A challenging weekend--Sunitha Daniel

ST3

Case1 KM, 50 years

Admitted to hospice on 22/10/11

Diagnosis locally advanced uterine leiomyosarcoma with lung metastasis

Diagnosed in Aug 2010

6 cycles of neoadjuvant chemo(Ifosfamide+ Doxorubicin)

Initial response-decrease in size of tumor and lung mets

TAH with BSO in April 2011 –clear margins

Stable lung disease being considered for resection but progressed with abdominal lymph nodes

Palliative chemo 1st cycle on 06/10/11

Admitted to SJUH on 11/10/11 with chest pain and SOB

CT scan showed progressive lung disease, pleural effusion and pelvic disease.

Treated with IV antibiotics for neutropenic sepsis

Rapid deterioration in breathing

Referred for management of breathlessness and likely terminal care.

Past History

PE

Fibroid Uterus

2 Hickman line infections

Social history Used to work as a clerical staff in fire station (health and safety)

Lives with husband and 2 sons aged 23 and 11.

Family –not coping especially eldest son.

Symptoms Pain 3/3 severe upper back pain radiating to front of chest ongoing for

weeks. Relieved on sitting up, lying to right side. opioid sensitive

Dyspnoea 3/3 on minimal exertion as well as talking. Stopping mid conversation. There was evidence of anxiety

Drowsiness 3/3 Noticed only after CSCI started. Dozing of during conversation.

Examination Generally looked anxious and tachypnoic

pallor+

Obs HR 112/mt,RR 28/mt SO2 93% on O2

Chest bibasal creps more on left.

Mouth: evidence of oral thrush

Management From SJUH On CSCI Morphine 90mg +Midazolam 10mg

Dexamethasone 8mg by Oncologist

Diclofenac TDS

At hospice Discussion with family Aware of progressive disease but told by oncologist

about possible chemo if chest improves.

Concerns regarding drowsiness

Patient be rather be more awake.

Continue CSCI with Morphine and but Midazolam 7.5 mg

Reduce Dexamethasone to 4mg.

Progress (23/10/11) Very agitated night –shouting screaming and moving around

Ongoing pain

PRN Morphine, midazolam and haloperidol overnight

Reviewed: gave stat haloperidol and changed driver to Morphine 100mg and midazolam 20mg.

Worsened during day : worsening hypoxia. ? Dying

D/W consultant Agreed could be dying. To speak with husband but not to speak /involve son (suicidal risk)

Husband visibly upset and shocked –called in family including son

Consultant review

lengthy discussion : patient accepting but not talking about it.

Family agreed for more sedation

Changed CSCI To Oxycodone 50mg and midaz 30mg

Commence LCP (18:00)

Family stayed in .

Called at 00:50 patient still unsettled PRNs 5 in 5 hours

Family upset

Reviewed stat levomepromazine and changed to Oxy 80mg,Midaz 60mg and Levo 12.5mg in CSCI at 3:00am

24/10/11 Few more PRNs

Review by Consultant(8am)

Unconscious but not settled moaning with each breath

Family present throughout night

Phenobarbitone 100mg at 9:00am -finally relaxed

RIP at 11:50 am

Case 2 EB 77 years male

Back ground End stage heart failure sec to IHD

Admitted on 21/10/11

Worsening Oedema, pain drowsy

Admitted for terminal care

Aware he is dying-‘Please put me to sleep’

On high dose opiates orally pain uncontrolled but S/C PRN worked.

Symptoms

Pain(3/3) across the chest and back ? Related to heart failure.

Nausea(3/3)

Peripheral oedema(3/3)

Examination Restless and agitated

SO2 90% BP 99/69

Raised JVP

Chest Bibasal fine creps and dull to percussion

Abdomen Ascites+

Management CSCI with Morphine25mg Midazolam 10mg Haloeperidol 3mg

Frusemide CSCI 160mg

Stop non essential meds.

Progress(22/10/11 -23/10/11) Unsettled night with worsening pain and agitation

Not clear as to cause of agitation? dying

CSCI changed to morph 40mg,midaz 20mg and halo 5mg

Continued to be more agitated all day and night( up all night needing extra nursing care)

D/W Consultant morphine 60mg,midaz 40mg with PRN 5-10mg for Levo PRN, ketorolac BD

Not clear if terminal

24/10/11 Still very restless.

Getting up to pass urine at night - catheterize

Still having meals with family during day –agitation and restlessness predominantly at night.

CSCI to Morphine 100mg,midaz 75mg and haloperidol1.5mg(?rigid)

Not clear if dying D/W family-

D/W consultant(16:00)

Stop Frusemide,Switch to Oxycodone,for midaz 30mg in day and 60mg at night,Stop haloperidol Ketorolac CSCI

Not for LCP as not clear if dying

CSCI started at 18:00

Settled later in night.

RIP during cares at 02:45 am on 25/10/11

Good death (BMJ 2000;320:129) To know when death is coming,

To understand what can be expected

To be able to retain control of what happens

To be afforded dignity and privacy

To have control over pain relief and other symptom control

To have choice and control over where death occurs.

To have access to information and expertise of whatever kind is necessary

To have access to any spiritual or emotional support

To have access to hospice care in any location, not only in hospital

To have control over who is present and who shares the end

To be able to issue advance directives which ensure wishes are respected

To have time to say goodbye, and control over other aspects of timing

To be able to leave when it is time to go, and not to have life prolonged pointlessly

Factors considered important at the end of life by patients pain and symptom management,

communication with one's physician,

preparation for death.

opportunity to achieve a sense of completion

Ref(JAMA 2000; 284(19): 2476-82)

Diagnosing dyingProfound weakness

Confined to bed for most of the day

Drowsy for extended periods

Disorientated

Severely limited attention span

Loss of interest in food and drink

Too weak to swallow medication.

Why is it Important? Allows withdrawal of unnecessary treatments

Preparation of the patient and family/carers for death.

Establish patient’s PPOC.

NICE Quality Standard for End of Life Care for Adults. 16 steps for people approaching end of life care

Identification in timely way

Communication and information provided to patients and families.

comprehensive holistic assessments in response to their changing needs and preferences,

physical and specific psychological needs safely, effectively and appropriately met

offered timely personalised support for their social, practical and emotional needs,

offered spiritual and religious support

Families and carers of people approaching the end of life are offered comprehensive holistic assessments.

receive consistent care that is coordinated effectively across all relevant settings

who experience a crisis at any time of day or night receive prompt, safe and effective urgent care.

who may benefit from specialist palliative care, are offered this care in a timely way appropriate to their needs and preferences,

last days of life are identified in a timely way and have their care coordinated and delivered in accordance with their personalised care plan,

Care after death, bereavement support and work force planning and training.

“…we will do all we can not only to help you die peacefully, but to live until you die.”

Dame Cicely Saunders

References YCN symptom management

NICE

BMJ