dignity and symptom control rachel sheils gsfch conference 10.7.2009
TRANSCRIPT
Dignity and Symptom Control
Rachel Sheils
GSFCH Conference
10.7.2009
Dignity
state worthy of esteem and respect,
especially humanness
Ethical principles
• Autonomy• Beneficence
• Non-malfeasance
• Social justice
Symptoms in the last days
Asthenia (debility)
Anorexia
Dry mouth
Dyspnoea
Confusion
Noisy respiratory tract secretions
Pain
Restlessness / agitation
Nausea
82%
80%
70%
17 - 47%
56%
46%
46%
43%
14%
…worthy of esteem and respect…
• What makes us feel worthy of respect?
• What stops us from feeling worthy of respect?
...especially humanness…
• What makes us feel human?
• What stops us from feeling human?
Case 1- Autonomy
• PP
• 60 years old
• Motor neurone disease
• Rapid deterioration
• Living alone at home
• Independent– Maintain sitting posture
• Dependent – 8 visits/day– All cares– All mobility– Communication – scanning light writer– Oral intake – sips of cola
• Wants to stay at home until the end – at all costs
• Has the mental capacity to make this decision
• Finally agrees to be admitted when attends day hospice and appears to be dying
• Initially rallied
• Improved pain• Discharge planning – patient insistent on
going home when care arranged
• Died knowing we were trying to get her home
• Respected autonomy
• Would most of us want to be at home despite – faecal soiling– Slumping in chair if falls forwards
Case 2 Symptoms vs Side Effects
• 66 year old woman
• Ovarian cancer
• Widespread disease in abdomen
• No more surgery / chemotherapy possible
• Vomiting
• Abdominal distension
• Constipation
• Bowel obstruction
• Tried various treatments– Dexamethasone 8mg– Metoclopramide 60mg in 24 hrs in syringe
driver– Sodium docusate– Granisetron
– Not much better
• Generally deterriorating– Discussions about what was happening
• Vomiting once every 24 hours – BIG volume– Tried levomepromazine– Then cyclizine– Helped nausea but not vomiting– made her sleepy
• Pt decided to withhold levomepromazine until last few days
• Vomiting but awake
• Who knows what would make us feel more human– Vomiting, nauseated but alert– Sleepy, less aware of vomiting
Anti-emetics
• Acid - lansoprazole etc• Gastric stasis - metoclopramide/domperidone• Chemical - cyclizine, haloperidol
levomepromazine, granisetron / ondnsetron
• Cerebral - steroids, cyclizine, granisetron• Bowel - cyclizine OR metoclopramide,
granisetron, steroids• Environment• Constipation
Case 3 The pain is what the patient says
it is• 70 year old lady
• Breast cancer
• Severe lymphoedema in left arm
causing pain
• Learning disability
• Bipolar disorder
• Lived with / dependent on elderly sister
• Admitted to the hospice for pain control
• Zomorph 10mg BD
• Mirtazepine, Lithium, Sodium Valproate
• Escalating doses of Oxynorm – 80mg BD– Didn’t reduce PRN morphine use
• Crying out in pain
• Very anxious
• When nurse came – anxiety gone, still in pain– “Is this really pain or is it anxiety, a cry for help
and attention?”
• Noticed she had a history of Crohn’s disease and bowel resection– IS SHE ABSORBING THESE ORAL DRUGS
• Started a syringe driver with oxynorm
• Eventually converted to a patch
• Pain settled
• Transferred to a nursing home
• How would it feel I was vulnerable, and someone didn’t believe that:
– I was in pain
– What they were doing was helping the pain
The drugs don’t work
• Is the patient taking the drugs?
• Are they keeping them down?
• Are they absorbing them?
• Is the dose high enough?
• Is it the right pain killer?
• Syringe driver– Is it running behind?– If so, why?
Opioids
Different opioids have different strengths
Variety of routes
oral, subcutaneous, transdermal, buccal, sublingual, ??? Nebulised
Dignity
• We are all human• We are all different
• Dignity will be achieved for each individual in different ways
• Listen• Patient’s priority should be ours• Side effects vs benefits
• Any questions?