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Palliative Care

Palliative Care. Dr Philip Lomax Consultant in Palliative Medicine. Case Scenario.

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Palliative Care

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  1. Palliative Care Dr Philip Lomax Consultant in Palliative Medicine

  2. Case Scenario • Mr John Smith is a 63 year old gentleman who was diagnosed three months ago with Right sided squamous cell carcinoma of the bronchus. He presented with weight loss, hoarse voice and cough. Investigations at diagnosis demonstrated mediastinal node involvement and pleural effusion with calcified pleural plaques. • He was treated with palliative radiotherapy to his lung and 6 week review showed a disease response. He is due to be followed up shortly by the oncologist and has contact details of the lung cancer nurse specialist • He is non insulin dependent diabetic, well controlled on diet alone and has no other significant previous medical or family history.

  3. Case Scenario • He lives with his wife and has two sons in their mid to late twenties and one grandchild who he helps to look after during the week. He was made redundant from his job as a plumber 2 years ago having worked for large industrial companies. He has a 17 pack year smoking history and stopped smoking twenty-eight years ago when his son was born. • He attends surgery having felt less well for the past 2 weeks his problems are:- • Back pain • Fatigue and reduced mobility • Increased breathlessness • Poor appetite • Nausea and some dysphagia • Constipation

  4. Superior Vena Cava Obstruction • Symptoms include:- • breathlessness • facial swelling • head fullness and headache • cough • arm swelling • chest pain • dysphagia • orthopnea • distorted vision • hoarseness • stridor • nasal stuffiness • nausea • Examination • venous distension of the neck and chest wall • facial oedema • upper extremity oedema • mental changes • plethora • cyanosis • papilloedema • stupor, and even coma • Bending forward or lying down may aggravate the symptoms and signs

  5. SVCO • Can be presentation of malignancy • Mainstay of initial treatment in established cancer diagnosis is steroids • Radiotherapy palliates SVCO in up to 70% of lung cancer patients • In patients who are well enough, SVCO stenting will provide best and longest relief

  6. Other symptoms • Swallowing • Exclude oro-pharyngeal monilia (Steroids and diabetes) • Consider Metoclopramide • Extrinsic compression from mediastinaldisesase • SALT advice - thickened fluids? • Breathlessness • Evaluate reversible causes (infection, anaemia, PE, recurrence pleural effusion, pericardial effusion, collapse etc) • Non drug - position, fan, breathlessness management, • Use of Oramorph 50-100% of analgesic dose • Benzodiazepines • OT assessment – fatigue management, aids to daily living

  7. Hypercalcaemia of Malignancy Symptoms • Poor appetite • nausea • constipation • Thirst • Polyuria • Fatigue • Confusion Examine for:- • signs of dehydration • may see myoclonus • Mini mental state

  8. Hypercalaemia • Check Calcium 7 days after treatment • Repeat blood tests every 2-3 week or earlier if symptoms recur • Outpatient treatment for recurrent episodes • Switch to Zoledronate if becoming resistant to Pamidronate • Discussions around when to cease treatment • Occurs in 10% of all cancer cases • More common in myeloma, squamous cell lung, breast and urological cancers • 20%of cases in absence of bony metastatic disease

  9. Spinal Cord Compression • Micturitional difficulty and Urinary retention • Bilateral nerve root pain especially band-like • Acute escalation of severe spinal pain • Unsteadiness/heaviness in legs • Tingling or electric shocks in spine with a cough or sneeze • Neurological signs may be equivocal but could have sensory loss, motor weakness Next steps? http://www.christie.nhs.uk/the-foundation-trust/treatments-and-clinical-services/spinal-cord-compression.aspx

  10. Pain Control • Pain assessment • Consider increase opioid by 30-50% or be guided by rescue doses if less • NSAID if Gastrointestinal and Renal risks OK • Consider temporary step back up on steroids • Neuropathic pain consider increasing Gabapentin

  11. Ongoing Care • Monitor diabetic control more closely until steroid dose reduced • Significant milestone in disease • Check allowances eg DLA/AA • GSF register • Information to OOH and NWAS • Consider advance care planning (PPC, ADRT, Statement of wishes and preferences) • Consider family support, need for carers, psycholoical and spiritual issues) • Referral to Specialist Palliative Care services if ongoing difficulty with needs

  12. NORTH WEST END OF LIFE CARE MODEL Advancing disease Increasing decline Last Days of Life First Days after Death Bereavement 1 year+ Death 1 year+ 1 2 3 4 5 6 months Single Assessment Process completed DS1500 completed AnticipatoryMedications initiated Liverpool care of The Dying Pathway initiated Verification of death Psychological support ACP initiated Ongoing bereavement support Carer need Assessment completed Certification of Death completed OOH, informed of ACP AnticipatoryMedications supplied Out of Hours updated Counselling support GSF/KITE initiated Death registration Respite care arranged Signposting to providers Advance Care Planning Update NWAS Funeral Director Fast track to Fully funded Continuing Health Care GSF/KITE meetings Significant event Analysis reviewed In MDT DNAR Initiated by GP Prognosis communicated Key worker team nominated Update NWAS with DNAR & Care Planning Info Support Arranged for Provision of Terminal care at home Care after death Section of LCP Goal 12 Patient-held record issued DWP1027 Notify NWAS ACP reviewed 1 2 3 4 5 6

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