palliative symptom management

Palliative Symptom Management

Content

• Introduction to Palliative Care

– Definition

– Scope of palliative care

– Specialist and generalist palliative care

– Service outline

– End of Life Programmes and recognition of dying

• Symptom Management

– Dyspnoea

– Nausea & Vomiting

What is Palliative Care?

Palliative Care is interdisciplinary care whose approach improves the quality of life for patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

World Health Organisation 2002

Scope of palliative care

• A holistic approach (physical, psychological, spiritual, social) to patients with:

Malignant diseases

Other non-curable, life-limiting or terminal illnesses

– MND

– MS, Parkinson’s Disease

– Advanced organ failure (cardiac, respiratory, renal)

– Dementia, Learning disability

The Palliative Care Approach

• focus on quality of life

• whole - person approach

• care for person and significant others

• respect for autonomy

• communication

Palliative Care – Overview of Services

• Multidisciplinary specialty

– Doctors, nurses, Physiotherapy, Occupational Therapy, Social work, Chaplain, Volunteers, Fundraisers

• General roles – all health care professionals [Community and secondary care]

• Holistic vs strictly ‘Medical’

• Patient centred approach

• Specialist roles [Hospital, Hospice, Community]

• NHS and Voluntary Sector

• Specialist Palliative Care has a range of Services available to patients;

• Inpatient (Hospices)

• Outpatient (Hospices, Hospital Teams)

• Day Hospice

• Specialist clinics (Dyspnoea, Lymphoedema, Complementary therapies)

• Marie Curie Nurses and Hospice at Home

Specialist Palliative Care Units (Hospice Units)

• Full MDT

• Symptom management

• Rehabilitation

• Family or patient psychological distress in relation to death or loss

• Respite care

• Terminal care

• Day care

• Bereavement service

• Other therapies

• Research & Education

Cure/Life-prolonging Intent

Palliative/ Comfort Intent

D E A T H

“Active Treatment”

Palliative Care

D E A T H

EVOLVING MODEL OF PALLIATIVE CARE

previously

now

• End of Life

Programmes

• Recognition of dying

Top 5 regrets of the dying

• Peoples’ first regret is that they haven’t been true to themselves and have lived the life others expected them to live rather than the life they wanted to live. They haven’t “lived their dreams.”

• Next, and I knew this was coming, people—actually mainly men—wished that they hadn’t worked so hard.

• The third regret people have is that they haven’t had the courage to express their feelings.

• People’s fourth regret is that they haven’t stayed in touch with friends.

• Finally, people regretted that they hadn’t allowed themselves to be happier.

Richard Smith – Contemplating my deathbed - 19 Aug, 10 – BMJ Blogs “Through Twitter I have received a list of the five things that people most commonly regret when dying.” http://ezinearticles.com/?Top-Five-Regrets-of-the-dying&id=3268063

http://ezinearticles.com/?Top-Five-Regrets-of-the-dying&id=3268063











Planning a good death - BBC 2006

http://www.bbc.co.uk/health/support/includes/planning_a_good_death.pdf

Practical check list for a good death - from the BBC document

• Recorded clearly all my personal details

• Drawn up will and have it checked with solicitor

• Consider writing a living will

• Make arrangements for care of children

• Ensure someone knows my wishes re future care

• Discussed thoughts re funeral

Emotional checklist for a good death - from the BBC document

• Talked about what dying means with family/friends

• Agreed with family/friends what I would want to know about a serious illness and what medical treatment(s) I would refuse

• Thought seriously about people with whom I have unfinished business

• Talked to at least one of those people

• Begin recording memories of my life for future

Dying trajectories

(Lynn & Adamson Rand - Health White Paper 2003)

Effects on patient if diagnosis of dying not made (BMJ 2003)

uncontrolled symptoms

Cultural/spiritual issues not addressed

Conflicting messages

Loss of trust (patient and carers)

Unaware that death is imminent

Lack of dignity

?Inappropriate CPR

UK End of life programme Patient Choice

• Gold Standards Framework

– GP proactive care

• Preferred place of care

• Care of the dying pathway

Keep patients where they want to be [Community].

Do they want to be at home?

Know what to do. Do it well. Make a diagnosis?

Physiotherapist

O.T. Chaplain

Pharmacist

Social worker

Family

Carer

Other Specialists

Clin. Nurse Spec.

