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INSTRUCTIONS FOR THE DOCTOR

This is a short viva.

Please discuss your management of this situation with a GP colleague.

Scenario

Frank is a 68-year-old retired postman who is dying from bowel cancer. He is now receiving palliative care and has a prognosis of weeks to months. He lives with his wife in a country town; their daughter lives nearby and helps a lot. You visit Frank at home and glean the following:

  • Frank is taking 20 mg oxycodone (Oxycontin) BD and 5 mg oxycodone (Endone) for breakthrough pain two to three hourly

  • he sleeps badly as he is waking throughout the night to take breakthrough pain medication. It relieves the pain for about 90 minutes.

Please answer the examiner’s questions about Frank.

INSTRUCTIONS FOR THE FACILITATOR

This is a viva. The doctor is expected to talk with you as a professional colleague.

Please ask the following questions:

  1. How would you manage Frank’s pain?

  2. What are some of the symptoms you may need to consider in Frank’s end-of-life care?

    Prompts if needed:

    • Do you think he is on the right pain medication?

    • What do you think of the dose?

    • Are there any non-opioid options to consider?

    • Are there any non-pharmacological options?

  3. Who else might be involved in Frank’s care?

SUGGESTED APPROACH TO THE CASE

Overall aim is a ‘good death’ by managing Frank’s pain and any other symptoms and taking a holistic approach to palliative care for him and his family.

  1. Ask about the detail of his pain to determine best options for management:

    • consider if the pain is from the tumour, metastases, constipation or another new condition

    • Frank most likely needs a higher dose of slow-release pain medication

    • calculate his current total daily dose from the slow-release oxycodone and the total breakthrough doses of oxycodone

    • increase the slow-release oxycodone dose to the current total daily dose

    • provide breakthrough oxycodone at a sixth to a twelfth of the total dose

    • if a patient is on two different opioids, use an opioid conversion chart to calculate current total 24-hour dose of morphine, and then calculate the slow-release and breakthrough doses

    • ask Frank to document his breakthrough doses so that you can increase slow-release doses as needed in future

    • reassure that using opioids is appropriate

    • provide scripts for laxatives, as well as asking about constipation

    • add paracetamol regularly as this potentiates the action of opioids

    • consider the role of palliative radiotherapy, chemotherapy or nerve blocks, but these would require hospital care away from home

    • heat/cold packs, antispasmodics, nifedipine (for tenesmus) and corticosteroids could also be tried.

  2. Palliative care patients can experience many complex symptoms and it is important to consider your patient and their family holistically.

    A helpful mnemonic is PAIN DOCTORSSS1

    • Pain

    • Anorexia

    • Insomnia

    • Nausea

    • Dyspnoea

    • Oedema

    • C...

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