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INSTRUCTIONS FOR THE DOCTOR
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Please discuss your management of this situation with a GP colleague.
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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.
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INSTRUCTIONS FOR THE FACILITATOR
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This is a viva. The doctor is expected to talk with you as a professional colleague.
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Please ask the following questions:
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How would you manage Frank’s pain?
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?
Who else might be involved in Frank’s care?
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SUGGESTED APPROACH TO THE CASE
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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.
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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.
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
...