Emergencies in Palliative Care

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Emergencies in Palliative Care

• C. Woelk MD, CCFP, FCFP
• Medical Director of Palliative Care RHA Central
  Manitoba
• Physician, Community Cancer Program Boundary
  Trails Health Centre
• Family Physician Winkler, MB

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Oxymoron

• Definition
• Two concepts that do not really go together, but
  are used together
• A phrase containing two contradictory terms

C. Woelk MD
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Oxymoron Examples

• Old news
• Extensive briefing
• Random order
• Free gift
• Palliative Emergencies

C. Woelk MD
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Objectives

• To appreciate the concept of palliative
  emergencies
• To review a number of the potential emergencies
• To develop an approach of prevention, and early
  diagnosis and management

C. Woelk MD
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Mandatory Underlying Premise
Orders
Actions
Palliative Care Do not resuscitate / DNR Allow
Natural Death / AND Advanced Care Plan / ACP 4
Do not intervene Ignore Sedate
?
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Managing Palliative Emergencies

• Prevention
• Anticipating the Potential
• Early Recognition
• Appropriate Response

• Communication

Communication
C. Woelk MD
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An ounce of prevention is worth a pound of
cureBenjamin Franklin
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Anticipation

• Be aware of potential emergencies
• Be aware of patient wishes in case of emergency
• Be aware of family member wishes in case of
  emergency

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Questions to ask Yourself

• Is this person palliative?
• Is this an emergency?
• Is this event reversible or is this a terminal
  event?
• Is reversing this event reasonable?
• Emergent syndrome management vs. Emergent symptom
  management

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Is this person palliative?
Death
Diagnosis
Disease-oriented treatment
Symptom-oriented treatment
Bereavement
Palliative Care
Terminal Care
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Is this person palliative??? How palliative ??
Increasingly Aggressive Life- Prolonging Measures
Increasing Palliative Care
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Is this emergency?

• What is an emergency?
• Who defines this as an emergency?

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Is this a reversible event?
Is reversing this event reasonable?
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Is reversing this event reasonable?
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Emergent syndrome management?SometimesEmergent
symptom management?Always
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Potential Goals in Treating Palliative Emergencies

• Improvement in function
• Decrease in symptoms
• Prolongation of life
• Improved quality of life
• Less complicated bereavement

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Working with excess Adrenalin in the room

• Anxiety
• Fear
• Panic
• Fight

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Pain Crises
This is as much of a crisis as a code
Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Definition of Pain Crisis

• An event in which the patient reports severe
  uncontrolled pain that is the patient, family or
  both severe distress.
• The pain may be acute in onset or have progressed
  gradually to an intolerable threshold (as
  determined by the patient), but requires
  immediate intervention.

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Severe Pain CrisisIncidence

• No epidemiological data available that describes
  incidence

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Severe Pain CrisisEtiology

• Most common potential sources
• Acute fracture
• Ruptured organ
• Nerve compression

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Severe Pain CrisisApproach

• Rapid thorough clinical assessment
• Titration of analgesics
• Direct supervision by individuals or a team
  familiar and comfortable providing this care

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Severe Pain CrisisApproach

• Rapid thorough clinical assessment
• The extent of the workup depends on the clinical
  situation
• i.e. the goals of care, patients wishes, and the
  risk-burden ratios of tests and their
  implications

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Severe Pain CrisisApproach

• 2. Titration of analgesics
• Convert oral to IV equivalents
• Give one breakthrough dose (BTD) repeat in 15
  minutes
• If pain remains gt 7/10, double the BTD
• Continue q15 minutes until pain score reduced by
  50, or adverse events occur
• Calculate new 24 hour, and BTD after pain relief
  obtained.
• Adjust route of administration

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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World Health Organization Pain Ladder
?
Step 3
Opioid for moderate to severe pain /-
Non-opioid /- Adjuvant
Step 2
Opioid for mild to moderate pain /-
Non-opioid /- Adjuvant
Step 1
Non-opioid /- Adjuvant
Increasing Pain
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Severe Pain CrisisApproach

• 2. Titration of analgesics
• Remember the use of adjuvants
• Remember opioid rotation
• Expect emotional response from family and other
  caregivers

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Severe Pain Crisis - Approach

• 3. Direct supervision by individuals or a team
  familiar and comfortable providing this care
• One of the pearls of wisdom that we talked about
  as a team the next day is that in situations at
  the end of life, its really important to get
  people involved just as if someone was having a
  heart attack. In that case, you would call a
  cardiologist. If someone had a dropped lung, you
  would call a surgeon. In a similar way, you have
  to treat someone who is terminal, meaning death
  being imminent, as almost a code, in the sense
  that you have to get the people involved who can
  best provide care at that point.

