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Palliative Care

• Dr David Plume MBBS DRCOG MRCGP
• Macmillan GPF, GP Advisor and Primary Care
  Network Lead.

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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

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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?

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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 lt or gt 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

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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.

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Symptom Control

• Nausea and Vomiting.
• Breathlessness.
• Setting up a syringe driver.

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Nausea and Vomiting
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DEFINITIONS

• 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.
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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/regurgi
  tation
• Psychological assessment

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PATTERN

• 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

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EXAMINATION

• 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

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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

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MANAGING NAUSEA VOMITINGANTI-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

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MANAGING NAUSEA VOMITINGANTI-EMETICS

• Dexamethasone
• ? Reduces permeability of BBB to emetogenic
  substances
• Benzodiazepines
• Amnesic, anxiolytic sedative
• Cannabinoids
• AIDS / chemotherapy
• Brainstem cannabinoid receptor
• Octreotide
• Anti-secretory properties

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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.

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CAUSE First-line Anti-emetic Stat Dose 24 Hr Range Second-line Anti-emetic Stat dose 24 Hr Range Third-line Anti-emetic other treatments
Gastric stasis /Outlet obstruction Metoclopramide Or Domperidone 10-20mg po/im/iv 30-60mg po/sc/iv Cyclizine (substitute) 50mg po/sc 150mg Po/sc Consider Dexamethasone (2-8mg / 24hr sc/iv/po) Consider Asilone (defoaming agent)
Gastric irritation Lansoprazole Or Omeprazole 30mg po 30-60mg po Metoclopramide 10-20mg sc/iv 30-60mg Sc/iv Consider Levomepromazine or Ondansetron
Bowel obstruction without colic Metoclopramide 10-20mg sc/iv 30-60mg sc/iv Cyclizine or (substitute) Haloperiodol 50mg sc 1.5 2.5mg sc 150mg sc 5-10mg sc Consider Buscopan for colic (60-120mg / 24hr sc) Consider Dexamethasone to reduce GI oedema (8-16mg / 24hr sc/iv) Consider Levomepromazine as 3rd line antiemetic (6.25-25mg/24hr sc) Consider Octreotide for large volume vomiting (300-100mcg/24hr)
Bowel obstruction with colic Cyclizine Or Haloperidol 50mg sc 5-10mg sc 150mg sc 5-10mg sc Haloperidol or (add) Cyclizine 1.5 2.5 sc 50mg sc 5-10mg sc 150mg sc Consider Buscopan for colic (60-120mg / 24hr sc) Consider Dexamethasone to reduce GI oedema (8-16mg / 24hr sc/iv) Consider Levomepromazine as 3rd line antiemetic (6.25-25mg/24hr sc) Consider Octreotide for large volume vomiting (300-100mcg/24hr)
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CAUSE First-line Anti-emetic Stat Dose 24 Hr Range Second-line Anti-emetic Stat dose 24 Hr Range Third-line Anti-emetic other treatments
Chemical / Metabolic Drugs eg Morphine, Uraemia Hypercal-caemia Haloperidol 1.5-2.5mg sc/po 1.5-10mg po/sc Cyclizine (add) 50mg Sc 150mg Sc Consider Levomepromazine (6.25-25mg/24hr sc) Ondansetron (8-16mg/24hr po/iv/sc) may help sickness due to uraemia
Raised intracranial pressure Cyclizine and Dexamethasone 50mg sc 8-16mg po/sc/iv 150mg Sc 8-16mg po/sc/iv Consider Levomepromazine (6.25-25mg / 24hr sc)
Motion sickness Cyclizine 50mg sc/po 150mg sc/po Consider Levomepromazine (6.25-25mg / 24hr sc) Consider Prochlorperazine (25mg pr or 3.6mg buccal)
Cause unknown Cyclizine And / or Haloperidol 50mg po/sc 1.5-2.5mg 150mg Po/sc 1.5-10mg Po/Sc Metoclopramide (substitute) 10 20mg Po/im/iv 30-60mg po/sc/iv Consider Levomepromazine (6.2525mg / 245hr sc) Consider Prochlorperazine (25mg pr or 3-6mg buccal) Consider Dexamethasone 2-8mg/24hrs Consider Benzodiazepine
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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 gt 3 days.
• - Continue indefinitely unless the cause is
  self-limiting.

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Breathlessness
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Dyspnoea

• Unpleasant awareness of difficulty in breathing
• Pathological when ADLs affected and associated
  with disabling anxiety
• Resulting in physiological behavioural
  responses

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Dyspnoea

• Breathlessness experienced by 70 cancer patients
  in last few weeks of life
• Severe breathlessness affects 25 cancer patients
  in last week of life

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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

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Causes of Breathlessness-Treatment

• Pneumonectomy
• Radiation induced fibrosis
• Chemotherapy induced
• Pneumonitis
• Fibrositis
• Cardiomyopathy
• Progestogens
• Stimulates ventilation
• Increased sensitivity to carbon dioxide.

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Causes of Breathlessness- Debility

• Atelectasis
• Anaemia
• PE
• Pneumonia
• Empyema
• Muscle weakness

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Causes of Breathlessness-Concurrent

• COPD
• Asthma
• HF
• Acidosis
• Fever
• Pneumothorax
• Panic disorder, anxiety, depression

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Reversible causes of breathlessness!

• Resp. Infection
• COPD/Asthma
• Hypoxia
• Obstructed Bronchus/SVC
• Lymphangitis Carcinomatosa
• Pleural Effusion
• Ascites
• Pericardial Effusion
• Anaemia
• Cardiac Failure
• PE

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Breathlessness Cycle
PANIC
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Independent predictor of survival
weeks
days
months
Symptomatic drug treatment
Non-drug treatment
Correct the correctable
Breathless on exertion
Breathless at rest
Terminal breathlessness
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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.

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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.

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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

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Maximize function

• Encourage exertion to breathlessness to improve
  tolerance/desensitise to breathlessness
• Evaluation by physios/OTs/SW to target support
  to need.

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Reduce feelings of isolation

• Meet others in similar situation
• Day centre
• Respite admissions

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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.

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Drug Treatment
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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.
• Opioids reduce 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 gt
  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

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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

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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.

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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

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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

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Setting up a syringe driver

• www.syringedriver.co.uk
• YouTube

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Current Initiatives

• EOL Drug Charts
• At piloting stage
• Aim to clarify and simplify prescribing at the
  EOL
• DNACPR
• 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

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Q and A

• I am not a palliative care physician and you have
  an excellent resource in Gail!
• Happy to answer questions.