Community/ Church

Dentist

District Nurse

Psychologist

Pall. Med. Cons.

Oncologist

Patient

General Practitioner

Surgeon

Most common symptoms seen in patients with advanced disease.

SYMPTOM % SYMPTOM LAST YEAR IN LIFE

Pain 84

Loss of appetite 71

Nausea / Vomiting 51

Sleeplessness 51

Dyspnoea 47

Constipation 47

Depression 38

Loss of bladder control 37

SIGNS OF IMPENDING DEATH

• Rapidly increasing weakness and fatigue • The patient is usually bed bound • Decreasing intake of food and fluids

• Difficulty in swallowing

• Decreasing level of consciousness •

Preparing for the Last Hours

• Make sure the family is prepared:

– Is there an advanced directive ?

– Has a DNAR order been established?

• Educate the family

– What to expect as the end nears

– The signs of imminent death (Cheyne-Stokes respiration, skin mottling, loss of consciousness)

Reassess Treatments

Consider discontinuing

– Redundant oral medications

– Intravenous or subcutaneous (hypodermoclysis) fluids

– Oxygen (if patient is unconscious or finds oxygen administration uncomfortable. )

– Invasive monitoring

• Care of the dying pathway

The Last Hours

If patient is unable to swallow:

Prepare for alternative administration routes for essential drugs

Sub-cut injections (SC)

Syringe driver (CSCI – Continuous sub-cut infusion)

Rectal administration

(Transdermal- if already in use)

Dealing with “Death Rattle”

• Reassure family, visitors that choking is unlikely

• Try gentle oro-pharyngeal suctioning

• Avoid deep or frequent suctioning

• If severe, consider drugs

• Most families are reassured with an explanation

“Death Rattle” Pharmacological Management

Scopolamine (hyoscine hydrobromide) SC: 400mcg (0.4 mg) SC (onset 1–3 minutes)

Duration of action: ± 1 hour

May worsen delirium or agitation

Glycopyrrolate: 200mcg (0.2 mg) SC or IV

onset is 1 min,

Duration of action: ± 6 hours

Pronouncement and Certification of Death

• Notify family.

• Do not ask family or other loved ones to leave the room while you examine the patient.

• Confirm absence of pulse and heart and lung sounds. Confirm dilatation of pupils.

• Document these.

“Medicine is not about conquering disease and death, but about alleviation of

suffering, minimising harm, smoothing the painful journey of man to the grave.”

Strabanek

BREATHLESSNESS

Content

• Introduction - physiology of normal breathing

• Causes of dyspnoea

• Management

• History, examination and investigations

• Specific Treatments

• General Non-pharmacological approaches

• General Pharmacological approaches

• Management of terminal breathlessness

Respiration

Physiology of normal breathing

• Central

medulla

(CO2)

• Peripheral

(O2)

Mechanical receptors in intercostal muscles, diaphragm, stretch receptors in airways

Physiology of normal breathing

• With malignant lung disease dyspnoea is often due to distortion and stimulation of the mechanical receptors, and blood gases are often normal

• Some patients with COPD have a blunted response to CO2 due to chronic retention – caution is required if using oxygen therapy as these patients are dependent on a hypoxic drive for breathing

• Dyspnoea occurs in 50% of hospice patients

Dyspnoea

• Breathlessness or dyspnoea – a subjective experience of breathing discomfort

• Not to be confused with tachypnoea

• Can be distressing for

patients and carers

Cycle of increasing panic and breathlessness

Breathlessness

Fear of dying.

Lack of understanding

Increased anxiety

panic

Causes of dyspnoea – related to cancer

• Lung tumour causing obstruction

• Lung infiltration

• Lymphangiitis carcinomatosis

• Pleural effusion (malignant)

• SVC obstruction

• Pericardial effusion

• Ascites

• Chest wall pain

Assessment of Dyspnea

• Pattern

– Intermittent

– Continuous

– Acute intense episodes

• Triggers

• Associated emotions

Dyspnoea – treat underlying causes

• Tumour – chemo/radiation • Infections – antibiotics • Anaemia – transfusion • Fluid overload – diuretics • Effusions – draining / pleurodesis • Bronchospasms – bronchodilators • Inflammation – steroids • Cough – asthma, sinusitis, reflux, steroids • Chest wall pain – radiotherapy, nerve blocks, analgesia • Retained secretions

Pulmonary and nodal metastases

Gross ascites causing SOB- elevation

and limitation of movement of diaphragm

Lung “white-out” secondary to lung collapse

Copyright ©1997 BMJ Publishing Group Ltd.

