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Palliative Care

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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  1. Palliative Care Dr Rachel Dawson

  2. Objectives • Increase your confidence in dealing with palliative care cases

  3. 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

  4. Who Is a Palliative Care Patient?

  5. 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

  6. 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

  7. Palliative care Emergencies • Hypercalcaemia • Spinal cord compression • SVC obstruction • GI obstruction • Haemorrhage – esp Upper GI • ( Raised ICP)

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Medication – What, When & How Much to Use • Analgesia • Antiemetic • Anticholinergics • Sedatives/ Anxiolytics • Anti-inflammatory • Others – secretions, mouth care & constipation.

  16. 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

  17. 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

  18. Analgesia - Types • Non-opioids: Paracetamol, NSAID • Weak Opioid : Codeine, Dihydrocodeine, Tramadol • Strong Opioids : Morphine (1st line), Diamorphine, Fentanyl, Oxycodone, Hydromorphone, Methadone • Others – Ketorolac; Ketamine

  19. 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

  20. 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 • Can use combinations. • Doses may be higher eg 60-100mg metoclopramide over 24hrs. • Avoid Metoclopramide if obstruction

  21. 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

  22. 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

  23. 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

  24. 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 • Review regularly & if problems – seek help

  25. Syringe Drivers – When, What , How • When - Try & anticipate - Team decision - Can always be stopped - Ensure family aware. - Communicate well - STOP all other meds

  26. What - Diamorphine (5-10mg if naïve) • Cyclizine (150mg) &/or Metoclopramide (60mg) • WFI • +/- Midazolam – 20-30mg/24hrs initailly • Ensure stat doses available & instructions to increase after 24hrs if necessary. • Special instructions eg GI haemorrhage.

  27. 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

  28. 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 • DNR form for transport

  29. Cases

  30. Conclusion • Hopefully confidence increased • Information packs include: - Handout - Yorkshire cancer network booklet - Dose comparisons of Strong Opioids - Syringe driver compatability info - Local pharmacy info - Forms – DNR, Level 6, LCD, Syringe driver, PEPSI COLA + DS1500 advice. • Marie Curie Talks

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