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
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Spinal Cord Compression

• Compression of the spinal cord somewhere along
  its length by a primary or secondary malignancy

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Spinal Cord CompressionIncidence

• 5 of all cancer patients
• Average age 58
• Vertebral column is the most common site of
  skeletal metastases
• Up to 30 of patients with metastatic
  compression will survive more than 1 year after
  first symptoms

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Spinal Cord CompressionSite of Cancer Origin

• Lung 16
• Breast 12
• Unknown 11
• Lymphoma 11
• Myeloma 9
• Sarcoma 8
• Prostate 7
• Kidney 6

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Spinal Cord CompressionInvestigation

• Spine x-rays
• Bone scan
• MRI test of choice
• (CT Myelography
• former test of choice)

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Spinal Cord CompressionTreatment

• Rapid diagnosis and therapeutic intervention is
  essential
• Paraplegia from malignant SCC is always
  irreversible and is no longer an emergency

• Immediate high dose steroids
• Dexamethasone 100 mg i.v. then 4 () mg q6h
• Radiation
• Surgery
• Chemotherapy

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HypercalcemiaIncidence

• 10 of advanced cancers
• May be the first presentation of multiple myeloma

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HypercalcemiaIncidence

• Breast cancer (gt20)
• Non-small cell lung cancer (25)
• Hypernephroma
• Multiple Myeloma (40-50)
• Squamous cell cancers of head, neck, esophagus
• Thyroid cancers
• Prostate, Small cell lung cancers and colorectal
  cancers have small incidence, despite frequently
  metastasizing to bone

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HypercalcemiaEtiology

• Bone metastases / osteoclastic action
• PTH-like substances
• Dietary factors are generally not considered
  important in developing hypercalcemia

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HypercalcemiaPresentation

• Early symptoms and signs
• Polyuria, nocturia, polydipsia
• Dehydration
• Anorexia
• Easily fatigued / weakness
• hyporeflexia

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HypercalcemiaPresentation

• Late symptoms and signs
• Neuropsychological apathy, irritability,
  depression, decreased concentration, coma
• Profound muscle weakness
• Gastrointestinal nausea, vomiting, abdominal
  pain, constipation, increased gastric secretions,
  acute pancreatitis
• Pruritis
• Visual disturbances
• Cardiac arrythmias

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HypercalcemiaInvestigation

• Serum Calcium
• Serum Albumin

CaCORR CaMEAS (0.02 x albNORM albMEAS)
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HypercalcemiaInvestigation Example Calculation

• Serum Calcium 2.48 mmol/L (N 2.2-2.6)
• Serum Albumin 17 g/L (N 35-45)

CaCORR CaMEAS 0.02 x (albNORM albMEAS)
2.48 0.02 x (40-17) 2.48
0.46 2.94
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Hypercalcemia

• Calcium levels
• Normal 2.2 2.6
• Mild 2.7 2.9
• Moderate 3.0 3.2
• Severe 3.3 3.7
• Life-threatening gt 3.7

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HypercalcemiaEKG findings

• Shortened QT interval (Ca gt 3.2)
• Prolonged PR and QRS intervals
• Increased QRS voltage
• T-wave flattening and widening
• Notching of QRS
• AV block, progressing to complete heart block and
  cardiac arrest (Ca gt 3.7)

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HypercalcemiaTreatment

• Consider the goals
• Hydration and saline diuresis
• Bisphosphonates
• Steroids

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Superior Vena Cava Syndrome

• The clinical manifestation of superior vena cava
  (SVC) obstruction, with severe reduction in
  venous return from the head, neck and upper
  extremities

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Superior Vena Cava SyndromeIncidence and Etiology

• Usually associated with malignancies
• Often the initial presentation of cancer
• Bronchogenic carcinoma (80)
• Lymphoma (15)
• Metastatic disease (5)

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Superior Vena Cava SyndromePresentation

• Symptoms
• Dyspnea 63
• Facial and neck swelling 50
• Fullness in head 50
• Cough 24
• Arm swelling 18
• Chest pain 15
• Dysphagia 9

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Superior Vena Cava SyndromePresentation

• Signs
• Venous distention of neck 66
• Venous distention of chest wall 54
• Facial edema 46
• Cyanosis 20
• Edema of the arms 14
• Plethora of the face 10
• Vocal cord paralysis 3
• Horners syndrome 3

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Superior Vena Cava SyndromeManagement

• Does not usually imply immediate threat to life,
  except when trachea or pericardium is compromised
• Important is to establish a diagnosis
• Emergency treatment indicated if
• Compromised airway
• Decreased cardiac output
• Cerebral dysfunction

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Superior Vena Cava SyndromeManagement

• Chemotherapy SCLC, NHL
• Radiation - NSCLC
• Bed rest with head elevated
• Oxygen
• Diuretics
• Steroids

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Severe hemorrhageEtiology

• Epistaxis
• GI bleeding
• Hematemesis,Hematochezia,Melena
• Hemoptysis
• Hematuria
• Internal Bleeding
• Bleeding from fungating tumours
• Hemolysis

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Severe hemorrhageImportant General Questions

• Is treatment of the underlying condition possible
  in the context of the bleeding?
• Is it possible to keep up with the loss of blood,
  and for how long?
• These may need to be addressed early, with the
  patient, family and caregivers.

