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“Palliative Care”. Dr David Plume MBBS DRCOG MRCGP Macmillan GPF, GP Advisor and Primary Care Network Lead. “Palliative Care”. “talk about medicine” or “talk about air” Enormous subject! Feedback regarding questionnaires and PPoC Choice of Topic Areas:

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palliative care

“Palliative Care”


Macmillan GPF, GP Advisor and Primary Care Network Lead.

palliative care1
“Palliative Care”
  • “talk about medicine” or “talk about air”
  • Enormous subject!
  • Feedback regarding questionnaires and PPoC
  • Choice of Topic Areas:
    • Symptom Control inc Breathlessness and Nausea/Vomiting, setting up a syringe driver.
    • Current initiatives/developments inc improved drug charts for EOL, transferable DNACPR forms, end of treatment letters etc.
    • Q and A
local feedback questionnaires
Local Feedback-Questionnaires
  • In late 2007 and again in late 2008 I sent out questionnaires looking at twenty nine criteria for palliative care provision in 1’ care.
  • These included;
    • Nominated lead?
    • Keeping a list?
    • Information getting to 1’ care rapidly enough?
    • Support for patients on the cancer journey
    • Frequency of palliative care meetings
    • Who goes?
    • H/O forms used and updated?
    • Are you recording PPoC, concerns etc and using LCP?
    • Do you have educational input from specialist team?
local feedback questionnaires1
Local Feedback-Questionnaires
  • Regionally there had been significant improvements between 2007 and 2008.
  • Increased numbers with a nominated lead, cancer dx list, who were getting better info from 2’ care, palliative care list.
  • Meetings were now monthly for majority with only small minority having < or > frequency
  • Meetings continued to predominantly be GPs/DNs and SPCN but 17% of surgeries also have SW
  • Better recording of attendance/use of h/o forms/provision of benefits advice.
  • Many more surgeries were making sure they were updating the h/o forms and also patients concerns/expectations and needs.
  • 98% of surgeries use the LCP
local feedback ppoc pilot
Local Feedback-PPoC Pilot
  • Many thanks for your involvement.
  • Regionally 58% wanted to remain at home, 34% wanted a nursing home/care home and the other 8% wanted to go to hospital.
  • 83% of patient initiated on the document died in their PPoC
  • Usual reason for not achieving this were care/carer issues or unexpected decline.
  • Very +ve feedback
  • With PCT, with costings, for regional rollout.
symptom control
Symptom Control
  • Nausea and Vomiting.
  • Breathlessness.
  • Setting up a syringe driver.
  • Nausea “an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms”
  • Retching “rhythmic, laboured, spasmodic movements of the diaphragm and abdominal muscles”
  • Vomiting “forceful expulsion of gastric contents through the mouth” – complex reflex process

Nausea is worse than vomiting.

Occurs in 60% of people with advanced cancer.

establishing the probable diagnosis in nausea vomiting
ESTABLISHING the probable diagnosis in NAUSEA & VOMITING
  • History
    • Is there any relationship with food or pain – peptic ulcer?
    • Is it projectile or faeculant – high obstruction?
    • Did it start with certain medication (eg morphine, digoxin, NSAIDS)?
    • Do certain events or situations trigger it? (eg hospital, anxiety, chemotherapy)
    • ? Large volume vomit – gastric stasis
    • Distinguish between vomiting/expectoration/regurgitation
    • Psychological assessment
  • Nausea relieved by vomiting – gastric stasis / bowel obstruction.
  • Vomiting shortly after eating or drinking, with little nausea – oesophageal / mediastinal disease
  • Sudden unpredictable vomit, possibly worse on waking – raised intracranial pressure
  • Persistent nausea with little relief from vomiting – chemical / metabolic cause
  • Eyes - Possible jaundice

