AKT – Palliative care

Margaret O’Connell, aged 78, presents with her daughter due to increasing confusion and reduced oral intake over the past week. She has metastatic ovarian cancer with known hepatic and peritoneal involvement.

She is no longer tolerating oral morphine due to nausea and frequent vomiting. She is drowsy but rousable. She has a subcutaneous butterfly in place. Her current medications include metoclopramide 10 mg tds, morphine 10 mg orally q4h, and PRN midazolam 2.5 mg subcut. She has no known allergies.

On examination, she is cachectic, with dry mucous membranes. Her respiratory rate is 24/min with mild terminal secretions. GCS is 13. She is unable to swallow tablets reliably.

What is the MOST appropriate management of her pain at this stage?

Thomas Kaye, aged 84, with advanced COPD and congestive heart failure, is admitted to your palliative care unit with increasing dyspnoea and anxiety. He has been having panic episodes triggered by breathlessness.

His current medications include frusemide, tiotropium, salbutamol PRN, and sertraline. He is oxygen-dependent at home. His ECG and bloods are unremarkable. Family agree on a comfort-focused approach.

On examination, RR is 30/min, SpO2 is 91% on 4L/min oxygen. He is visibly anxious and is calling out for help.

What is the MOST appropriate initial pharmacological intervention?

Jenny Clarke, aged 69, has metastatic breast cancer and is now bedbound. She is no longer eating and is minimally responsive. Her daughter is distressed and asks whether intravenous fluids should be started as Jenny has had no oral intake for two days.

Jenny has an ACD stating her wish for comfort care only. She is not currently in distress and her mouth appears moist with regular oral care.

What is the MOST appropriate response regarding the provision of IV fluids?

Leo Peterson, aged 56, has inoperable pancreatic cancer with liver metastases. He presents with progressive pruritus, dark urine, and pale stools. He is visibly jaundiced. Blood tests show elevated bilirubin and ALP. He is receiving palliative chemotherapy.

He is distressed by his symptoms but keen to continue treatment if possible. CT shows an obstructed common bile duct due to tumour compression.

What is the MOST appropriate next step?

Dorothy Newton, aged 87, has end-stage dementia and is in residential aged care. She is non-verbal and has had decreased oral intake over several weeks. Staff report recent agitation, grimacing, and vocalisations, particularly during hygiene care. She has no known cancer. Her regular medications include paracetamol, donepezil, and escitalopram.

What is the MOST appropriate next step in assessing her symptoms?

Ahmed Farouk, aged 64, with metastatic prostate cancer involving spine and pelvis, presents with new onset back pain and bilateral leg weakness. He has not opened his bowels in three days and is incontinent of urine.

He is alert and oriented. His mobility has significantly decreased in the past 48 hours. On examination, there is decreased power in both legs and a sensory level at T10.

What is the MOST appropriate next step in management?

Mei Ling Chan, aged 49, has stage IV cholangiocarcinoma. She has ongoing anorexia and weight loss. Her partner is distressed that she is refusing food and asks whether she should be admitted for tube feeding.

Mei Ling is lucid and states she is not hungry and does not want feeding tubes. She understands her condition and prognosis and has previously expressed a wish for comfort care only.

What is the MOST appropriate response?

James Brennan, aged 72, is receiving palliative care for end-stage renal failure. He has declined dialysis. He now reports nausea, pruritus, and difficulty sleeping. He is currently taking metoclopramide, paracetamol and temazepam.

His latest bloods show rising urea and creatinine, consistent with progression. He wishes to remain at home and avoid hospitalisation.

What is the MOST appropriate next step to address his symptoms?

Alinta Fraser, aged 55, has metastatic breast cancer and is now experiencing severe bone pain and functional decline. She has completed radiotherapy and her oncologist has recommended no further disease-modifying treatment.

She asks about options to manage her pain better at home. Her current analgesia includes regular paracetamol and morphine SR 30 mg BD with morphine IR 10 mg PRN.

What is the MOST appropriate next step in optimising her pain management?

