PALLIATIVE CARE MCQs

Q-1
You review a patient with metastatic melanoma who is currently taken MST 50mg bd. Unfortunately he is
experiencing significant sedation and nausea and you decide to try switching him to oxycodone. What is
the most appropriate dose of Oxycontin (modified release oxycodone) to prescribe initially?

A. Oxycontin 10mg bd
B. Oxycontin 15mg bd
C. Oxycontin 50mg bd
D. Oxycontin 30mg bd
E. Oxycontin 100mg bd

ANSWER:
D. Oxycontin 30mg bd

EXPLANATION:
The current BNF gives a conversion factor of 1.5 (i.e. 10mg of oral morphine = 6.6 mg of oral oxycodone).
Other sources of guidance (e.g. palliative care formularies) often use a conversion factor of 2. Either way
the most appropriate dose from the given options is 30mg bd. This gives a conversion factor of 1.66.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

PALLIATIVE CARE PRESCRIBING: PAIN

NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below.
Please see the link for more details.

Starting treatment
 when starting treatment, offer patients with advanced and progressive disease regular oral modified-
release (MR) or oral immediate-release morphine (depending on patient preference), with oral
immediate-release morphine for breakthrough pain
 if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example,
15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
 oral modified-release morphine should be used in preference to transdermal patches
 laxatives should be prescribed for all patients initiating strong opioids
 patients should be advised that nausea is often transient. If it persists then an antiemetic should be
offered
 drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

SIGN guidelines
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
 the breakthrough dose of morphine is one-sixth the daily dose of morphine
 all patients who receive opioids should be prescribed a laxative
 opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine
and fentanyl are preferred
 metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion
that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong
opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in
contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral
to a clinical oncologist for consideration of further treatments such as radiotherapy

Other points
When increasing the dose of opioids the next dose should be increased by 30-50%.

In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat
metastatic bone pain.

Opioid side-effects

Usually transient Usually persistent

Nausea Constipation
Drowsiness

Conversion between opioids

From To Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10**

Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.

From To Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2***

The current BNF gives the following conversion factors for transdermal perparations
 a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
 a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

From To Conversion factor

Oral morphine Subcutaneous morphine Divide by 2
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*BMJ 2015;350:h315 Cancer induced bone pain

**this has previously been stated as 5 but the current version of the BNF states a conversion of 10
***historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral
morphine). The current BNF however uses a conversion rate of 1.5

Q-2
A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral
morphine solution should he be prescribed for breakthrough pain?

A. 5 mg
B. 10 mg
C. 15 mg
D. 20 mg
E. 30 mg

ANSWER:
B. 10 mg

EXPLANATION:
Breakthrough dose = 1/6th of daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of
this, 10 mg

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-3-5
Theme: Palliative care prescribing: converting opioids

A. 10 mg / day
B. 20 mg / day
C. 30 mg / day
D. 40 mg / day
E. 45 mg / day
F. 15 mg / day
G. 70 mg / day
H. 80 mg / day
I. 100 mg / day

For each of the following select the equivalent daily dose of oral morphine:

Q-3
Codeine 200mg / day
ANSWER:
B. 20 mg / day

Q-4
Tramadol 400 mg / day

ANSWER:
D. 40 mg / day

Q-5
Oral oxycodone 30 mg / day

ANSWER:
E. 45 mg / day

EXPLANATION Q-3-6:

Please see Q-1 for Palliative Care Prescribing: Pain

Q-6
A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal
metastases but until now has not had any significant problems with pain control. Unfortunately, he is now
getting regular back pain despite taking paracetamol 1g qds. The pain is stopping him sleep at times.
Neurological examination is unremarkable. What is the most appropriate next step?

A. Add amitriptyline
B. Add a strong opioid
C. Add an oral bisphosphonate
D. Add naproxen
E. Add dexamethasone

ANSWER:
Add a strong opioid

EXPLANATION:
The assertion that NSAIDs such as naproxen are particularly effective in cancer-induced bone pain is not
supported by recent studies. Whilst there is a role for oral bisphosphonates in treating such pain the
effects may take several weeks to materialise and the number needed to treat is higher than that of
strong opioids. Referral to a clinical oncologist should be considered for all patients with such pain as
radiotherapy is an effective treatment.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-7
An elderly man who has metastatic prostate cancer is reviewed. His pain is currently controlled with MST
30mg bd but he is now unable to take medication by mouth and has become drowsy. A syringe driver is
set-up. What is the most appropriate prescription?

