Palliative & End-of-Life Care

What is the guidance on using morphine in palliative care?

If advanced and progressive disease offer - regular oral modified-release (MR) or oral immediate-release morphine

If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain (immediate release)

Laxatives should be prescribed

Nausea is often transient; give antiemetic if persisting

What alternate opioids to morphine should be given in CKD?

Oxycodone in palliative patients with mild-moderate renal impairment

If more severe, alfentanil, buprenorphine, fentanyl are preferred

What drug is useful in the management of pain associated with liver metastases?

Dexamethasone → reduces pain by decreasing tumour-related inflammation and hepatic capsular oedema (capsular stretch is a source of pain)

Dexamethasone - MOA, uses, administration, adverse effects?

Glucocorticoid corticosteroid; binds to intracellular glucocorticoid receptors → alters gene transcription → reduces inflammation

Cerebral oedema → brain tumours; inflammatory / autoimmunity; croup in children; antiemetic (chemotherapy and post-operatively); severe COVID19; malignant spinal cord compression; palliative care (incl. pain management in liver metastases)

^also used in dexamethasone suppression test when investigating Cushing’s syndrome

Oral, IV, or IM; needs to be gradually reduced rather than cut due to suppression of HPA

Hyperglycaemia / steroid-induced diabetes; immunosuppression; osteoporosis; muscle wasting / proximal myopathy; weight gain; Cushingoid; psychiatric (insomnia, agitation); hypertension; peptic/GI irritation; cataracts / glaucoma; adrenal suppression