Felicity Brown, aged 81, is in the terminal phase of dementia. She is no longer able to swallow her tablets. You are reviewing her medications at the request of nursing home staff who note that she has multiple regular tablets prescribed including metoprolol, simvastatin, and aspirin.

She is bedbound, non-verbal, and receiving comfort-focused care. Her family are supportive of comfort measures only.

What is the MOST appropriate action regarding her medication chart?

Patrick Sullivan, aged 66, has metastatic colorectal cancer. He is receiving home-based palliative care. His wife reports he has become increasingly drowsy and has had several episodes of myoclonic jerks over the last 24 hours. He is currently on morphine SR 60 mg BD and morphine IR 20 mg PRN, which he has used frequently for escalating pain.

What is the MOST likely cause of his new symptoms?

Amira Yusuf, aged 61, has advanced lung cancer and has recently developed worsening dyspnoea and distressing terminal secretions. She is being cared for at home. Her family is distressed by the noisy breathing.

She is unconscious, with no signs of respiratory distress or discomfort. Her current medications include morphine and midazolam by subcutaneous infusion.

What is the MOST appropriate management of her terminal secretions?

Lara McEwan, aged 73, is in the terminal phase of metastatic ovarian cancer. She is unconscious and has had no oral intake for three days. Her son asks whether she should be given antibiotics for a suspected UTI, as her urine is dark and has a strong smell.

What is the MOST appropriate response?

Gregory Lewis, aged 59, has metastatic melanoma and is receiving palliative care at home. He has become agitated and confused over the last 12 hours. He is no longer communicating clearly. He was previously oriented and managing symptoms well. There has been no recent medication change. Family reports normal urine output and no fever.

What is the MOST likely cause of his symptoms?

Wendy Haines, aged 82, has metastatic breast cancer with bone involvement. She is cared for in a residential aged care facility and is now in the terminal phase. Staff have contacted you due to observed grimacing and moaning. She is non-verbal but appears distressed. She has no analgesia prescribed other than paracetamol.

What is the MOST appropriate management?

Angela Morton, aged 76, has pancreatic cancer and is approaching end-of-life. She is experiencing existential distress, asking questions such as “What was the point of all this?” and “Why am I still here?” Her physical symptoms are controlled, but she appears withdrawn and tearful.

What is the MOST appropriate response to her distress?

Eric Zhou, aged 81, with end-stage heart failure, has made it clear he does not want hospital admission. He has developed orthopnoea and is unable to sleep lying flat. He is currently on frusemide, metoprolol and low-dose morphine for breathlessness.

What is the MOST appropriate addition to his current management?

Chloe McGrath, aged 62, is dying from metastatic breast cancer and is being cared for at home. Her daughter calls you because Chloe has become agitated, is picking at the sheets, and seems confused. She had been calm earlier that day.

She is receiving morphine and midazolam via a syringe driver. There has been no change to medications in the last 72 hours.

What is the MOST appropriate initial approach?

Nathan Callaghan, aged 58, has stage IV lung cancer with recent onset of hiccups that have persisted for three days. They are interfering with his sleep and causing distress. He is alert and his vital signs are stable. He is on regular oxycodone and dexamethasone for cerebral mets.

What is the MOST appropriate next step in managing his hiccups?

Betty Randall, aged 88, has end-stage dementia and advanced frailty. She is no longer mobile or verbal. Her son asks whether she should be transferred to hospital for IV antibiotics for a suspected chest infection. She has an ACD stating her wish to avoid burdensome interventions.

Her vital signs are stable. She is comfortable and shows no signs of respiratory distress.

What is the MOST appropriate management?

Julie Tran, aged 51, is receiving palliative care for metastatic breast cancer. She has developed significant constipation despite regular oral docusate and senna. She is on sustained-release oxycodone 40 mg BD. She has mild abdominal discomfort and has not opened her bowels for 5 days.

What is the MOST appropriate next step in her management?