A. Diamorphine 15mg over 24 hours in 'water for injection'

B. Diamorphine 20mg over 24 hours in sodium chloride 0.9%
C. Diamorphine 20mg over 24 hours in 'water for injection'
D. Diamorphine 30mg over 24 hours in 'water for injection'
E. Diamorphine 30mg over 24 hours in sodium chloride 0.9%

ANSWER:
C. Diamorphine 20mg over 24 hours in 'water for injection'

EXPLANATION:
'Water for injection' is the preferred diluent in syringe drivers. There are a number of exceptions, please
see below.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

SYRINGE DRIVERS
A syringe driver should be considered in the palliative care setting when a patient is unable to take oral
medication due to nausea, dysphagia, intestinal obstruction, weakness or coma. In the UK there are two
main types of syringe driver:
 Graseby MS16A (blue): the delivery rate is given in mm per hour
 Graseby MS26 (green): the delivery rate is given in mm per 24 hours

The majority of drugs are compatible with water for injection although for the following drugs sodium
chloride 0.9% is recommended:
 granisetron
 ketamine
 ketorolac
 octreotide
 ondansetron

Commonly used drugs

 nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
 respiratory secretions: hyoscine hydrobromide
 bowel colic: hyoscine butylbromide
 agitation/restlessness: midazolam, haloperidol, levomepromazine
 pain: diamorphine is the preferred opioid
Mixing and compatibility issues
 diamorphine is compatible with the majority of other drugs used including cyclizine*, dexamethasone,
haloperidol, hyoscine butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide,
midazolam
 cyclizine is incompatible with a number of drugs including clonidine, dexamethasone, hyoscine
butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, sodium
chloride 0.9%

*precipitation may be seen at higher doses

Q-8
ou review a 72-year-old man with metastatic bowel cancer who is in the terminal phase and has a syringe
driver. Unfortunately he has developed intestinal obstruction and is suffering with bowel colic. What is
the most appropriate drug to add to the syringe driver?

A. Metoclopramide
B. Hyoscine hydrobromide
C. Levomepromazine
D. Haloperidol
E. Hyoscine butylbromide

ANSWER:
E. Hyoscine butylbromide

EXPLANATION:
Syringe drivers
 respiratory secretions: hyoscine hydrobromide
 bowel colic: hyoscine butylbromide

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-7 for Syringe Drivers

Q-9
A 76-year-old patient has recently been diagnosed with lung cancer and has been commenced on a
chemotherapy regime. He is taking 15mg of morphine sulphate twice daily with a breakthrough dose of
5mg of oramorph as needed. Unfortunately, he has developed diffuse oral pain as a consequence of
treatment and is distressed by this.

What is the single most appropriate treatment to improve his pain?

A. Add a neuropathic agent such as amitriptyline to be taken at night

B. Increase in breakthrough oramorph dose
C. Prescribe a chlorhexidine mouthwash
D. Arrange blood tests to check for B12 deficiency
E. Prescribe a benzydamine mouthwash

ANSWER:
E. Prescribe a benzydamine mouthwash
EXPLANATION:
Benzydamine hydrochloride mouthwash or spray may be useful in reducing the discomfort associated with
a painful mouth that may occur at the end of life

Mouth care is important in patients receiving cancer treatment as well as in end of life care. There can be
numerous causes of mouth pain including the effect of dentures/sharp teeth, intercurrent infection e.g.
Candida, haematinic deficiency, dry mouth from reduced oral intake and mucositis of various grades as a
result of chemotherapy and/or radiotherapy.

The Applied Knowledge Test summary reports indicated that candidates can improve upon specific
prescribing of drugs in end of life care (including mouth care).

There is specific guidance on mucositis depending on the severity. However, in the absence of significant
ulceration and severe mucositis, for diffuse oral pain, a benzydamine mouthwash is a useful starting point.

There is nothing from the clinical history to suggest a neuropathic agent will be of benefit.

Although using oral opioids for pain is useful in this case, it is not suggested that the patient's as required
or regular use has increased and therefore this is not the best option.

