NES Pharmaceutical Care Model Schemes Palliative Care Case Study
Case 1 Suggested answers
What further questions would you ask Mrs Brown?
Is her tongue coated or furry, does she have a bad taste in her mouth or bad breath?
How much fluid is she drinking?
Does she wear dentures?
Can she still eat things like yoghurt and custard?
Is she in pain? Is she nauseous?
What are the likely causes of her swallowing difficulties?
Oral candidiasis
Poor oral hygiene-tooth and denture cleaning
Dry mouth due to medication i.e. morphine and amitriptyline
Immunosuppression caused by dexamethasone or chemotherapy
Dehydration
What advice would you give the patient through her home carer?
Regular, unsweetened drinks, sucking ice, sugar free chewing gum, using an atomised water spray.
Ensure dentures are cleaned regularly
Adequate fluid intake
What would be the therapeutic options for oral candidiasis?
Anti-fungal. Chlorhexidine mouthwash may sometimes be used as well. Note if both prescribed advise patient to use at least one hour apart.
What are the alternatives to MST and co-danthramer?
Consider a one-week trial of Zomorph® instead of MST, as the capsules can be opened and contents sprinkled on a spoonful of soft foods. Alternatively the same can be done with MST XL, given once daily.
Change to liquid co-danthramer but review for patient acceptability due to taste and smell.
What, if any, are the communication and confidentiality issues raised by this case and how would you overcome them?
Do you have a system in place for obtaining permission from a patient to discuss their personal details with their carer if necessary? Otherwise you should only offer general advice on managing the condition and suggest that you will refer the case to the GP if you feel more confidential advice is required.
Case 2 Suggested answers
What are the actual or potential care issues?
Adverse effects of opioid - dose increase is too high. Regular opioid dosing should be increased by 30-50% unless the patient has been taking three or more breakthrough pain doses in the preceding days. If on a high dose of regular opioid a 30% increase is safer, unless the patient has had more than two breakthrough doses in a day without any adverse effects. Renal cancer may involve renal impairment, so caution should be exercised when increasing a dose of morphine
Effectiveness of pain management is being compromised by adverse effect.
What advice would you give to the patient/carer?
Ø Try to relax as anxiety can make nausea worse
Ø Eat little and often and brush teeth regularly
Ø Try to get some fresh air before mealtimes and eat in a well-ventilated area
Ø The following foods are often well tolerated: Fizzy water, dry biscuits, crackers or toast, ginger flavoured foods, sucking boiled sweets and mints, cold foods e.g. sandwiches and salty foods e.g. peanuts, crisps
Ø Don’t try to prepare food and avoid food/cooking smells or unpleasant odours where possible.
Ø With the correct dose the nausea and drowsiness should go away within the next 5- 10 days and 4 to 5 days respectively. Anti-emetics should be taken until nausea settles down and then stopped.
Ø Do not dispense the balance at the moment as this may cause confusion, but say that you will contact the doctor, with regard to the dose of MST. If Mr Grey is due to take another dose of MST before hearing from the doctor, suggest he takes a 30mg dose and uses breakthrough medication (5ml dose) as required – check that he still has enough of each.
What recommendations would you make to their GP?
Suggest discontinuing MST® 60mg at the moment, increase of 30-50% in regular opioid dose and review in 48 hours.
Breakthrough pain dose should be one sixth of total regular opioid dose.
Prescribe short course of anti-emetic to be taken regularly, either metoclopramide 10mg tid or haloperidol 1.5mg at night.
Case 3 Suggested answers
What are the actual or potential care issues?
Lack of understanding, he is taking sustained release medication every 14 hours rather than 12 hourly and does not know how to take his breakthrough pain dose.
The effectiveness of pain control is sub-optimal, as he is not taking paracetamol regularly or breakthrough medication soon enough.
Adverse effects of opioid leading to constipation
Non-compliance with laxative
The effectiveness of constipation management is sub-optimal due to inadequate dose and choice of laxative as well as a lack of fluid intake.
What advice would you give to the patient/carer?
- Breakthrough analgesia should be taken at onset of pain and should not wait until pain is too bad. He should wait 30 minutes to see if breakthrough medication is effective; if not, he can take a further dose and assess affect after another 30 minutes. He should contact his doctor/nurse if he needs more than two doses of breakthrough in 24 hours.
- He should take his Oxycontin® 12 hourly, agree times that suit him.
- He should take the paracetamol regularly four times daily and should be encouraged to report back to you or his GP after 24 hours to tell you how effective, or not, the changes have been.
- Laxative must be taken regularly and advise him if opioid dose increases, he may have to change his laxatives.
- Encourage the patient to drink plenty of fluids, approximately 6 – 8 cups every day if possible (water, tea, juice, milk).
- Try prunes at breakfast or prune juice, other fruit juices, plums or rhubarb.
- Encourage the patient to eat a high fibre cereal (porridge, bran flakes etc) if he can manage it. However, this will also require him to take extra fluids.
- Encourage the patient to keep as active as he can.
- Give the patient a leaflet on laxatives and strong painkillers if they are available in your area.