Michael Stevens, aged 75, has end-stage liver failure and is receiving home-based palliative care. His wife reports he is increasingly confused, with reversed sleep-wake cycle, and musty breath. He is not on any opioids or sedatives. He last opened his bowels 2 days ago.

What is the MOST likely cause of his confusion?

Isabel Deegan, aged 87, is admitted to a hospice with advanced lung cancer and increasing breathlessness. She is already on a low-dose morphine infusion for symptom control. She is anxious and reports a feeling of air hunger. Her SpO2 is 95% on room air.

What is the MOST appropriate next step in management?

Steven O’Malley, aged 69, is in the final days of life from metastatic gastric cancer. He has developed noisy, moist breathing and appears unconscious. Family are distressed and ask if he is “drowning” and suffering.

What is the BEST explanation to offer the family?

Marion Taft, aged 80, with end-stage COPD, is receiving palliative care in the community. She has become increasingly drowsy and has not passed urine for over 24 hours. She is on low-dose morphine, midazolam, and regular frusemide.

What is the MOST appropriate immediate action?

Denise Holloway, aged 85, is in residential aged care with advanced Alzheimer’s disease. She is non-verbal, unable to mobilise or feed herself, and has developed a stage 3 sacral pressure injury. The facility nurse has asked you to review for possible transfer to hospital for IV antibiotics and wound debridement.

Her family is clear that her goals are comfort care only, with no hospital admissions. She is afebrile and appears comfortable.

What is the MOST appropriate management?

Yusuf Ahmed, aged 72, is receiving palliative chemotherapy for pancreatic cancer. He reports worsening fatigue and weight loss. Blood tests show normocytic anaemia (Hb 90 g/L) and a ferritin of 110 µg/L. He has no bleeding symptoms. He asks if he should have a blood transfusion to boost his energy.

What is the MOST appropriate advice?

Karl Weaver, aged 61, has metastatic prostate cancer and is developing signs of hypercalcaemia – fatigue, nausea, constipation, and mild confusion. Blood tests confirm corrected calcium of 3.1 mmol/L. He is receiving palliative care at home and is keen to avoid hospitalisation.

What is the MOST appropriate management?

Olivia Jenkins, aged 67, with metastatic breast cancer, is having increasing difficulty swallowing due to local oesophageal invasion. She has pain on swallowing and is unable to manage her oral morphine. She wants to remain at home.

What is the MOST appropriate management?

Robert Nolan, aged 91, has end-stage Parkinson’s disease and is now bedbound, minimally responsive, and unable to swallow. His carer reports that he has been on regular levodopa for years. You are asked to review medications during his transition to terminal care.

What is the MOST appropriate management of his Parkinson’s medication?

Emily Dawson, aged 79, is receiving palliative care for advanced ovarian cancer. She has developed intractable nausea despite regular metoclopramide and haloperidol. She is no longer able to tolerate oral medications. She has no signs of bowel obstruction.

What is the MOST appropriate antiemetic to trial next?

Tony Wilkins, aged 63, with metastatic lung cancer, is being managed at home. His wife calls in distress because he is unconscious and has been breathing with long pauses between breaths. She asks if he is suffering or about to die.

What is the MOST appropriate response?

Harriet Bell, aged 88, has metastatic breast cancer and is in the terminal phase. She has been increasingly drowsy and has not taken oral medications for 2 days. Her family is concerned she will be in pain without her regular opioids. She previously used oxycodone SR 20 mg BD and oxycodone IR 5 mg PRN.

What is the MOST appropriate opioid conversion for subcutaneous infusion?

Leonard Tuhiwai, aged 85, is receiving palliative care in a rural aged care facility. He is Māori and his family wish to conduct a traditional tangihanga (mourning ritual) involving extended whānau staying with him continuously in the final days of life. Staff are concerned about numbers and space.

What is the MOST appropriate GP response?

Fiona Long, aged 71, has motor neurone disease with bulbar involvement. She has progressive dysphagia, sialorrhoea and is developing dyspnoea. She wishes to remain at home and avoid hospital. She is no longer able to take oral medications.