Chlorhexidine mouthwash can be useful in certain circumstances. However, due to the high alcohol
contact, it can exacerbate pain in an individual's mouth. In this instance, it is therefore not the best option.
For prevention, washing with water or sodium chloride regularly is recommended.

Although a deficiency in vitamin B12, iron, or folate can feasibly cause a painful mouth and aphthous
ulceration, in this scenario the patient's pain is likely a result of their chemotherapy treatment and
therefore checking vitamin B12 level is not a priority.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-10
A 65-year-old man with metastatic squamous cell lung cancer presents to surgery. He complains of acute
pain in his right arm which is the site of a known skeletal metastasis. He is currently taking slow-release
morphine sulphate (MST) 90mg bd to control his pain along with regular naproxen and paracetamol. What
is the most appropriate medication to prescribe to control the acute pain?

A. Oral morphine solution 30mg

B. Oral morphine solution 15mg
C. Oral morphine solution 10mg
D. Add alendronate 70mg weekly
E. Tramadol 50mg
ANSWER:
A. Oral morphine solution 30mg

EXPLANATION:
This patient is describing break-through pain. Whilst bisphosphonates have a role in bone metastases they
are not suitable for acute pain. A suitable break-through dose is therefore 1/6th of the total daily
morphine dose i.e. 1/6th of 180mg = 30mg.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-11
A syringe driver is prescribed for a patient who is dying from metastatic breast cancer. Which one of the
following drugs is incompatible with dexamethasone, metoclopramide and midazolam?

A. Diamorphine
B. Hyoscine hydrobromide
C. Cyclizine
D. Levomepromazine
E. Haloperidol

ANSWER:
C. Cyclizine

EXPLANATION:
Syringe drivers - cyclizine is incompatible with a number of other drugs

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-7 for Syringe Drivers

Q-12
A 65-year-old man on palliative treatment for metastatic oesophageal cancer is finding it increasingly
difficult to take his morphine and as such is in increasing discomfort. His current prescription is for 60 mg
BD oral.

Which of the following is the most appropriate option to manage his pain?
A. Switch to subcutaneous morphine infusion at 120 mg/24hrs
B. Switch to gabapentin
C. Switch to fentanyl ‘100’ patch (100 micrograms/hour)
D. Switch to subcutaneous morphine infusion at 60 mg/24hrs
E. Increase oral morphine solution to 90 mg BD

ANSWER:
D. Switch to subcutaneous morphine infusion at 60 mg/24hrs

EXPLANATION:
Divide by two for oral to subcutaneous morphine conversion

This patient’s daily dose of oral morphine is 120 mg in total. Based on the history provided, his increasing
pain is a result of his inability to swallow, rather than a change in his condition. As such the most
appropriate option is to switch to an equivalent dose of an opioid via a more tolerable route.

1) The ratio of oral to parenterally administered morphine is 2:1, that is to say, subcutaneous or
intravenous doses are half that of the oral dose. This dose is, therefore, double his current requirements.

2) There has been no change in his condition or nature of his pain. As such, it would not be appropriate to
switch to a different class of pain relief.

3) Transdermal patches are suitable for those with stable levels of pain who will not require regular
titration of their pain relief. This will not always be the case in a palliative cancer patient. They should also
not be given to opioid naïve patients. At this dose, a fentanyl 100 patch will deliver 2400 micrograms or
2.4 mg of fentanyl per 24 hours. The conversion of oral morphine to transdermal fentanyl is however
1:100, and as such this is equivalent to 240 mg oral morphine per 24 hours, double his current
requirements.

4) This is correct as a subcutaneous dose of 60 mg/24 hours is equivalent to 120 mg of oral morphine.

5) This option would be inappropriate as it is the patient’s difficulty in taking his pain relief that is causing
his pain, not an increase in his pain requirements.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-13
A 72-year-old male with metastatic lung cancer is referred to the palliative care team for end of life care.
Currently, he takes 10mg oral morphine daily which effectively controls his pain. Anticipatory medications
are prescribed in a syringe driver.

How much daily subcutaneous morphine needs to be given?

A. 3.3mg
B. 5mg
C. 6.7mg
D. 10mg
E. 15mg

ANSWER:
B. 5 mg

EXPLANATION:
Divide by two for oral to subcutaneous morphine conversion

Switching the route and choice of opioid requires dose adjustment. Oral morphine is half as strong as
subcutaneous/intravenous morphine mainly due to first-pass metabolism.