- Examine fundi for papilloedema

  • Abdomen - Masses

- Hepatomegaly

- Distension / ascites

- Presence or absence of bowel sounds

  • PR - If constipation suspected
  • Bloods - Renal & Liver function

- Calcium

- Specific drug levels if indicated

management of nausea and vomiting
  • Review of drug regime
  • Cough = Antitussive
  • Gastritis = Reduction of gastric acid =

? Stop gastric irritant drugs

  • Constipation = Laxative
  • Raised intracranial pressure = Corticosteroid
  • Hypercalcaemia = IV Saline / Bisphophonate (correction is not always appropriate in a dying patient)
  • Ascites = ?Paracentesis

R. Twycross 1997

managing nausea vomiting anti emetics
  • Dopamine receptor antagonists D2
    • Metoclopramide
    • Haloperidol
  • Histamine & muscarinic receptor antagonists H1
    • Cyclizine
  • Prokinetic
    • Metoclopramide
    • Domperidone (does not cross BBB)
  • 5HT3 antagonists 5HT3
    • Granisetron
    • Tropesitron
    • Ondansetron
managing nausea vomiting anti emetics1
  • Dexamethasone
    • ? Reduces permeability of BBB to emetogenic substances
  • Benzodiazepines
    • Amnesic, anxiolytic & sedative
  • Cannabinoids
    • AIDS / chemotherapy
    • Brainstem cannabinoid receptor
  • Octreotide
    • Anti-secretory properties
drug administration
  • Oral route suitable for mild nausea.
  • Syringe driver or rectal route for moderate to severe nausea and / or vomiting.
  • Anti-emetics should be given regularly rather than PRN.
  • Optimise dose of anti-emetic every 24 hours.
drug administration summary of guidelines
DRUG ADMINISTRATIONSummary of Guidelines
  • After clinical evaluation, document the most likely cause(s).
  • Monitor the severity of nausea and vomiting.
  • Treat reversible causes.
  • Assess psychological aspects, eg anxiety.
  • Prescribe first-line anti-emetic for most likely cause both regularly and prn.
  • Optimize does of anti-emetic every 24 hours.
  • Reassess and change drugs by adding or substituting the second-line anti-emetic.

- If little benefit, reassess the cause and change to appropriate first-line anti-emetic.

- ?converting to oral route after > 3 days.

- Continue indefinitely unless the cause is self-limiting.

  • Unpleasant awareness of difficulty in breathing
  • Pathological when ADLs affected and associated with disabling anxiety
  • Resulting in : physiological behavioural responses
  • Breathlessness experienced by 70% cancer patients in last few weeks of life
  • Severe breathlessness affects 25% cancer patients in last week of life
causes of breathlessness cancer
Causes of breathlessness-Cancer
  • Pleural effusion
  • Large airway obstruction
  • Replacement of lung by cancer
  • Lymphangitis carcinomatosa
  • Tumour cell microemboli
  • Pericardial Effusion
  • Phrenic nerve palsy
  • SVC obstruction
  • Massive ascites
  • Abdominal distension
  • Cachexia-anorexia syndrome respiratory muscle weakness.
  • Chest infection
causes of breathlessness treatment
Causes of Breathlessness-Treatment
  • Pneumonectomy
  • Radiation induced fibrosis
  • Chemotherapy induced
    • Pneumonitis
    • Fibrositis
    • Cardiomyopathy
  • Progestogens
    • Stimulates ventilation
    • Increased sensitivity to carbon dioxide.
causes of breathlessness debility
Causes of Breathlessness- Debility
  • Atelectasis
  • Anaemia
  • PE
  • Pneumonia
  • Empyema
  • Muscle weakness
causes of breathlessness concurrent
Causes of Breathlessness-Concurrent
  • COPD
  • Asthma
  • HF
  • Acidosis
  • Fever
  • Pneumothorax
  • Panic disorder, anxiety, depression
reversible causes of breathlessness
Reversible causes of breathlessness!
  • Resp. Infection
  • COPD/Asthma
  • Hypoxia
  • Obstructed Bronchus/SVC
  • Lymphangitis Carcinomatosa
  • Pleural Effusion
  • Ascites
  • Pericardial Effusion
  • Anaemia
  • Cardiac Failure
  • PE
independent predictor of survival
Independent predictor of survival




