• Double removal
• Reality: 25 days
• Optimistic doctor thinks 75 days
• Doctor tells patient 90 days

Three cardinal clinical skills

• Diagnostics
  
• Therapeutics
• Prognostication 

Pain types

• Nociceptive
• Opiods
  
• Neuropathic
• (Opioids) but not really
• Amitriptyline (1st line)
  
• Gabapentin
• Clonazepam

Gold Standards Framework

• "Enabling a gold standard of care for all people nearing the end of life"
• http://www.goldstandardsframework.org.uk
• 3 triggers indicating approaching death:
  
• The Surprise Question
• ‘Would you be surprised if this patient were to die in the next few months, weeks, days’?
• General indicators of decline
  
• Deterioration, increasing need or choice for no further active care
• Specific clinical indicators related to certain conditions
• Trajectories:
• Rapid
• Erratic
• Slow
  

Notes

• Midazolam is 1st line for terminal agitation
  
• Haloperidol has double effect
• Antipsychotic
• Antiemetic
• "Ceiling of care"
• Need to know the prognosis, so you know how much intervention is appropriate
• e.g. Treat neutropaenic sepsis, but not necessarily chest infection in terminal AIDS
• Total pain
• Physical, but also psychological, social, spiritual
• Tapentadol
• Centrally acting analgesi with opioid and non-opioid activity
• Dual mode of action
• Agonist of the μ-opioid receptor
• Norepinephrine reuptake inhibitor
• Potency between tramadol and morphine
• Steroids can => Proximal myopathy
• Referred pain to the back from upper GI disturbance is via the COELIAC PLEXUS
• Pinpoint pupils are common when pain is managed with opioids
• DON'T give naloxone unless RR < 8
• Oral oxycodone is twice as strong as oral morphine
• Domperidone doesn't cross BBB => Good antiemetic choice in Parkinson's
• Ondansetron => Constipation
• Need to contact coroner to certify death if you haven't seen the patient in >1 week