Fentanyl, buprenorphine and other opioids have varying conversion ratios for different routes.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-14
A 76-year-old female with multiple myeloma is experiencing acute back pain. Her oral regular analgesic
medications include 7.5mg morphine QDS and 1g paracetamol QDS.

What breakthrough dose of morphine should be given?

A. 3mg
B. 5mg
C. 7.5mg
D. 10mg
E. 15mg

ANSWER:
B. 5 mg

EXPLANATION:
Breakthrough dose = 1/6th of daily morphine dose

The total daily dose of morphine is equal to 30mg (7.5*4). The breakthrough dose is 1/6 of the total daily
dose of morphine which is 5mg (30/6).

Please see Q-1 for Palliative Care Prescribing: Pain

Q-15
A 60-year-old veteran with a background of metastatic lung cancer and CKD stage 4 is deteriorating and
complains of a chronic generalised pain in his chest. Which regular pain relief would be the most
appropriate option for him?

A. Morphine sulphate liquid

B. Morphine sulphate tablets
C. Diamorphine
D. Naproxen
E. Oxycodone

ANSWER:
E. Oxycodone

EXPLANATION:
Oxycodone is a safer opioid to prescribe in a patient with renal failure

Morphine sulphate liquid - This is the wrong answer for two reasons: 1. It is short-acting so would be
better for PRN use 2. It is not recommended in patients with renal failure as its active metabolites are
renally excreted. Immediate release Oxycodone liquid would be the preferred choice for PRN use.

Morphine sulphate tablets - Active metabolites are renally cleared so not recommended in patients with
renal failure.

Diamorphine - As above however if a patient is imminently dying, it may be used in a syringe driver
preferably after discussion of the risk/benefits with the palliative care team.

Naproxen - Not recommended as it would be nephrotoxic in this case and also unlikely to provide
adequate pain relief for this gentleman.

Oxycodone - A relatively safer opioid to use as it is mostly cleared by the liver. Other options options
include fentanyl, buprenorphine, alfentanil and methadone although it is best to discuss with palliative
care team first.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '
Please see Q-1 for Palliative Care Prescribing: Pain
Q-16
A patient is taking tramadol 100mg qds. Despite this he has poor pain control. What is the equivalent 24
hour dose of oral morphine?

A. 20 mg
B. 40 mg
C. 50 mg
D. 80 mg
E. 100 mg
ANSWER:
B. 40 mg

EXPLANATION:
Tramadol to morphine - divide by 10

Please see Q-1 for Palliative Care Prescribing: Pain

Q-17
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST 60mg bd for pain. He has
become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of
diamorphine should be prescribed for the syringe driver?

A. 60 mg
B. 40 mg
C. 120 mg
D. 30 mg
E. 20 mg

ANSWER:
B. 40 mg

EXPLANATION:
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be
divided by 3 (120 / 3 = 40mg)

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-18
A 67-year-old with chronic kidney disease stage 4 and metastatic prostate cancer presents as his pain is
not controlled with co-codamol. Which one of the following opioids is it most appropriate to use given his
impaired renal function?

A. Buprenorphine
B. Morphine
C. Hydromorphone
D. Diamorphine
E. Tramadol

ANSWER:
A. Buprenorphine
EXPLANATION:
Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-19
A 71-year-old woman with metastatic breast cancer comes to surgery with her husband. She is known to
have bone metastases in her pelvis and ribs but her pain is not controlled with a combination of
paracetamol, diclofenac and MST 30mg bd. Her husband reports she is using 10mg of oral morphine
solution around 6-7 times a day for breakthrough pain. The palliative care team at the hospice tried using
a bisphosphonate but this unfortunately resulted in persistent myalgia and arthralgia. What is the most
appropriate next step?

A. Switch to oxycodone
B. Increase MST
C. Increase MST + add dexamethasone
D. Increase MST + suggest course of complimentary therapies
E. Increase MST + refer for radiotherapy

ANSWER:
E. Increase MST + refer for radiotherapy

EXPLANATION:
Metastatic bone pain may respond to analgesia, bisphosphonates or radiotherapy

Dexamethasone should be considered if the metastatic spinal cord compression, but this is not a feature
given the location of the lesions.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '
Please see Q-1 for Palliative Care Prescribing: Pain
Q-20
You are considering switching a palliative care patient from oral morphine to oral oxycodone. Which one
of the following is more likely to occur with oxycodone?