Davis, C. L BMJ 1997;315:931-934

Pleuropericardial effusion

Pulmonary infiltration – miliary pattern

CT showing

pleural thickening.

PET positive.

“Hot pleural plaques”

implying malignancy -

mesothelioma

Causes of dyspnoea – treatment related

• Surgery

• Radiation induced fibrosis

• Chemotherapy-pneumonitis, Interstitial fibrosis

• Drugs e.g NSAIDS

Causes of dyspnoea – related to debility

• Infection

• Anaemia

• Fatigue

• Muscle weakness

• Pulmonary embolism

Other causes of dyspnoea

• COPD/Asthma • Cardiac failure • Arrhythmias • Pneumothorax • Blocked tracheostomy • Acidosis Also: • Anxiety/fear/distress

Assessment of Dyspnoea

The patient’s assessment of their dyspnoea is the most reliable---take a good HISTORY.

• Clinical signs don’t always correlate with the symptom experience

• Dyspnoea is NOT necessarily related to the respiratory rate or oxygen saturation

• Do not use oxygen saturation as a sole measure of Dyspnoea

• The palliation of dyspnoea depends on the cause and the patient’s prognosis’ (Palliative Adult Network Guidelines, 2011)

Assessment of Dyspnoea

• Pattern

– Intermittent

– Continuous

– Acute intense episodes

• Triggers

• Alleviating factors

• Associated emotions

• Use scales to measure and monitor

• Investigations as needed

Non-Pharmacological Management

• Use a fan

• Position: lean forward, head up

• Physiotherapy / OT input

• Avoid exacerbating activities

• Conserve energy

• Limit people in room

• Reduce room temperature, maintain humidity

• Open window and allow to see outside

• Avoid irritants, e. g. smoke

• Relaxation therapy

Specific Treatments

• PE – anticoagulation

• Pleural effusion – pleural aspiration +/- pleurodesis

• Pain – analgesia

• Anaemia – transfusion

• Depression/panic attack – antidepressants, benzodiazepines, non-pharmacological approaches

• Heart failure – diuretics, fluid restriction (oxygen)

Specific Treatments

• Infection – antibiotics, physiotherapy

• Airway obstruction

– Large – stenting, XRT, brachytherapy (endobronchial), laser, corticosteroids (dexamethasone, prednisolone)

– Small – bronchodilators (nebs), corticosteroids

• SVCO – corticosteroids, stenting, chemo/XRT

• Lymphangitis – corticosteroids, chemotherapy

Pharmacological Measures to Control Dyspnoea

• Oxygen

• Opioids

• Benzodiazepines

• Opioids

– Reduce ventilatory response to hypercapnia (↑CO2), hypoxia, and exercise

– Benefit is seen with oral or parenteral doses that do not cause respiratory depression

– No evidence for the use of opioids by nebulised route

– CSCI morphine may suit some patients better, avoiding peaks and troughs of oral medications

– Titration is required, as with pain management

– Main side effects: nausea and vomiting, constipation

General Management: Pharmacological approaches

• Opioids (PCF4)

– Opioid-naïve patients:

• 2.5-5mg PO PRN

• If ≥ 2 doses/24 hours are needed, then prescribe regularly

– Relatively small doses may suffice e.g. 20-60mg/24 hours

– Patients already on opioids for pain:

• dose equivalent of 100% or greater of 4 hour breakthrough if dyspnoea severe

• 50-100% of breakthrough if moderate dyspnoea

• 25-50% of breakthrough if mild dyspnoea


• Opioids (PCF4): use in non-cancer patients

– Lower dose is advocate in patients with COPD

• e.g. 1mg bd, increased to 1mg -2.5mg 4 hourly over one week

• Then increase by 25% per week

• Consider switch to a MR formulation when stable


Caution with renal and hepatic impairment, elderly or frail patients

Opioids in Dyspnoea

• Safe and effective

• Diminishes the sensation of being short of breath

• RCTs have confirmed the usefulness and safety of opioids in patients with advanced cancer, ALS and end-stage heart and lung diseases

