Palliative care
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Palliative Care. Dr Rachel Dawson. Objectives. Increase your confidence in dealing with palliative care cases. Content. Who is a palliative care patient? Presentation/ likely symptoms Palliative care emergencies Help available Medication – what, when & how much to use

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Palliative Care

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Palliative care

Palliative Care

Dr Rachel Dawson


Objectives

Objectives

  • Increase your confidence in dealing with palliative care cases


Content

Content

  • Who is a palliative care patient?

  • Presentation/ likely symptoms

  • Palliative care emergencies

  • Help available

  • Medication – what, when & how much to use

  • Setting up a syringe driver

  • Case studies/ ethical dilemmas


Who is a palliative care patient

Who Is a Palliative Care Patient?


A patient for whom the objective of any treatment is to offer symptom relief only

A patient for whom the objective of any treatment is to offer symptom relief only

  • For example –

    - Any end-stage chronic illness; cancer, heart failure, renal failure, COPD, MS ….

    - Dementia

    - Old age

  • It is NOT just for cancer patients


Common symptoms pepsi cola

Common Symptoms(PEPSI COLA)

  • Pain

  • Drowsiness

  • Breathlessness

  • Nausea / Vomiting

  • Constipation

  • Anxiety/ Agitation / Restlessness/ Confusion – remember carer

  • Dysphagia

  • Other symptoms are more common in certain scenarios e.g. ascites in ovarian cancer


Palliative care emergencies

Palliative care Emergencies

  • Hypercalcaemia

  • Spinal cord compression

  • SVC obstruction

  • GI obstruction

  • Haemorrhage – esp Upper GI

  • ( Raised ICP)


Palliative care emergencies hypercalcaemia

Palliative Care Emergencies – Hypercalcaemia

  • Calcium > 2.6mmol/l

  • Suspect if known bony mets or any common tumour; Breast/ kidney/ myeloma/ lung or CRF

  • Symptoms – non-specific : thirst, constipation, N/ V, Abdo pain, anorexia

  • Management – STOP any calcium (!) & admit for re-hydration & IV Pamidronate


Palliative care emergencies spinal cord compression

Palliative Care Emergencies – Spinal Cord Compression

  • Incidence of ~5% of all cancer patients – 70% occur in T spine

  • Always suspect if known bony mets/ common metastasising tumours

  • Symptoms include – pain / leg weakness/ constipation/ incontinence

  • Management: ADMIT – IV Dexamethasone, MRI & RTx


Palliative care emergencies gi obstruction

Palliative Care Emergencies –GI Obstruction

  • Can occur with any cancer – not just physical obstruction

  • Symptoms include – V (faeculent), Constipation (empty rectum), Abdo distension, Pain

  • Management - ? Admit, ? NGT, Consider stopping prokinetic (dom/ met) & switch cyclizine/ haloperidol, buscopan. Soften stool & consider dexamethasone


Palliative care emergencies svc obstruction

Palliative Care Emergencies –SVC Obstruction

  • Rare – 75% are due to 1y lung cancer. ~3% lung cancers develop SVCO

  • Symptoms – periorbital oedema, SOB/ stidor, neck or arm swelling. Usually dilated veins can be seen on chest wall.

  • Management – Treat breathlesness/ anxiety with opioid +/- BZD. ADMIT – IV dexamethasone & RTx


Palliative care emergencies haemorrhage

Palliative Care Emergencies-Haemorrhage

  • Rare, but most common with upper GI (Remember steroids)

  • Usually fatal

  • Need to anticipate / warn carer

  • Management – Midazolam +/- diamorphine to alleviate suffering


Palliative care emergencies 7

Palliative Care Emergencies(7)

  • Raised ICP – presents with drowsiness/ headache/ V. Can usually be anticipated. Mx= dexamethasone 16mg/day

  • In essence emergency drugs include – Diamorphine, Anti-emetic, Midazolam & Dexamethasone


Help available

COMMUNITY

District Nurses ->LCP

Macmillan Nurses

Hospice at home ->LCP

Consultants

Pharmacist – Twycross/ Pall care BNF

Bradford Cancer Support ->benefits

HOSPITAL

Consultants

Specialist nurses

2nd opinion

Help Available


Medication what when how much to use

Medication – What, When & How Much to Use

  • Analgesia

  • Antiemetic

  • Anticholinergics

  • Sedatives/ Anxiolytics

  • Anti-inflammatory

  • Others – secretions, mouth care & constipation.


