Emergencies in palliative care

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Emergencies in palliative care

• Dr Pete Nightingale
• FRCGP,DCH,DTMH,DRCOG,Cert Med Ed,Cert Pal Care.
• Macmillan GP

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Last hours of living

• everyone will die
• lt 10 suddenly
• gt 90 prolonged illness
• last opportunity for life closure
• little experience with death with reduced number
  of home deaths. This has led to some exaggerated
  sense of dying process

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Two roads to death
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Preparing for the last hours of life

• caregivers
• awareness of patient choices
• knowledgeable, skilled, confident
• rapid response
• likely events, signs, symptoms of the dying
  process

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Situations to be considered

• Delirium at the end of life
• Sudden unexpected deterioration diagnoses to
  consider
• Haemorrhage
• Spinal cord compression
• Pathological fracture
• Upper airway or SVC obstruction
• Hypercalcaemia

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Case 1

• 56 yr old teacher with Ca breast but no known
  metastases
• Relatives call, patient unexpectedly more unwell,
  thirsty and constipated.
• What diagnostic ideas would you consider?

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Which do you feel is most likely?

• A Renal Failure
• B Dose of opioid too high
• C Hypercalcaemia
• D Diabetes

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Hypercalcaemia suspect with

• Ca breast, prostate, lung, myeloma
• With OR without bone metastases
• (especially if previous episodes of
  hypercalcaemia)
• Nausea and vomiting
• Dry, polydipsia, polyuria

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Hypercalcaemia (2)

• Constipation
• Tiredness and lethargy
• Muscle weakness
• Confusion
• Coma
• generally unwell

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Hypercalcaemia (3)

• ADMIT IF ILL
• Measure serum calcium
• Rehydrate
• I/V bisphosphonate (pamidronate or zoledronic
  acid)

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Case 2

• John is 56 yrs old. He has Ca Lung. His wife
  phones on Monday morning
• 6 week story of backache since gardening
• Settled with diclofenac, but this caused nausea
  and vomiting
• Stopped diclofenac on Friday
• Woke up with severe pain in back, thigh
• Cant get out of bed
• Still being sick

• What diagnoses are you considering?
• What key questions will you ask to make a more
  accurate clinical assessment?
• What action will you take?

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What do you think is most appropriate action?

• A Arrange an urgent visit
• B Alter analgesia and assess during the week
• C Discuss blood tests with PHCT
• D Phone an ambulance and arrange admission

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Spinal cord compression in cancer
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Spinal cord compression

• 1-2 of all cancer
• Ca breast, prostate, lung with bone mets
  (myeloma)
• Back pain (especially thoracic)
• Radiating pain in nerve root distribution
• Numbness, sensory change, motor weakness.
• Loss of bladder and bowel sensation

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Spinal cord compression-typical history
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KEY MESSAGE

• Ask about symptoms in high risk groups (? Give
  high risk patients information)

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Why does it matter?

• 30 of patients will survive at least a year.
  Although rare, it is devastating if diagnosed too
  late as irreversible paraplegia ensues.
• 70 of patients walking at the time of diagnosis
  retain their mobility.
• less than 5 of patients with paraplegia at the
  time of diagnosis regain any mobility.
• Only 21 of patients catheterised before
  treatment regain sphincter control

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KEY MESSAGE

• Diagnosis, referral and treatment in less than
  24h improves outcome.

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First presentation is to
General practitioner 205 (68)
Hospice 4 (1)
DGH 64 (21)
Oncology treatment centre 28 (9)

• During referral process
• 214 (78) seen by GP
• 235 (78) seen by DGH
• at some stage
• First presentation to oncology centre reduced
  delay and improved neurological outcome
  D. J Husband BMJ (1998) 317 18-21

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KEY MESSAGE

• In the presence of symptoms/signs, discuss
  with/refer to oncology early (within 24h)

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Spinal cord compression

• Suspect
• Ask for symptoms of radicular pain, sensory
  change, weakness
• Check power, reflexes, sensory level
• If symptoms/signs
• Give dexamethasone 12-16mg immediately
• Discuss with oncologist ASAP (w/i 24h)

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Case 3

• Friday night, 68 yr old man with myeloma, was
  going to toilet and suddenly pain and swelling
  ocurred in L leg
• Unable to weight bear

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Which is most likely?

• A DVT
• B Haemorrhage into the leg
• C Pathological Fracture
• D Hypercalcaemia

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Pathological fracture

• Ca breast, prostate, myeloma
• Lytic (destructive) metastases
• Weight bearing bones
• one-third cortex lost
• Limb pain ? with weight bearing

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Pathological fracture

• Little/no trauma
• Sudden and severe pain
• ? with smallest movement
• Limb deformity
• Local swelling/bruising/tenderness

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Case 4

• 45 year old lady with Ca Lung, suddenly more
  breathless and has developed a headache
  overnight.
• She is known to the hospice, what diagnosis may
  be possible and what management options would you
  consider?