• Benzodiazepines

– No evidence for breathlessness but may be used for anxiety

– Panic Attacks – education and reassurance regarding fear of suffocation, teaching breathing techniques, CBT, +/- benzodiazepines

• Lorazepam 0.5mg SL PRN

• Diazepam 2mg-5mg b.d. recommended in Palliative Adult Network Guidelines

• Midazolam CSCI in terminal care


• Oxygen

– Both air and oxygen reduce breathlessness in patients with cancer

– Can be helpful even in absence of hypoxia – although trial has shown no benefit of oxygen over room air in these patients

– Considerable costs – financial, patient and family anxiety, safety issues, practical issues

– Always remember special considerations in patients with COPD and MND

– Trial fan first



• Bronchodilators

– Even in absence of wheeze there may be element of reversible bronchoconstriction

– Trial of Salbutamol 2.5-5mg QID Neb/ 2 puffs via spacer QID +/- Ipratropium 250-500 mcg QID Neb

• Corticosteroids—for bronchospasm or reduced airway calibre due to tumour

– Lymphangitis carcinomatosis, reduction of peri-tumour oedema in patients with multiple lung mets

– Benefit should be apparent within days

– Dexamethasone 4mg-8mg mane for 1/52 trial and if no improvement stop

– Monitor blood sugars

Pharmacological approaches

Panic attacks-patient advice

• Stay calm

• Purse your lips

• Relax shoulders, back, neck, arms

• Concentrate on breathing out slowly

Severe Dyspnoea in Last Hours of Life

• Traumatic for patient, family and staff

• Needs active management

• Parenteral medications essential ie SC or CSCI

• Focus on controlling dyspnoea rather than the dose of opioids and other medications

• Call for help if you have not managed this before

Severe Dyspnoea in Last Hours of Life

• Opioid naïve

– 2.5 – 5 mg morphine IV/SC stat then reassess

• Opioid tolerant

– 25% to 100% increase in dose IV/SC stat

• Add midazolam and titrate dose if above ineffective

• Intractable dyspnoea – seek advice from Specialist Palliative Care

NAUSEA AND VOMITING

Content

• Causes of nausea and vomiting in palliative care

• Pathophysiology of N/V

• Neuroanatomy and transmitters involved

• Management of N/V

• Drug options

• Summary table

Common Causes of Nausea and Vomiting in Palliative Care

Cause often has multi-factorial etiology: • Constipation • Drugs

– Opioids – Non-steroidal anti-inflammatories (NSAIDs) – Selective serotonin reuptake inhibitors

• Reduced gastro-intestinal motility – Drugs (opioids, tricyclic antidepressants) – Autonomic neuropathy

• Metastatic bowel disease / obstruction

Common Causes of Nausea and Vomiting in Palliative Care (continued)

• Anorexia-cachexia syndrome • Metabolic causes:

– Hyper Ca++ – Uraemia – Hypo Na+

• Increased intracranial pressure • Oral candidiasis • Anxiety • May be aggravated by uncontrolled pain

The vomiting reflex - 1

Direction of muscular

contractions

Flow of gastric contents

The vomiting reflex - 2

Anatomical representation of parts of brain involved with nausea and vomiting

Cerebellum

4th ventricle

Vomiting Centre

Area postrema

and CTZ Nucleus of the

solitary tract

Factors influencing nausea and vomiting

Vomiting Centre

(medulla)

Stomach

Small intestine

Higher cortical

centres

Chemoreceptor

Trigger Zone

(area prostrema,

4th ventricle)

Labyrinths

Vomiting Reflex

Neuronal pathways

Receptors involved

Factors influencing nausea and vomiting

Vomiting Centre

(medulla)

Stomach

Small intestine

Higher cortical

centres

Chemoreceptor

Trigger Zone

(area prostrema,

4th ventricle)

Memory, fear, anticipation

Surgery

Surgery

Labyrinths

Anaesthetics

Vomiting Reflex

Neuronal pathways

Factors which can

cause nausea & vomiting

Chemotherapy

Chemotherapy

Radiotherapy

Opioids

Drug treatment of nausea and vomiting

Vomiting Centre

(medulla)

Stomach

Small intestine

Higher cortical

centres

Chemoreceptor

Trigger Zone

(area prostrema,

4th ventricle)

Memory, fear, anticipationSensory input (pain, smell, sight)

