End of Life Care

1. End of Life Care Dr Anant Sachdev GPSI Palliative Medicine 07976 608871 anant.sachdev@nhs.net

2. Learning objectives • Urological Cancer symptoms in End of Life • Identify those at risk from the following 2 serious clinical scenarios • Understand treatment options • Refer appropriately • General principles

3. Symptoms Pain Malaise, Fatigue & Cachexia GI: Poor appetite, nausea Weight loss Bleeding Incontinence Delirium Spinal Cord Compression Hypercalcaemia

4. Malignant spinal cord compression • First contact is usually primary health care team! • Common • Significant impact on QOL and survival • Requires rapid decision making

5. Incidence • 5% of all cancers in final 2 years • Presenting feature • ACUP, NHL, myeloma and lung • Decreases with age, but 90% are >50yrs • Depends on primary site • 60% are lung, prostate or breast • NHL, Multiple myeloma and renal (5-10%) • Colorectal, ACUP and sarcomas

6. Pathophysiology • Vertebral body mass – anterior compression • Vertebral body collapse • Direct tumour growth through vertebral neural foramen (lymphoma) • Metastases in epidural space (rare)

7. Clinical featuresLocalisation • 60-80% thoracic spine • 15-30% lumbosacral • <10% cervical • 50% have more than 1 level

8. Clinical features • Pain – early sign • Up to 95% for 8/52 • localised then radicular • Worse when • recumbent • valsalva manoevre • Neck flexion/SLR • Motor deficits – late sign • 60-85% weakness at diagnosis • 2/3 non ambulatory at diagnosis • Thoracic>lumbosacral

9. Clinical features • Sensory deficits – late sign • 40-90% at diagnosis • Sensory level 1-5 segments below lesion • Lhermitte’s sign • Autonomic deficits – late sign • Urinary retention most common. • 50% catheter dependent at diagnosis. • Unlikely to be an isolated sign.

10. Investigation • Plain Xray • False negative 17% • Bone scan • Back pain + negative bone scan & plain xray unlikely to have SCC • CT Myelography • MRI • Sensitivity 93%, specificity 97% • Diagnostic accuracy 95% • Multi level common therefore image entire spine

11. Spinal Cord CompressionTreatment • Corticosteroids • 8mg BD (morning and lunchtime) and PPI cover • Random daily BMs • Bed rest and pressure area care • Bowel care • RT (early as poss) • 1# for pain mgt if no poss of recovery; • 5# for treatment • Surgery • Early rehab

12. Recurrent Spinal Cord Compression • 10% pt will develop local recurrence • 25-50% pts surviving > 1 yr will experience local relapse. • Mgt – surgery (may be inappropriate); Re-irradiation; supportive and palliative care

13. Spinal Cord CompressionPrognosis • Median survival is 3-6 months • If ambulatory pre compression 8-10 months • Non-ambulatory pre compression 2-4 months • Primary tumour myeloma / lymphoma – 6-9 months • Primary tumour lung – 2-3 months • Almost all patients have recurrence within 3 years

14. Referral guidelines • Immediate investigation (same day) • New onset weakness +/- sensory symptoms +/- autonomic symptoms • Prescribe steroid + PPI • Urgent investigation • Persistent severe back pain/nerve root pain without neurological symptoms if: • High risk group • Thoracic pain • Recumbent pain • Exacerbated by valsalva manoevre/Lhermitte’s sign • No investigation • Too frail for treatment • Very short life expectancy (weeks) • Already irradiated to tolerance or unfit for neurosurgery • So disabled, cord compression will not effect overall mobility

15. Key points • Common • Poor outcome unless early diagnosis • Pain is the key • Subtle motor changes • Neurological deficit is too late • Be aware of: • High risk groups • Clinical features

16. Hypercalcaemia in Advanced Cancer • The Commonest life-threatening metabolic emergency associated with advanced cancer • A condition which is usually amenable to treatment • If untreated distressing and fatal • Always consider when there is deterioration for no clear cause