A. Depression
B. Pruritus
C. Constipation
D. Vomiting
E. Sedation
ANSWER:
C. Constipation

EXPLANATION:
The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-21
A 71-year-old man with metastatic prostate cancer presents for review. His pain is currently controlled
with a combination of paracetamol 1g qds, ibuprofen 400mg tds and Zomorph (slow release morphine)
60mg bd. You have also supplied him with a bottle of oral morphine solution (10mg/5ml) for
breakthrough pain. What volume of oramorph should he take when he experiences breakthrough pain?

________ ml

ANSWER:
10 ml

EXPLANATION:
It is recommended that patients take one-sixth of their total oral morphine dose for breakthrough pain.

The correct dose is therefore (60 * 2) / 6 = 20mg

The volume of oral morphine 10mg/5ml required is 20 / 10 = 2 * 5 = 10ml

The October 2011 AKT feedback stated: 'We regularly test candidates' ability to calculate drug doses, for
example where the drugs need to be given in mg/kg. A worrying number of candidates were apparently
unable to correctly perform a relatively simple calculation regarding a drug dose for a child, and this poses
concerns about patient safety. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-22
You review a palliative care patient at home. They are currently on 30mg MST bd. This is controlling the
pain but the patient is no longer able to swallow. After discussion with all concerned you agree to switch
to morphine through a syringe driver. What would be the most appropriate dose to start on?

A. 60mg over 24 hours

B. 30mg over 24 hours
C. 40mg over 24 hours
D. 10mg over 24 hours
E. 6mg over 24 hours
ANSWER:
B. 30mg over 24 hours

EXPLANATION:
Source: Clinical Knowledge Summary - Palliative cancer care (last reviewed April 2015)

When changing the route of administration of one strong opioid to another, the most common switch is
from oral morphine sulphate to subcutaneous diamorphine or morphine.

Diamorphine is much more soluble than morphine and therefore easier to administer in higher doses. It is
also compatible with most other drugs which may need to be administered by a subcutaneous infusion.
However, morphine is preferred in most cases as most people do not require doses large enough to cause
solubility issues:
Parenteral diamorphine is approximately three times as potent as oral morphine, so the total daily dosage
of oral morphine should be divided by three to obtain the 24-hour subcutaneous dose of diamorphine.
The oral to subcutaneous potency ratio of morphine is between 1:2 and 1:3 (that is, the subcutaneous dose
is one third to one half of the oral dose). In practice, most centres divide the oral dose by two and re-
titrate as necessary.

See also the British National Formulary section: Prescribing in palliative care - continuous subcutaneous
infusions for further information and a table showing equivalent does of morphine sulphate and
diamorphine hydrochloride given over 24 hours.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-23
A patient with metastatic cancer asks to be switched from MST 90 mg bd to fentanyl patches. What is the
equivalent number of patches which should be applied?

A. Half a fentanyl '25' patch

B. One fentanyl '25' patch
C. One fentanyl '50' patch
D. One fentanyl '75' patch
E. One fentanyl '100' patch

ANSWER:
D. One fentanyl ‘75’ patch

EXPLANATION:
The current BNF would suggest that 180mg a day (90 * 2) is equivalent to a fentanyl '75' patch.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-24
A 70-year-old man with metastatic lung cancer comes in for review. His pain is not currently controlled
with MST 100 mg bd. He also takes paracetamol 1g tds and diclofenac 50mg tds. What is the most
appropriate next step?

A. Increase MST to 140 mg bd

B. Increase MST to 120 mg bd
C. Increase MST to 110 mg bd
D. Increase MST to 160 mg bd
E. Add codeine 60mg qds

ANSWER:
A. Increase MST to 140 mg bd

EXPLANATION:
In palliative patients increase morphine doses by 30-50% if pain not controlled

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-25
A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes oral
modified-release morphine sulphate 60mg bd but it is decided to convert this to subcutaneous
administration as he is frequently vomiting. What is the most appropriate dose of morphine to give over a
24 hour period using a continuous subcutaneous infusion?