Surgery

Surgery

Labyrinths

Anaesthetics

Vomiting Reflex

Neuronal pathways

Factors which can

cause nausea & vomiting

Chemotherapy

Chemotherapy

Radiotherapy

Opioids

Sites of action of drugs

5HT3

antagonists

Sphincter modulators

Histamine antagonists

Muscarinic antagonists

Gastroprokinetic

agents

BenzodiazepinesHistamine antagonists

Muscarinic antagonists

Dopamine antagonists

Cannabinoids

Common causes of vomiting

• GI causes

• Drugs

• Metabolic

• Toxic

• Brain metastases

• Psychosomatic factors

• Pain

• Vestibular

• Obstruction

• dysMotility

• Infection, inflammation

• Toxins

Clinical pictures/ Fairmile Guidelines on management of Nausea and vomiting

Bentley, Boyd Pall Med 2001

• Chemical / Metabolic – Persistent, little relief vomiting

• Gastric stasis/ gastric outlet obstruction – Intermittent, relief from vomiting

• Regurgitation – Dysphagia, little nausea

• Bowel obstruction – Nausea, colic, faeculent vomiting

• Cranial disease / treatment

• Movement related

• Unclear, multiple

Nausea & Vomiting Management principles

• Reverse cause if possible

• Non drug measures

• Continuous problem requires continuous antiemetic therapy

• If vomiting, consider route- may need syringe driver / iv route

• PRN medication • Reassessment

Nasogastric Suction versus Venting Gastrostomy

• Only justified in carefully defined circumstances

• Intrusive and potentially distressing

• Complications

• If decompression needed for prolonged periods.

• C/I uncorrectable coagulopathy

• Unfavourable anatomy

• Massive ascites

• Gastric cancer

• Active gastritis/ peptic ulcer

• Gastric varices

Self-expanding metal stent

Self-expanding metal stent in-situ

Management of Nausea

• Attempt to identify the underlying cause(s)

• Attempt to correct the underlying cause(s) if possible and if appropriate

• Treat the symptoms

– Anti-emetics selected according to the inferred underlying mechanisms

• Prevent nausea

– Employ a regular anti-emetic regimen if nausea is prolonged

– Prevent constipation

• If one agent not completely effective, review and add another or replace with another

Anti-Emetics

• Anti-dopamine agents

– Metoclopramide

– Domperidone

– Haloperidol

– (Olanzapine)

• Anticholinergic

– Hyoscine Hydrobromide

• Anticholinergic and antidopaminergic

– Levomepromazine

• 5HT3 antagonists

•Ondansetron

•Antihistamines

•Cyclizine

Anti-Emetics

Pro-motility and anti-dopamine agents

• Metoclopramide 10-20 mg qid po/sc/pr – Extrapyramidal side effects may occur

– Upper GI pro-motility

• Domperidone 10-20 mg qid po – Only po formulation

– Less likely to cause extra-pyramidal side effects

– Upper GI pro-motility

• Extra-pyramidal side effects and akathisia are relatively uncommon, but monitor for these.

Anti-Emetics

• Antidopamine agents – Haloperidol 0.5 - 2 mg po/sc (max 5mg per 24 hours)

– Levomepromazine 5 - 10 mg po/sc od-tid

– Useful in the context of malignant bowel obstruction

Steroids – Dexamethasone 4-8 mg po/sc, od-bid

• 5 HT3 antagonists – Useful second and third line agents

– e.g. Ondansetron (4mg stat up to max 16mg/24 hrs)

Cause Drug Oral dose Syringe driver (24

hrs)

Gastric stasis Prokinetic agent eg

metoclopramide

10-20mg tds 40 - 80mg

Renal failure Haloperidol (anti-DA)

Cyclizine

1-3mg od

50mg tds

1 - 3mg (may accumulate)

150mg

Chemotherapy Ondansetron

(5HT-3 antagonists)

Dexamethasone

8mg bd

4mg bd

8 - 16mg

Unclear or multiple causes Cyclizine (anti-cholinergic)

OR

Levomepromazine (broad

spectrum)

50mg tds

6-12.5mg bd

100 -150mg

5 - 25mg

Intestinal obstruction Cyclizine (anti-cholinergic)

±

Haloperidol (anti-

dopamine)

150mg

3mg

Indications for using syringe-drivers

• Intractable vomiting

• Severe dysphagia

• Unable to swallow orals

• Reduced level of consciousness

• Poor alimentary absorption

• Poor compliance

Fatigue and quality of life

Fatigue

“ACUTE”

• Short duration.

