morphine daily makes it worthwhile.
2. Renal function Falling renal function causes opioid metabolites to accumulate and produce toxicity, which changes the drug rather than the dose. Loss of the oral route on 120 mg of oral morphine daily makes it relevant.
3. No investigation; treat symptoms and review correct Correct. He is dying and the cause is known. Bloods and imaging would not change anything that is going to be done, and taking them costs him comfort in the hours he has left.
4. Bladder scan For retention as a cause of agitation, which is common, easily missed and immediately treatable. Loss of the oral route on 120 mg of oral morphine daily makes it worth doing.
5. Urgent MRI whole spine For suspected metastatic spinal cord compression, within 24 hours, because function is only preserved if it is treated before it is lost. Loss of the oral route on 120 mg of oral morphine daily demands it.

The point: Oral morphine to subcutaneous morphine: DIVIDE BY TWO. His 120 mg daily oral becomes 60 mg subcutaneous over 24 hours. Breakthrough is one sixth of the 24-hour subcutaneous dose, so 10 mg. Getting this conversion wrong in either direction, a doubled dose or a halved one, is one of the most consequential errors 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 opioid-induced respiratory depression, but it must be titrated in tiny doses in a palliative patient or it precipitates severe pain and distress. Loss of the oral route on 120 mg of oral morphine daily makes caution essential.
2. Anticipatory prescribing for the five symptoms Subcutaneous medication written up in advance so that nobody has to wait for a prescription at three in the morning. Loss of the oral route on 120 mg of oral morphine daily makes it the right preparation.
3. Hyoscine butylbromide For respiratory secretions. It does not clear existing secretions, so it works best given early, and repositioning helps as much as the drug. Loss of the oral route on 120 mg of oral morphine daily makes it appropriate.
4. Subcutaneous midazolam For terminal agitation and restlessness, after reversible causes have been looked for. Loss of the oral route on 120 mg of oral morphine daily indicates it.
5. Subcutaneous morphine via syringe driver correct Correct. 120 mg oral morphine over 24 hours converts to 60 mg subcutaneous over 24 hours, divide by two, because subcutaneous morphine bypasses first-pass metabolism and is twice as potent. Prescribe 10 mg subcutaneous as required for breakthrough, which is one sixth of the 24-hour dose, and write up the other four anticipatory medicines at the same time.

The point: Oral morphine to subcutaneous morphine: DIVIDE BY TWO. His 120 mg daily oral becomes 60 mg subcutaneous over 24 hours. Breakthrough is one sixth of the 24-hour subcutaneous dose, so 10 mg. Getting this conversion wrong in either direction, a doubled dose or a halved one, is one of the most consequential errors in palliative prescribing.

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