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Which is most likely?

• A Anxiety
• B Pleural Effusion
• C SVC obstruction
• D Infection

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SVC Obstruction

• Ca lung
• Especially small cell or mediastinal disease
• Central lines (thrombosis)
• Breathlessness, cough
• Swelling face upper body
• Headache
• Venous distension oedema upper body
• Cyanosis or plethora upper body

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Treatment of SVCO

• I/V dexamethasone 12mg
• (thrombolysis/LMWH)
• Radiotherapy
• stents

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Case 5

• A 60yr old man with Ca Prostate has suddenly
  become confused and agitated at home over Easter
  weekend. Unfortunately he has not been put on the
  Liverpool Care Pathway even though his death
  seems imminent. No drugs have been left in the
  home.
• How would you assess and manage this situation-he
  wishes to end his life at home

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Terminal Restlessness and Agitation

• As death approaches
• affects between 40-80 of patients
• motor restlessness,
• fear, anxiety,
• mental confusion with/without hallucinations
• or a combination of these symptoms.

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Terminal Restlessness and Agitation

• Check for basic comfort-smooth bedclothes, not
  too tightly tucked in, excessive heat/cold
• Exclude a full bladder or rectum
• Is the patient in pain?
• Is there a need to have a family member visit or
  reconciliation/forgiveness/permission to move
  on? Even if the patient appears unconscious they
  may respond to words spoken by a significant
  person to them

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Terminal Restlessness and Agitation 2

• Sedation may be necessary. Always explain what
  you are offering to the patient if possible and
  to the family We can make you more comfortable
  and less afraid, but this may mean you are more
  sleepy. Is that OK?
• Haloperidol 5-10mg/24hrs SC will usually settle
  confusion/hallucinations (occasionally higher
  doses are necessary)
• Midazolam 10-30mg/24hrs SC will usually provide
  relief of motor restlessness, fear and useful
  sedation. (occasionally higher doses are
  necessary)

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Acutely disturbed or aggressive patients

• If young consider 5mg haloperidol sc/im with
  possible lorazepam 1-2mg sc/im
• If elderly halve these doses but possibly repeat
  after 30minutes

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Case 6

• A 55 yr old man with a glioblastoma has suddenly
  deteriorated at home.
• How would you assess and manage this?

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Sudden, unexpected deterioration

• KEY DECISION
• is this reversible?
• or is the patient dying?

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Sudden, unexpected deterioration 2

• KEY QUESTIONS
• Does the underlying diagnosis suggest short
  prognosis?
• Is there a history of decline in function with no
  other explanation?
• Is there progressive loss of ability to eat,
  drink, talk?

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Is this a reversible situation?

• Have I excluded correctable causes?
• Reversible renal failure (pelvic tumours
  obstructing ureters, vomiting causing
  dehydration)
• high calcium
• spinal cord compression,
• Dehydration (poor intake, vomiting, diarrhoea,
  diuretics)
• Haemorrhage (especially NSAIDS/steroids)
• hypo or hyperglycaemia,
• severe anaemia,
• medication error,
• infection

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Recognising dying

• The multidisciplinary team agrees the patient is
  dying
• Intervention for correctable causes is not
  possible or not appropriate
• 2 or more of the following apply-
• the patient is-
• Bedbound
• Only able to take sips
• Semicomatose
• Unable to take medication orally

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Case 7

• A 65 year old lady with a squamous cell tumour in
  the nasal cavity develops severe bleeding at 7am
  one Monday. She is expected to die and expressed
  her preferred place of care as being home.
• How would you deal with this?

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Catastrophic haemorrhage

• WHO IS AT RISK?
• Head and neck cancer
• Haematological malignancies
• Any cancer around a major artery
• Bone marrow failure where platelets ? 15
• Disseminated intravascular coagulation

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Managing risk of catastrophic haemorrhage

• ROBUST MDT assessment of risk level and
  management plan
• STOP therapy predisposing to haemorrhage
  (aspirin, warfarin etc.)
• PRO-ACTIVE CARE
• Crisis box
• Crisis medication?
• Crisis cleanup

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Crisis haemorrhageif it happens

• ORDER OF PRIORITIES
• Appear calm
• Stay with the patient
• Stem/disguise blood loss as much as possible
• Summon assistance
• Consider crisis medication (if easy/available/not
  detracting from overall care)
• Ensure aftercare

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Our management options are determined by clinical
context

• Patients general condition
• Disease and prognosis
• Patients and families wishes
• Burden of treatment
• Distress of symptoms

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To summarise

• Time is short for these patients
• Always step back and look at the bigger picture
• Keep comfort and patient/family wishes foremost
• Dont let the burden exceed the benefit
• For ca breast, prostate, lung and myeloma,
  remember SCC, hypercalcaemia and pathological
  fractures