• Rapid onset.

• Resolves quickly.

• Identifiable cause.

• Expected or anticipated.

• Serves protective function.

Fatigue

“CHRONIC”

• Longer duration.

• Gradual,cumulative onset.

• Does not resolve quickly.

• Multiple causes, not easily identified.

• Often no relation to activity.

• Maladaptive,no protective function. Major impact on quality of life.

Fatigue Assessment

• Fatigue pattern.

• Type and degree of disease.

• Treatment history.

• Current medications.

• Sleep and/or rest patterns.

• Nutrition intake and any appetite or weight changes.

Domains in Quality of Life Macmillan & Mahon

physical/

functional

social

psychological/

spiritual economic

PAIN

B

A

Time

Hopes,

ambitions

Present

reality

Modified

expectations

Improved

circumstances

Gap reflects QOL

“Calman Gap”

Key points

Venous Access Devices • Choice of device depends on type of therapy, duration, frequency, volume and

location of delivery. Vascular anatomy and patient choice important too. – Peripheral

– Midline (rare in oncology, tip around axilla)

– Central

• Peripheral catheters: – Most common

– Short term therapy

– Gauge: 24 the smallest, want to minimise discomfort or risk of damage. yellow.

– Site: above wrist, below elbow. 2 bones act as a splint.

– Care and maintenance: infection control

– Extravasation: inadvertent release of drug into surrounding tissue potentially causing necrosis or tissue damage.

– Smallest cannula in biggest possible vein to reduce phlebitis

• Midline Catheters – Does not extend beyond the axillary vein

– Short term therapy 2-4weeks

– No vesicant drugs: potential to cause necrosis if extravasated. Can lead to amputation

– No high pH drugs

– No high osmolarity

Venous Access Devices • Central Catheters

– TIP LOCATED IN SUPERIOR VENA CAVA – Non-tunnelled: neck, ICU – Peripherally Inserted Central Catheter: PICC – Tunnelled: Hickman line – Implantable port – 50-60cms long, 2-12.5 Francs – Single/double/triple lumen configurations – Open end/closed valve system

• PICC 4-5French. 1200/year. – Non-surgical procedure, put in by nurses, takes 2hours – Blue can have single or double lumen. Purple is suitable for power infusions – Topical anaesthetic, access above antecubital, cephalic or median vein – Basilic largest and straightest route leading to SVC, catheter advanced to tip in SVC – Confirmed radiologically – Cannula generally enough but: poor venous access, some chemo requires bigger lumen

• Tunnelled: Hickman. 11 French. – Cuffed catheter, in angiosuite or theatre. Surgical procedure – Local anaesthetic, access via subclavian/jugular vein with subcutaneous tunnel to exit – Dacron cuff, sutured in: 7 days neck, 21 chest wall. Confirmed by fluoroscopy. – Dacron cuff causes granulation tissue to develop which holds port in place – Needed for pts with double mastectomy due to lymphoedema and vein preservation. – Haematology patients: thicker bore so can take thicker solution. 11 French.

Venous Access Devices • Implantable port

– Surgical procedure requiring general anaesthetic/local

– 2 components: port and catheter

– Catheter tunnelled under skin, access through subclavian vein

– Port sits subcut on chest wall

– Anchored with sutures, overlying skin surgically closed

– Confirmed by fluoroscopy

– Access by Huber needle – locate port chamber and put Huber needle on.

• Potential Complications: – Air embolism

– Pneumothorax/haemothorax

– Mechanical phlebitis

– Infection: lowest risk with port.

– Occlusion: use urokinase to unblock

– Thrombosis: erythema of affected limb, discomfort/pyrexia, pain, swelling and distension, infusion difficulties. Rx: correct flushing, anticoagulate. Catheter removal LAST RESORT

– Migration/malposition: more with RCC as no suture etc

– Extravasation

– Catheter fracture

Palliative Care • Most common symptoms:

– Pain 84%

– Nausea and vomiting 51%

– Dyspnoea 47%

– Constipation 47%

• How you know you are near the end: – rapidly increasing weakness or fatigue

– Bed bound

– Decreasing intake of food and fluids

– Difficulty swallowing

– Decreasing Level of consciousness

• Check its not another cause which can be treated e.g. infection/toxicity

• Death rattle: phlegm in throat that cant shift as cilia paralysed giving pt a rattle which distresses family – scopolamine (hyoscine hydrobromide) or glycopyrolate

Palliative Care • Pain Management

– Types of suffering: pain, physical symptoms, psychological, cultural, spiritual, social and financial

– Pain: unpleasant sensory and emotional experience associated with actual or potential tissue damage

– Acute pain generally begins suddenly, is temporary and subsides itself/after treatment of the cause

– Chronic pain persists or recurs for prolonged, indefinite periods of time: change in pain pathway so pain persists despite healing.