A. 20mg
B. 30mg
C. 40mg
D. 60mg
E. 120mg

ANSWER:
D. 60mg

EXPLANATION:
The BNF recommend half the oral dose of morphine in this situation:
The equivalent parenteral dose of morphine (subcutaneous, intramuscular, or intravenous) is about half of
the oral dose. If the patient becomes unable to swallow, generally morphine is administered as a
continuous subcutaneous infusion

This patient is on 60mg bd = 120mg. Divided by 2 = 60mg of subcutaneous morphine.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-26
A 72-year-old man with metastatic small cell lung cancer is admitted to the local hospice for symptom
control. His main problem at the moment is intractable hiccups. What is the most appropriate
management?

A. Chlorpromazine
B. Codeine phosphate
C. Diazepam
D. Methadone
E. Phenytoin

ANSWER:
A. Chlorpromazine

EXPLANATION:
Hiccups in palliative care - chlorpromazine or haloperidol

Haloperidol may also be used

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

PALLIATIVE CARE PRESCRIBING: HICCUPS

Management of hiccups
 chlorpromazine is licensed for the treatment of intractable hiccups
 haloperidol, gabapentin are also used
 dexamethasone is also used, particularly if there are hepatic lesions

Q-27
A 55-year-old male with sickle cell anaemia enters the emergency department. He is suffering another
episode of extreme pain, particularly in his hands. He has a past medical history of type 2 diabetes,
chronic kidney disease stage 4 and previous a DVT.
Which of the following analgesia would be most appropriate for the patient?

A. Co-codamol
B. Codeine
C. Diamorphine
D. Morphine
E. Oxycodone

ANSWER:
E. Oxycodone

EXPLANATION:
Oxycodone is a safer opioid to prescribe in a patient with renal failure

Clinicians should take care in prescribing opioids in the elderly and those with renal failure. Morphine,
diamorphine, codeine and other renally excreted drugs will accumulate in patients with poor kidney
function. These should be avoided unless in certain circumstances.

Oxycodone and alfentanil are two examples of analgesics which are mainly metabolised in the liver and
thus can safely be used in patients with kidney failure.

Sickle cell patients can experience many acute and chronic complications. Sickle cell crisis (where severe
anaemia occurs) can be extremely painful and solely codeine or co-codamol will likely not control the pain.

Longer-term patients may develop sickle cell nephropathy where hemolysis and vascular occlusion leads to
loss of tubular function. Patients can further develop chronic kidney disease and later end-stage renal
disease.

Please see Q-1 for Palliative Care Prescribing: Pain

Q-28
You are reviewing an elderly man with prostate cancer. Unfortunately his pain is not currently controlled
by co-codamol 30/500 2 tablets qds and diclofenac 50mg tds. You decide to switch him to oral morphine.
What is the conversion factor between oral codeine and oral morphine?

A. Divide by 4
B. Divide by 15
C. Divide by 6
D. Divide by 20
E. Divide by 10

ANSWER:
E. Divide by 10

EXPLANATION:
Codeine to morphine - divide by 10

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-29
A 72-year-old man with metastatic colon cancer is reviewed. He currently takes co-codamol 30/500 2
tablets qds for pain relief. Unfortunately this is not controlling his pain. What is the most appropriate
change to his medication?

A. Switch to MST 15mg bd + paracetamol 1g qds

B. Switch to MST 35mg bd + paracetamol 1g qds
C. Add tramadol 50-100mg 1-2 qds
D. Switch to MST 25mg bd
E. Switch to MST 15mg bd

ANSWER:
A. Switch to MST 15mg bd + paracetamol 1g qds

EXPLANATION:
His total codeine dose is 30 * 2 * 4 = 240 mg/day. Converting this to oral morphine = 24 mg/day. It is
therefore reasonable to start MST 15mg bd as his pain is not currently controlled. Paracetamol should be
continued as it has been shown to give benefits even to patients on large doses of morphine

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-30
Which one of the following statements regarding the use of opioids in patients with advanced cancer is
correct?

A. Transdermal patches should be used first-line for patients who require regular opioids
B. Drowsiness is usually a transient side-effect
C. All patients who are prescribed regular morphine should be given an antiemetic
D. Patients should be reviewed on a weekly basis and warned about the dangers of becoming addicted
E. An appropriate starting dose is 30mg of modified-release morphine sulphate twice a day with 10mg of
immediate-release morphine for breakthrough pain

ANSWER:
B. Drowsiness is usually a transient side-effect
EXPLANATION:
Drowsiness and nausea, in contrast to constipation, are usually transient in patients taking opioids. An
anti-emetic only needs to be prescribed if the nausea persists.

