NES Pharmaceutical Care of People Requiring Palliative Care
Case Studies
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.
Palliative Care – Case answers final (amended)
December 2011
Case 2 Suggested answers
What care issues have you identified for this patient?
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 offer to the patient/carer?
 Try to relax as anxiety can make nausea worse
 Eat little and often and brush teeth regularly
 Try to get some fresh air before mealtimes and eat in a wellventilated area
 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
 Don’t try to prepare food and avoid food/cooking smells or
unpleasant odours where possible.
 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.
 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 would you prescribe or what recommendations would you make
about this patient 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.
Palliative Care – Case answers final (amended)
December 2011
Case 3 Suggested answers
What care issues have you identified for this patient?
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 offer to the patient/carer?
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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 would you prescribe or what recommendations would you make
about this patient 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
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Palliative Care – Case answers final (amended)
December 2011
to consider a 10-20mg dose of hyoscine butylbromide three or four times a
day, if required.
Case 4 Suggested answers
What care issues have you identified for this patient?
The effectiveness of pain control is sub-optimal-requires
 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.
 She reports pain on movement, which could be due to her bone
metastases, and should be treated with NSAID if not contra-indicated.
 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 noncompliance.
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 offer to the patient/carer?
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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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Palliative Care – Case answers final (amended)
December 2011
What would you prescribe or what recommendations would you make
about this patient to their GP?
Consider addition of NSAID and discontinuation of tramadol
What would the appropriate starting dose of morphine be 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
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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
Palliative Care – Case answers final (amended)
December 2011
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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.
Palliative Care – Case answers final (amended)
December 2011