Symptomatic drug treatment

Non-drug treatment

Correct the correctable

Breathless on exertion

Breathless at rest

Terminal breathlessness

non drug therapies
Non-Drug Therapies
  • Explore perception of patient and carers
  • Maximise the feeling of control over the breathing
  • Maximise functional ability
  • Reduce feelings of personal and social isolation.
patient and carer perception
Patient and Carer Perception
  • Meaning to patient and carer
  • Explore anxiety esp. fear of sudden death
  • Inform that not life threatening
  • State what is likely to/not to happen
  • Realistic goal setting
  • Help patient and carer adjust to loss of roles/abilities.
maximize control
Maximize control
  • Breathing control advice
    • Diaphragmatic breathing
    • Pursed lips breathing
  • Relaxation techniques
  • Plan of action for acute episodes
    • Written instructions step by step
    • Increased confidence coping
  • Electric fan
  • Complementary therapies
maximize function
Maximize function
  • Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness
  • Evaluation by physios/OT’s/SW to target support to need.
reduce feelings of isolation
Reduce feelings of isolation
  • Meet others in similar situation
  • Day centre
  • Respite admissions
breathlessness clinic
Breathlessness Clinic
  • Nurse lead
  • NNUH-Monday Afternoon
  • Lung cancer and Mesothelioma
  • Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants
  • PBL Day Unit-Wednesday, link with NNUH.
what do i give
What do I give?
  • Bronchodilators work well in COPD and Asthma even if nil known sensitivity.
  • O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension.
    • Usual rules regarding COPD/Hypercapnic Resp. failure apply.
  • Opioidsreduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness.
    • If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed.
    • If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given
  • Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc

Repeated 4hrly as needed

ongoing treatment
Ongoing treatment

A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs

  • Diamorphine 10-20mg CSCI / 24hrs
  • Midazolam 5-20mg CSCI / 24hrs

Remember to prescribe stats

Review & adjust dose daily if needed

terminal breathlessness
Terminal Breathlessness
  • Great fear of patients and relatives
  • Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI
  • If agitation or confusion -haloperidol or Nozinan
  • Some patients may brighten.
  • Sedation not the aim but likely due to drugs and disease.
respiratory secretions death rattle
Respiratory Secretions (death rattle)
  • Rattling noise due to secretions in hypopharynx moving with breathing
  • Usually occurs within days-hours of death
  • Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases)
  • Patient rarely distressed
  • Family commonly are distressed
  • Treat early
  • Position patient semi-prone
  • Suction rarely helpful
respiratory secretions
If secretions are present, two options.

A) Hyoscine Butylbromide (Buscopan)

Stat-20mg 1hrly

CSCI-80-120mg/24 hrs

B) Glycopyrronium

Stat-0.4mg 4hrly

CSCI-0.6-1.2mg /24 hrs

Remember Stats at appropriate doses

Review & adjust dose daily

Respiratory Secretions
setting up a syringe driver
Setting up a syringe driver
  • YouTube
current initiatives
Current Initiatives
  • EOL Drug Charts
    • At piloting stage
    • Aim to clarify and simplify prescribing at the EOL
    • “Allow a natural and dignified death”
    • Development of transferable DNACPR form from 1’2’3’ and visa versa
    • Piloting later in year
  • EOT Letters
    • Much more info, especially on late effects, anticipated problems, points of re-referral etc.
    • Meet next week with Tom Roques
    • Integrate with electronic records
q and a
Q and A
  • I am not a palliative care physician and you have an excellent resource in Gail!
  • Happy to answer questions.