Analgesia

Analgesia

  • Tailor analgesic choice to type of pain – may need a combination

  • Give clear instructions

  • Gradually increase dose

  • Give regular dosage +/- PRN

  • Consider potential SE & co-prescribe

  • Follow up to ensure ok


Analgesia types of pain

Analgesia – Types of Pain

  • ‘Standard’ = WHO Analgesic ladder = Opioid

  • Bony pain – consider NSAID, RTx, Bisphosphonates

  • Neuropathic – Opioids, Gabapentin, Pregabalin

  • Abdo Spasm – Anticholinergics

  • Muscular – NSAID, Baclofen, BZD’s


Analgesia types

Analgesia - Types

  • Non-opioids: Paracetamol, NSAID

  • Weak Opioid : Codeine, Dihydrocodeine, Tramadol

  • Strong Opioids : Morphine (1st line), Diamorphine, Fentanyl, Oxycodone, Hydromorphone, Methadone

  • Others – Ketorolac; Ketamine


Analgesia choice

Analgesia – choice

  • Choose on basis of type of pain, route of delivery & previous analgesia used

  • 1st line build up ladder to morphine.

  • Start regular oromorph eg 5-10mg qds + prn.

  • Review amounts used & convert to MST. Can then convert to diamorphine as necessary.

  • Switch to oxycodone/ hydromorphone / fentanyl if morphine SE

  • REMEMBER to co-prescribe + PRN


Antiemetic

Antiemetic

  • Likely to be used a co-prescription or to reduce established nausea.

  • Try simple meds 1st line

  • 1st line = Cyclizine, Stemetil, Metoclopramide

  • Consider other choices if co-existing symptoms e.g. Haloperidol, Dexamethasone, Levo

  • Can use combinations.

  • Doses may be higher eg 60-100mg metoclopramide over 24hrs.

  • Avoid Metoclopramide if obstruction


Agitation anxiety

Agitation/ Anxiety

  • Consider reversible causes inc pain

  • Consider non-drug treatments

  • Consider underlying depression

  • Medication: Haloperidol, BZD’s

  • Short-acting BZD’s eg lorazepam s/l

  • Sedating BZD’s eg Midazolam s/c

  • Sedatives eg Phenobarbitol


Other meds

Other meds

  • Secretions– consider hyoscine patch or s/c

  • Constipation – try & avoid with co-prescribing

    - Prescribe regular laxatives

    - Remember Co-danthrusate/ docusate

    - Seek nurse advice/ involvement

  • Mouth Care – consider saliva sprays/ gel


Other meds dexamethasone

Other meds - dexamethasone

Has multiple uses at different doses & compatible in syringe drivers

  • Anorexia - 2-4mg/ d

  • Raised ICP – 16mg/d

  • Gut obstruction – 4-8mg/d

  • Hiccoughs – 4-12mg/d

  • Anti-inflammatory – 4 –16mg/d


Medication example

Medication example

If opioid naïve a good starting point for oral route:

  • Oramorph PRN & convert OR 10mg MST bd, then review. PLUS…

  • Cyclizine 50mg tds. PLUS…

  • Movicol1 sachet 2-4x per day – consider volume

  • Review regularly & if problems – seek help


Syringe drivers when what how

Syringe Drivers – When, What , How

  • When

    - Try & anticipate

    - Team decision

    - Can always be stopped

    - Ensure family aware.

    - Communicate well

    - STOP all other meds (special considerations – Insulin)


Palliative care

  • What

    - Diamorphine (5-10mg if naïve) – 15 amps

  • Cyclizine (150mg) &/or Metoclopramide (60mg) – 15 amps

  • WFI x10-20 amps

  • +/- Midazolam – 20-30mg/24hrs initailly – 15 amps

  • Ensure stat doses available & instructions to increase after 24hrs if necessary.

  • Special instructions eg GI haemorrhage.


Palliative care

  • How

    - Inform/ Involve family in decision

    - Inform DN’s or H at H

    - Prescribe meds

    - Write up instructions – Syringe driver & stat sheet. Be clear.

  • Inform LCD – fax

  • Ensure follow up in place – timing/ who


Other considerations

Other considerations

  • Always ensure the person still wishes to remain at home.

  • Keep family informed & advise re action to take in event of death

  • Benefits – DS1500

  • Level 6 care/ Continuing care – poor prognosis

  • LCD/ OOH form/ Gold Line

  • DNR form for transport


Cases

Cases


Conclusion

Conclusion

  • Hopefully confidence increased

  • Information packs include:

    - Handout

    - Yorkshire cancer network booklet

    - Dose comparisons of Strong Opioids

    - Syringe driver compatability info

    - Local pharmacy info (exemption form)

    - Forms – DNR, Level 6, LCD, Syringe driver, PEPSI COLA + DS1500 advice.

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