End of Life Care
Dr Anant Sachdev
GPSI Palliative Medicine
07976 608871
anant.sachdev@nhs.net
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

Symptoms
Pain
• Malaise, Fatigue & Cachexia
• GI: Poor appetite, nausea
• Weight loss
• Bleeding
• Incontinence
• Delirium
• Spinal Cord Compression
• Hypercalcaemia
•
Malignant spinal cord
compression
 First
contact is usually
primary health care team!
Common
 Significant impact on QOL and survival
 Requires rapid decision making

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 (510%)
 Colorectal, ACUP and sarcomas
Pathophysiology
Vertebral body mass – anterior
compression
 Vertebral body collapse
 Direct tumour growth through vertebral
neural foramen (lymphoma)
 Metastases in epidural space (rare)

Clinical features
Localisation
60-80% thoracic spine
 15-30% lumbosacral
 <10% cervical
 50% have more than 1 level

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
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.
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
Spinal Cord Compression
Treatment

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

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); Reirradiation; supportive and palliative care

Spinal Cord Compression
Prognosis

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




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
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
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

Definition?
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
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
Hypercalcaemia
 Cause
/ risk factors:
◦ Bone metastases
◦ PTHrP – secreting tumours e.g. Lung
Cancer
◦ Dehydration, renal impairment
◦ Tamoxifen flare
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.)
Recognising Hypercalcaemia
General
• Dehydration
• Polydipsia
• Polyuria
• Pruritis
Neurological
• Fatigue
• Myopathy
• Psychosis
• Confusion
• Seizures
• Coma
Cardiac
GI
• Anorexia
• Weight loss
• Nausea and vomiting
• Constipation / ileus
• Bradycardia
• Atrial arrhythmias
• Ventricular arrhythmias
• Cardiac asystole
• Death
Prognosis

Indicates disseminated Disease

Poor prognosis 80% die within 1 year

Median survival is 3 to 4 months

Hypercalcaemia likely to recur
Hypercalcaemia
Treatment may not be necessary if:
the patient is very near to death
or
 there are no symptoms distressing
the patient

Treatments of Hypercalcaemia
All treatments involve the correction of
serum calcium levels, which results in a
marked decrease in symptoms



Rehydration
Bisphosphonates
Steroids
Treatments of Hypercalcaemia
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

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

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
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

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
Thank you
any Q
Dr Anant Sachdev
07976 608871
anant.sachdev@nhs.net