Pharmaceutical care of people requiring palliative care Course activities

Pharmaceutical care of people requiring palliative care Course activities

Case Study 1 Mrs Green, a 70 year-old lady, has metastatic carcinoma of the breast (breast cancer with spread to other areas). Her home carer Mrs Brown comes into the pharmacy. Mrs Green is on the following medication: MST Tabs 80mg twice daily Oramorph 10mg/5ml - 25mg (12.5ml) as required Amitriptyline 50mg at night Dexamethasone 4mg in the morning Co-danthramer two at night Paracetamol 1g four times a day You ask how Mrs Green is. She is glad you asked as Mrs Green really struggled to swallow her breakfast and lunch today and she is worried about taking her medication. She has tried to contact the district nurse, but she isn t due back until next week. Her lips are quite cracked. Discussion points Case Study 1 What further questions would you ask Mrs Brown? What are the likely causes of her swallowing difficulties? What advice would you give the patient through her home carer? What would be the therapeutic options for oral candidiasis? What are the alternatives to MST and co-danthramer? What, if any, are the communication and confidentiality issues raised by this case and how would you overcome them?

Case Study 2 Mr Grey is a 70 year old man who has renal cancer. His wife comes in to collect the balance of the MST 60mg which you dispensed two days previously. You notice that Mrs Grey is a little anxious and you ask how her husband is getting on. She replies that he has been very nauseous with his new tablets and very drowsy he struggled to wake up this morning. You dispensed the following prescription two days ago: MST 60mg - one tablet every 12 hours (an increase from 30mg twice daily two weeks ago) Oramorph 10mg/5ml - 10ml as required (increased from 5ml) Paracetamol - 1g four times daily (6 months) Co-danthramer caps - two at night (5 months) You discover that : he was needing about three 5ml(10mg) doses of Oramorph a day for breakthrough pain before the GP increased his dose of opioid, from 30mg to 60mg twice a day, in one increment he has no anti-emetics at home he has become quite anxious since the pain got worse Discussion points Case Study 2 What care issues have you identified for this patient? What advice would you offer to the patient/carer? What would you prescribe or what recommendations would you make about this patient to their GP?

Case Study 3 Mr Black is a 65 year-old man, a retired miner with carcinoma of the bowel. He comes in with his prescription for laxatives and you ask how he is. He replies that his constipation and his pain are getting worse, but that he expects to have a bit of constipation as his cancer is in the bowel. He has looked on the Internet for some help and couldn t find any answers. He is prescribed lactulose - 15ml twice daily senna tablets - two at night OxyContin tablets - 40mg twice a day OxyNorm capsules 10mg when required Metoclopramide tablets - 10mg when required Paracetamol tablets 1g when required. You discover that: He doesn t like the sweet taste of the lactulose He finds the senna tablets difficult to swallow as they are very dry His bowels are moving every 3 to 4 days He drinks tea in the morning, coffee in the afternoon, and a glass of water with his lunch He is taking his OxyContin at 8am and at bed-time usually about 10pm He takes his OxyNorm when the pain is really bad He finds the OxyNorm and OxyContin very confusing as they have similar names and are in similar packets. Discussion points Case Study 3 What care issues have you identified for this patient? What advice would you offer to the patient/ carer? What would you prescribe or what recommendations would you make about this patient to their GP?

Case Study 4 Mrs White, a 56 year old woman, has carcinoma of the left lung with bone metastases (spread of disease to the bones). She comes into the pharmacy today and you ask how she is getting on. She replies not very well as the pain is getting on top of her. Her medication is Dihydrocodeine 30mg tablets one or two when the pain is bad (6 per day) Paracetamol 500mg tablets 1g four times daily Tramadol 50mg capsules one when pain is very bad (2 per day) Senna tablets 2 at night On questioning Mrs White you discover that Although she has pain almost constantly it is worse when she is active trying to do housework and going for a walk. The pain does ease when she takes the dihydrocodeine, but she is afraid of taking too many opioids. She sometimes has a bit of constipation, but nothing too bad. She is feeling quite isolated in coping with her illness. Discussion points Case Study 4 What care issues have you identified for this patient? What advice would you offer to the patient/carer? What would you prescribe or what recommendations would you make about this patient to their GP? What would the appropriate starting dose of morphine be and what would you recommend to control the potential adverse effects of morphine?

Case Study 5 You are a community pharmacist in your pharmacy on a Saturday morning when an on-call doctor asks you how to convert one of your regular patients onto a fentanyl patch due to swallowing difficulties. His pain appears controlled on 15mg Oramorph taken 4 hourly during the day and 30mg at night. Consider the following questions: Discussion points Case Study 4 Starting dose of fentanyl patch? When and how to start the patch? The appropriate breakthrough pain medication dose? What are potential side-effects of the patch and how can these be minimised or prevented? If an increase in fentanyl is required, what increments should be used? Discuss your role in following up the patient