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GI BleedingIncidence and Etiology

• 80 of GI bleeding in cancer patients is from
  benign sources good prognosis
• Massive hemorrhage is unusual
• ESOPHAGUS
• STOMACH
• SMALL INTESTINE
• COLORECTUM

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GI BleedingManagement

• Consider gastroscopy / colonoscopy / surgery if
  life expectancy reasonable.
• Avoid surgery if life expectancy lt 2 months
• Stop potentially offending agents e.g. NSAIDs
• Consider IV fluids, PPI

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GI BleedingManagement

• Massive Bleeding in the Terminal Phase
• Keep patient warm
• Consider sedation
• Green towels

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HemoptysisIncidence and Etiology

• Present in 30-50 of primary lung neoplasms at
  the time of presentation
• 10 of patients admitted to hospice
• Massive hemoptysis uncommon
• Pulmonary embolism
• Bronchial bleeding due to tumour erosion
• Epistaxis

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Massive HemoptysisManagement

• Trendelenburg position
• Consider sedation
• Green towels

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Wound BleedingIncidence and Etiology

• Bleeding is a common problem with malignant
  wounds
• May involve oozing from microvascular
  fragmentation to frank bleeding if vessels are
  involved

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Wound BleedingManagement

• For patients with malignant wounds, it will not
  be possible to heal the wound, unless one can
  treat the underlying cancer.
• Avoid adherent dressings.
• Keep the wound moist.
• Direct pressure, if actively bleeding
• Medicated dressing possibilities
• Topical thromboplastin
• Topical aminocaproic acid
• Topical dilute silver nitrate solutions

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Wound BleedingManagement

• If bleeding is possible, discuss this with the
  patient and family and staff
• If bleeding is catastrophic, dark towels may
  reduce anxiety of all involved
• If the patient is distressed, consider sedation

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Severe HemorrhageSystemic Interventions

• D/C antiplatelet and anti-thrombotic agents
• Vitamin K
• Transfusion of blood or platelets
• Antifibrinolytic Medication
• Tranexamic acid
• Aminocaproic acid
• Desmopressin
• Octreotide (somatostatin analog)

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Severe Hemorrhage - Management

• Antifibrinolytic Agents
• Prevent clot lysis by blocking the binding sites
  of plasmin and its activators
• Tranexamic Acid (1.5 g, then 1 g tid PO)
• Aminocaproic Acid (5 g, then 1 g qid PO)
• May be effective topically
• Main s/e dose-related nausea, vomiting, diarrhea
• Avoid in upper urinary tract bleeding
• May not be helpful in thrombocytopenic bleeding

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Severe Hemorrhage - Management

• Desmopressin (DDAVP)
• An analog of the posterior pituitary hormone
  vasopressin
• Extensively used in Type 1 von Willebrand Disease
• 0.3-0.4 mcg/kg IV over 20 minutes OR 150-300 mcg
  nasal inhalation
• Has been used successfully in acquired defects of
  platelet function e.g. uremia, cirrhosis, ASA
  and in variceal bleeding
• Avoid excessive fluid administration

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Severe Hemorrhage - Management

• Octreotide (Somatostatin analog)
• 100-600 mcg/day given in 2 or 3 doses
• Alters the physiological response to bleeding
• Results in decreased splanchnic bloodflow,
  reduced venous pressures, cytoprotection,
  suppression of gastric acid secretion

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Severe HemorrhageManagement

• Remember the goals of care
• Keep patient, family, staff informed of progress
  and prognosis

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Respiratory DistressIncidence

• Prevalence of Dyspnea is variably reported
  (21-79)
• Assessment of dyspnea has not been consistent
• Progressive dyspnea is much more common than
  acute onset dyspnea

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Respiratory DistressEtiology

• Progressive Hypoxia
• Progressive Hypercapnia
• Pneumonia
• Pulmonary Embolism
• Obstruction

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Respiratory DistressManagement

• General Measures
• Position of comfort
• Reassurance / Relaxation techniques
• Well-ventilated area / open windows/ use fans
• Medications
• Opioids PO/SC/IV depending on urgency and
  access
• Oxygen
• Salbutamol
• Benzodiazepines
• Clorpromazine
• Steroids

