1. Click to continue

2. Convulsions Most self limiting – only need supportive care – Reassure carer, advise contacting DN for support Rectal diazepam 10mg pr – DN or carer Midazolam 10mg sc or im – DN Click to continue

3. Convulsions Midazolam buccal 10mg Can use injectable formulation – eg hypnovel 5mg/ml 2ml amps Oral solution as special order Easier to give than rectal route May be quicker in onset Click to continue

4. Convulsions Condition deteriorates and he becomes unable to take oral medication Still needs anti-epileptic drugs Half life long – so can start any time within 24hrs of last dose Usually use midazolam via syringe driver – need minimum 20-30mg/24hrs Click to continue

6. Metastatic Spinal cord compression Called to see a 86 year old man with prostate cancer and widespread bone metastases Long standing lower back pain – worsening over last 2 weeks, worse at night Difficulty mobilising – struggling to get upstairs last few days and a couple of falls in living room O/E globally reduced power in lower limbs, especially feet Click to continue

8. Discuss with oncology team (MSCC coordinator?) Within 24 hours Pain in thoracic or cervical spine Spinal pain aggravated by straining Progressive lumbar pain Severe unremitting lower spinal pain Localised spinal tenderness Nocturnal spinal pain Immediately Neurological symptoms – Radicular pain – Limb weakness – Difficulty walking – Sensory loss – Bladder/bowel dysfunction Neurological signs of spinal cord or cauda equina compression Click to continue

9. Metastatic Spinal cord compression Dexamethasone 16mg od Admit (preferably under oncology team) Whole spine MRI After surgery/start of RT dexamethasone dose gradually reduced If neurological function deteriorates temporarily increase dose No consensus when to mobilise – OK if spine stable? Click to continue No video available for this slide

10. Hypercalcaemia 68 year old lady with ovarian cancer. Disease progressed despite palliative chemotherapy Presents with worsening nausea, constipation, thirst and fatigue Given anti-emetic and laxative Routine bloods show corrected calcium of 2.90 mmol/L Click to continue

12. Hypercalcaemia Consider: Patients wishes Prognosis Previous history of hypercalcaemia Care setting Symptoms Click to continue

13. Hypercalcaemia Rehydration – Patients are usually dehydrated Polyuria and vomiting – Fluids alone may improve symptoms (increase urinary ca excretion) but won’t achieve normocalcaemia Bisphosphonate – Zoledronic acid Takes 5-7 days to have effect Recheck every 3 – 4 weeks (or if symptoms) Click to continue

14. Hypercalcaemia Where? Depends on patient – Hospital – acute or community – Hospice – Day case? Click to continue

16. Acute Confusion (delirium) An aetiologically, non-specific, global, cerebral dysfunction characterised by concurrent disturbance of level of consciousness, attention, thinking, perception, memory, psychomotor behaviour, emotion and sleep- wake cycle Click to continue

18. Acute Confusion Treat reversible causes if possible Avoid drugs if possible – Reassurance, orientation, alleviate fear Night sedation – Consider other causes of insomnia eg pain, nocturia, drugs Click to continue

19. Acute Confusion Daytime sedation – Only if patient distressed or danger to themselves – Adjust dose Consider age, general condition, level of disturbance Antipsychotics drug of choice Haloperidol 0.5-3mg nocte or bd Levomepromazine if agitated Risperidone (caution in elderly) Click to continue

20. Acute Confusion May be primarily an anxiety state (with secondary cognitive clouding) Benzodiazepines more appropriate Diazepam Lorazepam (shorter acting, can be sl) Midazolam – esp if terminal agitation Click to continue

22. Top Tips in Palliative Care End