– Inflammatory response causes acute pain

– Pain assessment: measure regularly, scale of 1-10 or smiley faces. Cause of pain should be identified and treated.

– Investigations may be useful: Bone scans or CT

– Types of pain in cancer • Nociceptive pain: somatic or visceral

• Neuropathic pain: central or peripheral

• Visceral pain

• Bony pain

• Referred pain

• Breakthrough pain

Breathlessness • Dyspnoea:

– Subjective feeling: awareness of being short of breath

– Devastating symptom in advanced cancer, ALS, end-stage lung disease and heart disease: occurs in 60% of these patients

– Complex symptom

– Feel short of breath panic processed in amygdala and hippocampus, adrenaline released hyperventilation blow off CO2 respiratory alkalosis free calcium binds to albumin hypocalcaemic tetany cannot physically breathe

– Causes: lung tumours, lung collapse, effusion, TB, lymphangitis carcinomatosis, SVC obstruction, chest wall pain, muscle weakness, ascites from abdominal tumour pushing against diaphragm

– Causes treatment related: surgery e.g. lobectomy, radiation induced fibrosis, chemo: pneumonitis, interstitial fibrosis, drugs – NSAIDs

– Causes – debility: infection, anaemia, fatigue, muscle weakness, PE

– Others: COPD, asthma, arrythmias, pneumothorax, acidosis, anxiety/distress

• Assessment – Good history and examination to find cause if possible

– Not directly correlated to O2 sats

– Pattern: intermittent/chronic, continuous, short acute episodes, better/worse, triggers

• Management: – Pleural effusion: thoracocentesis

– Large airway obstruction: stenting, radiotherapy

– Pneumonia: Abx

– Lymphangitis carcinomatosis: high dose steroids

– Anaemia: transfusion trial

– CHF/COPD: optimise treatments

– ALS: non-invasive ventilation

• General Principles: – Reassure patient and explain what is happening

– Try distraction/relaxation techniques

– Change their expectations of what they can manage

• Non pharmacological – Use a fan/open a window, less people in the room

– Position: lean forward with head up..

– Avoid exacerbating factors, conserve energy

– Avoid irritants e.g. smoke and encourage relaxation therapy

• Drugs – Oxygen – caution type II respiratory failure

– Benzodiazepines: calm patient

– Opioids: diminished sensation of SOB, start small on orals. Especially in last hours.

Breathlessness

N&V • Causes:

– Constipation

– Drugs: opioids, NSAIDs, SSRIs (SIADH causing low Na also caused by several cancers)

– Reduced GI motility: due to drugs – opioids and TCAs, autonomic neuropathy

– MET bowel disease/obstruction

– Anorexia-cachexia syndrome

– Metabolic causes: hypercalcaemia, uraemia, hyponatraemia (lung tumours ADH)

– Raised ICP

– Oral candidiasis

– Anxiety, pain

• Management – Try identify and treat underlying cause

– Treat the symptoms by selecting anti-emetic that works on affected pathway

– Prevent nausea by giving regular anti-emetic as opposed to PRN

– Review – if one drug not working, add another/change

• Anti-dopaminergic – good for malignant bowel obstruction – metoclopramide: may get EPSEs, upper GI pro-motility

– Domperidone: less EPSEs

– Haloperidol: raised QT interval and EPSE

– olanzapine

N&V • Anticholinergic

– Hyoscine hydrobromide

• Anticholinergic and anti-dopaminergic – Levomepromazine

• Serotonin antagonists – 2/3 line. – Ondansetron: good for chemo/radiotherapy induced N&V. prolonged QT syndrome

• Antihistamines – Cyclizine

• Steroids: increased appetite – dexamethasone

palliative symptom management

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