17. Definition?

18. Hypercalcaemia • Defined as corrected plasma calcium >2.6mmol/l • Significant symptoms usually develop above >3.0 • Levels > 4.0 are fatal if untreated in a few days

19. Hypercalcaemia • Incidence • 10 – 20% of all cancer patients • Up to 20% of patients develop hypercalcaemia without bone metastases • Common cancers: bronchial, breast, myeloma, prostate • Rare in gastric/colorectal cancer

20. Hypercalcaemia • Cause / risk factors: • Bone metastases • PTHrP – secreting tumours e.g. Lung Cancer • Dehydration, renal impairment • Tamoxifen flare

21. Hypercalcaemia • Pathogenesis: • Increased bone resorption (osteolysis) and systemic release of humoral hypercalcaemic factors • Calcium is released from bone, and in addition there is may be a decrease in excretion of urinary calcium • Calcium release from bone by production of locally active substances produced by bone metastases: • Parathyroid hormone related peptide, • Ectopic parathyroid secretion • Tumour mediated calcitriol production • (Some may occur with or without bone mets.)

22. Recognising Hypercalcaemia General • Dehydration• Polydipsia• Polyuria• Pruritis Neurological • Fatigue • Confusion• Myopathy • Seizures• Psychosis • Coma Cardiac • Bradycardia • Atrial arrhythmias• Ventricular arrhythmias• Cardiac asystole • Death GI • Anorexia • Weight loss • Nausea and vomiting • Constipation / ileus

23. Prognosis • Indicates disseminated Disease • Poor prognosis 80% die within 1 year • Median survival is 3 to 4 months • Hypercalcaemia likely to recur

24. Hypercalcaemia Treatment may not be necessary if: • the patient is very near to death or • there are no symptoms distressing the patient

25. All treatments involve the correction of serum calcium levels, which results in a marked decrease in symptoms Rehydration Bisphosphonates Steroids Treatments of Hypercalcaemia

26. Rehydration: Dehydration due to vomiting and polyuria, large volume will lower calcium levels, note fluid-overload! 2-3 L/day usually Avoid concomitant use of diuretics, Vitamin A and D which promote hypercalcaemia Treatments of Hypercalcaemia

27. Steroids: Have been shown to inhibit osteoclast activity and calcium absorption from the gut in vitro Limited to haematological and Breast malignancies when oral prednisolone 40-100mg/day is usually effective Treatments of Hypercalcaemia

28. Bisphosphonates Reduce bone resorption by inhibiting osteoclast activity Highly effective But take 48 hours to be effective Mainstay of hypercalcaemia treatment Further benefit is that of reduction of bone pain due to metastases Treatments of Hypercalcaemia

29. Treatment • Dehydration should be corrected with iv fluids • Most common choices of drug IV: • Zolendronic Acid: 4mg over 15 minutes • Disodium Pamidronate: 30-90 mg over 2-4 hours • Effect seen after 4 - 7 days • Lasts 2-4 weeks, many patients have monthly infusions • 20% patients with hypercalcaemia will be resistant to infusion therapy

30. General EOL principles to follow: • Review patient regularly - holistically • Get District nurses involved early, others eg Macmillan • Inform Out of Hours, and practice team - & update! • Ascertain PPOC • Review symptoms and drugs • Communicate well with patient, family and carers • Explain management of crises, • whom to contact, • use of 999, • possible pathway for illness and symptoms expected when deteriorates, • ethical issues : nutrition, hydration, use of ab, oxygen, • supportive measures available, financial help • (DS1500) • Consider Just-in-Case medication • Consider DNACPR statement • All of the above - Adopt the Liverpool Care Pathway for holistic management of the dying patient

31. Thank you any Q Dr Anant Sachdev 07976 608871 anant.sachdev@nhs.net