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Management of Sudden Progressive Respiratory
Distress / Respiratory Panic

• Someone MUST remain with the patient
• Aggressive Opioid management, similar to managing
  Pain Crisis
• Expect RR to decrease and the patient to become
  more comfortable
• Explanation
• Consider sedation

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SeizuresIncidence

• 1 of patients with advanced cancer
• Higher incidence in children with underlying
  progressive neurological disorders

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SeizuresEtiology

• Most common
• Primary or metastatic brain tumours
• CVA / Stroke
• Pre-existing seizure disorder
• Less common
• Hypoxemia
• Metabolic uremia, hypoglycemia, hyponatremia
• Sepsis
• Drug or alcohol withdrawal

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SeizuresManagement

• Educate / Seizures are frightening, especially to
  family
• Concerns
• Will he swallow his tongue?
• Will she choke to death during a seizure
• Will the seizure cause brain damage?
• Will the seizure cause death?

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SeizuresEducation

• What to do if a seizure happens
• Help avoid harm / trauma
• Do not restrain
• Do not attempt to insert anything orally
• Recovery position after the seizure
• Expect drowsiness for a while after
• Call for help if seizure lasts more than 5
  minutes (it will feel like 30)

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SeizuresManagement

• Investigate as appropriate, based on patients
  status and course
• Generally felt unnecessary to give routine
  prophylaxis for seizures
• Grand Mal Seizures Phenytoin is first drug of
  choice
• Focal Seizures Carbamazepine is first drug of
  choice
• Other anticonvulsants may be needed

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Status epilepticusDefinition

• Continuous seizure activity for gt 30 minutes
• Two or more seizures, one after the other,
  without recovery of consciousness in between

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Status epilepticusManagement

• Protect airway
• Administer Oxygen
• Consider IV

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Status epilepticusMedications

• IV available
• Lorazepam 2-4 mg over 2-4 minutes
• Phenytoin load 20 mg/kg at 25 mg/min
• May need to go as high as 30 mg/kg
• Phenobarb 20 mg/kg at 100 mg/min
• IV unavailable
• Diazepam 10 mg solution PR
• May be repeated q10minutes
• Midazolam SC infusion 1-3 mg / hour
• Consider steroids

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Multifocal Myoclonus

• Jerking, involuntary movements of arms and legs
• May start as subtle movements, and then become
  bothersome and disturbing

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Multifocal MyoclonusIncidence

• Difficult to determine, especially with various
  etiologies
• Seems a common problem

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Multifocal MyoclonusEtiology

• Very often associated with delirium and related
  to opioid toxicity
• May be a pre-terminal event
• Important to consider the differences

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Opioid Neurotoxicity

• Cognitive Dysfunction
• Myoclonus
• Hyperalgesia
• Allodynia
• Perceptual Disturbance
• Seizures

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Delirium in advanced cancer

• Reversible in 40-60 of cases
• Pereira J, et al. Cancer 1996
• Lawlor P, Gagnon B, Mancini I,Pereira J,et al.
  Arch Intern Med 2000

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Multifocal MyoclonusManagement

• Stop the current opioid and rotate to a different
  one at 50-75 of the equivalent dose.
• Allow for adequate breakthrough doses
• Consider careful hydration
• Expect resistance from family / staff
• Interpreting the myoclonus and associated
  symptoms / signs as pain, and increasing the
  original opioid will eventually result in more
  myoclonus and delirium

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Intractable Symptoms

• Defining intractable
• Difficult to manage
• Resistant to treatment
• Difficult to alleviate
• Difficult to control
• A condition that does not respond to medical
  management

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Sedation at the End of Life

• Very common
• Expected
• Educate family !

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Sedation at the End of Life

• End of life sedation
• Palliative sedation
• Terminal sedation
• Sedation for intractable symptoms

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Sedation (noun) at the End of Life

• Very common
• Expected
• Educate family !

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Sedation (verb) at the End of Life

• End of life sedation
• Palliative sedation
• Terminal sedation
• Sedation for intractable symptoms

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Sedation at the End of Life when symptoms are
intractable

• Issues
• Are symptoms really intractable?
• Have others been formally consulted?
• Have details been documented?
• Are we on a slippery slope?

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Sedation at the End of Life Medications

• Usually a combination of
• Haloperidol or Methotrimeprazine
• /- Lorazepam or Midazolam

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Is it time to sedate someone who is imminently
dying?

• Then its also time to get a consult !

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Summary

• Emergencies happen, even in dying individuals.
• Emergencies may be treated differently in the
  palliative population, with much more of an
  emphasis on symptom management than on attempts
  at reversing the disease process.
• Communication with the patient and family is
  extremely important for dealing with emergencies.

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To cure sometimes,to relieve often, to comfort
always.Hippocrates
C. Woelk MD