What recommendations would you make to their GP?
- Change paracetamol prescription to 1q qid.
- Change laxative to bisacodyl 5mg nocte and docusate sodium 100mg bd, or Movicol® (although increased fluid intake is essential).
- Report patients confusion in relation to his pain medication, and the advice provided by you.
Also, the patient`s pain/constipation may be colic related, hence an opioid may not be the best choice for breakthrough pain. It may be more appropriate to consider a 10-20mg dose of hyoscine butylbromide three or four times a day, if required.
Case 4 Suggested answers
What are the actual or potential care issues?
The effectiveness of pain control is sub-optimal-requires
Ø Regular dosing of Step 2 medication dihydrocodine plus regular paracetmaol for trial period. If this is not effective a move up the WHO step-ladder to a strong opioid such as morphine may be required.
Ø She reports pain on movement, which could be due to her bone metastases, and should be treated with NSAID if not contra-indicated.
Ø Two Step 2 analgesics should not be prescribed together one should be discontinued.
Lack of understanding in relation to regular dosing that is complicated by fears of addiction and tolerance. This may be resulting in possible non-compliance.
Potential adverse effects of pain medication if doses are increased in the future, therefore appropriate anti-emetic and an increase in laxative dosing or change of laxative may be required.
Groups or help– Know where a patient can get information leaflets and advice both nationally and in your local area – see resource pack.
What advice would you give to the patient/carer?
- Take dihydrocodeine 30mg qid plus 30mg for breakthrough pain – up to 4 extra doses a day. She may take one of the extra doses as breakthrough before she undertakes activity in order to prevent pain occurring.
- Stop taking the tramadol.
- She may initially feel drowsy and may get constipated; the important thing at this point is to control her pain.
- Reassure her that she will not become addicted or tolerant.
- Suggest that she returns any discontinued medication for you to destroy.
- Ask her to come back in and see you or phone to tell you how she is getting on.
- Encourage patient to discuss feelings of isolation with GP, district nurse or Macmillan nurse if in contact with one. Offer details of national or local self-help organisations.
- Give the patient an information leaflet about strong opioids, if you have one available in your area.
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What recommendations would you make to their GP?
Consider addition of NSAID and discontinuation of tramadol
What would the appropriate starting dose of morphine and what would you recommend to control the potential adverse effects of morphine?
Normal release morphine 5-10mg every four hours and 5-10mg for breakthrough and reassess pain every 24-48 hours until pain is controlled. Then convert to sustained release preparation with appropriate breakthrough pain dose. (elderly people should be started on half this dose.
Add in docusate or change to a combination of stimulant laxative and stool softener or Movicol® can you confirm the appropriate laxative.
Prescribe short course of anti-emetic metoclopramide 10mg tid, to be taken if required
Case 5 Suggested answers
· As the patient’s pain is controlled with a daily dose of morphine of 90mg you suggest starting him on a 25mcg/hr fentanyl patch (The BNF recommends each 25mcg/hr of fentanyl patch is equivalent to 90mg oral morphine.)
· The patient should put the first patch on and continue to take Oramorph® 15mg 4 hourly for 12 hours. Thereafter he should take 15mg Oramorph when required for breakthrough pain. The patient should also understand that he can still take his 15mg dose of Oramorph® for breakthrough pain, as the fentanyl will take 6 hours before it starts to take effect, 12 hours before it becomes reasonably effective and 24 to 48 hours before it is fully effective
· To calculate a breakthrough dose of morphine to go with a fentanyl patch the strength of the patch should be taken back to the equivalent morphine daily dose and divided by six.
· If controlled release morphine sulphate was being used the first fentanyl patch should be applied at the same time as the last dose of Zomorph/MST is taken.
· Do not try to increase the dose of fentanyl until the first patch has been allowed to reach maximum effect (i.e. at least 48 hours and preferably 72 hours after patch is applied). If an increase is required this should be 12mcg. Any increases thereafter should be in no more than 25mcg/hr increments. The new 12mcg patch is only licensed for titrating purposes.
· Remember to increase the breakthrough dose if the patch strength is increased.
· The doctor should be aware that all patients can respond differently to a switch of opioid, so he should watch out for any signs of opioid toxicity - hallucinations, confusion, agitation, myoclonic jerks, drowsiness and nausea and vomiting.
· Note that the lowest strength fentanyl patch (25mcg/hr) may be too high a dose for frail or elderly patients who have previously had only low doses of morphine, and a fentanyl patch may therefore be unsuitable for such patients. (The 12mcg patch is not licensed as a starting dose of fentanyl patch, only as a titrating dose)
· As fentanyl is not as constipating as morphine the dose of laxative may need to be halved and should be given in liquid form in this case.
· As this is an out of hours doctor, he might not be following the patient up so you, as the pharmacist, should either follow the patient up at 24 hours or check that a nurse will do so. Also the on-call doctor should be encouraged to ensure that the patient’s GP will be following up in 48 hours.
PCMS Palliative Care – Case answers final (amended) 30.01.07