A more appropriate starting dose is 20-30mg of modified-release morphine a day with 5mg morphine for
breakthrough pain.

The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-31
You are visiting a 64-year-old lady who has breast cancer. She is currently taking MXL (slow-release
morphine) 90mg od for pain relief. What is the most appropriate dose of oral morphine to take if she
experiences breakthrough pain?

_______ mg

ANSWER:
15 mg

EXPLANATION:
It is recommended that patients take one-sixth of their total oral morphine dose for breakthrough pain.

The correct dose is therefore 90 / 6 = 15mg

The April 2014 AKT feedback report stated: 'Drug calculation questions are included in every AKT and we
have noted only a marginal improvement in candidates answering these correctly. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-32
A 60-year-old lady with metastatic endometrial cancer comes for review. She is currently taking MST (slow
release morphine) 75mg bd but is unfortunately troubled with pruritus. You therefore decide to switch
her to OxyContin (slow release oxycodone which is taken twice a day). Following BNF recommendations,
what dose of OxyContin should she take twice a day?

_______ mg

ANSWER:
50 mg

EXPLANATION:
The BNF recommends a conversion factor of 1.5. She should therefore be prescribed OxyContin 50mg bd.
The April 2014 AKT feedback report stated: 'Drug calculation questions are included in every AKT and we
have noted only a marginal improvement in candidates answering these correctly. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-33
NICE have published guidelines on the use of opioids in palliative care. What do they recommend as an
initial regime for patients who have advanced and progressive cancer without significant comorbidities?

(MR = modified release, IR = immediate release)

A. Oral MR morphine 20mg bd + Oral IR morphine 10mg prn for breakthrough pain
B. Oral codeine 30mg qds + oral codeine 15mg prn for breakthrough pain
C. Oral tramadol 50mg qds + oral tramadol 50mg prn for breakthrough pain
D. Oral MR morphine 30mg bd + Oral IR morphine 10mg prn for breakthrough pain
E. Oral MR morphine 15mg bd + Oral IR morphine 5mg prn for breakthrough pain

ANSWER:
E. Oral MR morphine 15mg bd + Oral IR morphine 5mg prn for breakthrough pain

EXPLANATION:
The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-1 for Palliative Care Prescribing: Pain

Q-34
A 65-year-old female with metastatic breast cancer is reviewed in clinic. Her husband reports that she is
increasingly confused and occasionally appears to talk to relatives that are not in the room. She undergoes
investigations for reversible causes, of which none are found. If conservative measures fail and she
continues to be confused/agitated, what is the most appropriate management?

A. Subcutaneous midazolam
B. Oral lithium
C. Oral haloperidol
D. Oral diazepam
E. Oral quetiapine

ANSWER:
C. Oral haloperidol

EXPLANATION:
Oral haloperidol is the most appropriate treatment here. If the patient was in the terminal phase and
agitated then subcutaneous midazolam would be indicated
The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

PALLIATIVE CARE PRESCRIBING: AGITATION AND CONFUSION

Underlying causes of confusion need to be looked for and treated as appropriate, for example
hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the following
may be tried:
 first choice: haloperidol
 other options: chlorpromazine, levomepromazine

In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

Q-35
A 79-year-old female with a history of COPD and metastatic lung cancer is admitted with increasing
shortness of breath. Following discussion with family it is decided to withdraw active treatment, including
fluids and antibiotics, as the admission likely represents a terminal event. Two days after admission she
becomes agitated and restless. What is the most appropriate management?

A. Subcutaneous midazolam
B. Intramuscular haloperidol
C. Oral lormetazepam
D. Oral haloperidol
E. Recommence fluids and antibiotics

ANSWER:
A. Subcutaneous midazolam

EXPLANATION:
The January 2019 AKT feedback report stated:

'There was a lack of knowledge about drugs used to treat specific end of life symptoms. Although many of
these drugs may be initiated by specialist teams, GPs will often be asked to continue the prescription and
need to be aware of the indications for the particular drugs. '

Please see Q-34 for Palliative Care Prescribing: Agitation and Confusion