What is the MOST appropriate pharmacological management of her sialorrhoea?

Georgia West, aged 69, has metastatic renal cancer with bony involvement and is currently receiving palliative care. She has developed sudden-onset confusion, increased thirst, and nausea. Her serum calcium is 3.3 mmol/L.

What is the MOST appropriate initial treatment?

Nigel Armstrong, aged 74, is dying from advanced mesothelioma and is in his final hours. He has a visible grimace and occasional moaning. He is unconscious and not rousable. He has no current analgesia prescribed other than paracetamol.

What is the MOST appropriate intervention?

Susan Locke, aged 68, has metastatic bowel cancer and is receiving palliative care. Her husband reports she becomes very restless and confused in the evening, though she is calm during the day. There is no fever, infection, or medication change.

What is the MOST likely cause of her evening confusion?

Bradley Morris, aged 59, has MND with progressive respiratory failure. He has refused non-invasive ventilation and wants to remain at home. He is anxious and fearful about the process of dying from breathlessness. He asks what can be done.

What is the MOST appropriate response?

Hannah Salim, aged 83, is in an aged care home with end-stage heart failure. She has been increasingly bedbound, with minimal oral intake, and is noted to be more drowsy. Staff are unsure whether she is actively dying or experiencing reversible deterioration.

What is the MOST appropriate action?

Louise Fraser, aged 87, has advanced Alzheimer’s disease and is no longer mobile or verbal. She has been refusing food for several days. Her daughter asks whether she should be given a PEG tube to continue nutrition.

What is the MOST appropriate response?

Daniel White, aged 58, has advanced head and neck cancer and is receiving home-based palliative care. He is now experiencing distressing noisy breathing due to upper airway obstruction. He is semi-conscious. Family are very concerned and want immediate relief for him.

What is the MOST appropriate next step?

Rosie Nguyen, aged 74, has metastatic gastric cancer and is being cared for at home. She has become increasingly drowsy, only responding to painful stimuli. Her daughter asks whether they should stop her current syringe driver that includes morphine and midazolam.

What is the MOST appropriate advice?

Ashok Bedi, aged 79, has advanced prostate cancer with spinal metastases. He is alert but has suddenly developed difficulty urinating and weakness in his legs. He has no fever or signs of infection. He is receiving home palliative care.

What is the MOST likely cause of his symptoms?

Natalie Green, aged 68, is receiving palliative care for metastatic breast cancer. She complains of tingling and burning pain in her feet and hands, which worsens at night. She is currently on oxycodone for bone pain, which is otherwise well controlled.

What is the MOST appropriate treatment for her new symptoms?

Kevin Rowe, aged 70, has advanced chronic kidney disease (CKD stage 5) and is receiving conservative management. He is experiencing persistent nausea, metallic taste, and has lost 5 kg over the past month. He is not on dialysis and wishes to avoid hospitalisation.

What is the MOST appropriate first-line pharmacological treatment for his nausea?

Linda Black, aged 81, is in a residential aged care facility and receiving palliative care for end-stage congestive heart failure. She is increasingly drowsy with poor oral intake. Her chart includes frusemide, bisoprolol, and ramipril. The nurse asks whether to continue her cardiac medications.

What is the MOST appropriate response?

Ava Thompson, aged 74, has metastatic breast cancer and is cared for at home. She becomes acutely agitated, shouting and picking at the bedclothes. Her daughter is distressed and asks for immediate help. Ava has no infection and is already on morphine and midazolam via syringe driver.

What is the MOST appropriate medication to add?

Pauline Morris, aged 83, has advanced dementia and is in palliative care at a residential facility. She becomes acutely agitated, moaning and appearing in distress when being moved. She is non-verbal and has not had regular analgesia. Staff ask for advice on first-line pain management.

What is the MOST appropriate next step?

Garry Li, aged 66, with end-stage COPD, is receiving home palliative care. He is anxious about experiencing a distressing death due to breathlessness. He asks if anything can be done in the final hours to make it easier.

What is the MOST appropriate response?