Bradford & Airedale Palliative Care
Managed Clinical Network
End of Life / Palliative Care
Education Programme
Managing Common
Symptoms in Palliative
Care
Learning Outcomes
• At the end of the session, the participant will
have increased knowledge of the End of Life
Care Strategy Core Competencies, including:
–
–
–
–
Symptom management
Maintaining comfort and wellbeing
Assessment
Care planning
Aim
• To identify common symptoms
experienced by patients requiring palliative
care
• To understand the principles of symptom
assessment and management
Welcome
• 2 days of education based on the
Department of Health end of life
competences to support the End of Life
Care Strategy (2008)
• Day 1: Symptom assessment, care
planning and symptom management;
• Day 2: Communication skills and
Advance Care Planning.
Ground rules
•
•
•
•
•
•
Confidentiality
Participation
Respect for others’ opinions
Permission to take time out
Mobile phones on silent
Anything else? …
Mentorship
• Portfolios of competencies are available
• Mentorship may be available from Specialist
Palliative Care Team
• Contact your local Palliative Care Team
• Module can be undertaken “Reflections on
learning from study days” at University of
Bradford (20 credits at any level)
What is Palliative
Care?
What is palliative care? Which descriptions
are closest to reality
The right of every patient?
True or false
Terminal care?
True or false
Cancer care?
True or false
What is palliative care? Which descriptions
are closest to reality
Physician assisted suicide?
True or false
Symptom control?
True or false
Duty of every professional
True or false
What is palliative care? Which descriptions
are closest to reality
Hospice care?
True or false
Care at home?
True or false
Care of advanced progressive disease?
True or false
Palliative Care / End of Life Care
Approach
•
Is Patient-centred, holistic and quality of life is main focus
- ‘whole person’ approach
- encompasses both the patient and those that matter to
them
- includes good symptom control
- Respect for patient autonomy and choice
- emphasis on open and sensitive communication for all
Should be regarded as a central feature in all good clinical practice
• Whatever the life-threatening illness and its stage.
• Wherever the patient is receiving care
•
NCHSPCS 2002
Advance Care Planning is an integral part of end of life care
Palliative Care / End of Life Care
Approach
The End of Life Strategy promotes the use of tools /
frameworks to support and improve care, such as:
• Gold Standards Framework (GSF)
• Liverpool Integrated Care Pathway for Dying
(LCP)
• Preferred Priorities of Care (PPC)
For further information:
www.goldstandardsframework.nhs.uk
www.mcpcil.org.uk
Specialist Palliative Care
•
Is provided by multi-professional team in services
and units with palliative care as their core speciality
•
Underpinned by same principles as general palliative
care
•
Provided for patients and families with moderate to
high complexity of palliative care need
(NCHSPCS 2002)
When should a Service refer to
Specialist Palliative Care?
“When they lack the skills, confidence or expertise to cope
adequately with a problem…”
• Uncontrolled/complicated symptoms
• Uncontrolled anxiety or depression
• Complex emotional needs involving children, family or carers
• Complex issues relating to physical and human environment (i.e
home, finances etc)
• Unresolved spiritual issues around self worth, loss of meaning and
hope (may include euthanasia issues)
Specialist Palliative Care
Provision
Who wants to be a
millionaire?
Symptom Management
“Some symptoms are difficult to manage, but for
the majority of patients a big difference can be
made with low tech, simple interventions
requiring really quite a small amount of
knowledge…..the key to achieving best
symptom management is the application of
principles and rules that underpin our care and
incorporate factual knowledge and technical
and communication skills’’
(Faull and Woof 2002)
Principles of Symptom Management
• THINK – what is causing this?
• UNDERSTAND – how does it cause
that?
• KNOW – what is the best treatment
for this cause?
Principles of Symptom Management
• Management of a problem should always
begin with sensitive explanation and
exploration of what that problem means to
the patient.
• Individualised Treatment
• Re-evaluation and Supervision
Multiprofessional Symptom Management
(Faull and Woof 2002)
ASSESS
PHYSICAL
EVALUATE
SOCIAL
SYMPTOM
PSYCHOLOGICAL
SPIRITUAL
MANAGE
PLAN
How to assess a symptom
ASK:
– Features (severity, timing, location)
– What makes it better?
– What makes it worse?
– Triggers?
– Associated symptoms?
– Drug history?
– Impact on activities of living and quality of
life?
What might be a barrier to
effective symptom management
from the viewpoint of -
…the patient?
…staff?
Barriers to effective symptom
management
Patients viewpoint:
 Staff perceived to be too busy
 Staff perceived to be
concerned with physical
aspects only
 Don’t want to be a burden
 Unwilling to “complain”
 Trivialise worries
 Fear of admission of inability to
cope
 Inarticulate
 Anxiety about having fears
confirmed
Barriers to effective symptom
management
Staff viewpoint:
 Fear of upsetting patient
 Causing more harm than good
 Fear of difficult questions
 Saying the wrong thing / getting into trouble
 Too busy
 Cannot handle emotions
 Not knowing answers
 Not their job
 Cant do anything for them!!
Maguire (1985)
Case study
• Mick Crabtree, 68 year old retired forklift
truck driver. Lives in a terraced house
with his wife, Beth, and his energetic
Bernese mountain dog, Harry
• Lifelong smoker but stopped last year
• Recently diagnosed with small cell lung
cancer and liver metastases
• Prognosis has not been discussed.
• Complaining of a persistent cough, and
shortness of breath on exertion
• Undergoing palliative chemotherapy
Case study
•During treatment, he had a poor appetite and Beth
was worried that he wasn’t eating enough
•Occasional nausea & vomiting
•He was frustrated at not being able to get out and
about as much as he could, and was feeling guilty
that he could not help Beth around the house
•Ongoing problems with pain since diagnosis and is
prescribed co-codamol 30/500 by GP
•He continues to complain of pain in his left
shoulder and abdomen
•A recent CT scan reported a metastasis in his left
third rib.
Case study
– What are the main issues?
Write a care plan for the three main issues
in the case study
Group 1: Breathlessness
Group 2: Nausea and Vomiting
Group 3: Pain
Coffee
Case Study
Feedback from Group 1….
Breathlessness
Breathlessness
Breathlessness in advanced cancer can be divided
into 3 categories:
• Breathlessness on exertion (prognosis =
months - years)
• Breathlessness at rest (weeks - months)
• Terminal breathlessness (days - weeks)
Causes of breathlessness
Sudden onset
Arisen over Several
days
Gradual Onset
Asthma
Exacerbation COPD
Congestive cardiac failure
Pulmonary oedema
Pneumonia
anaemia
Pneumonia
Bronchial obstruction by
tumour
pleural effusion
Pulmonary embolism
Superior vena cava
obstruction
primary/secondary lung
carcinoma
Ascites
Consider triggers e.g. physical activity, extremes of heat or cold &
emotional states such as anxiety, laughter or crying
Non-pharmacological management
Treat reversible causes e.g. anaemia, PE or infection
– Reassurance
– Modify lifestyle
– Relaxation
– Physiotherapist
– Hand / table fan
– Good mouth care
– Diversion
– well ventilated room
– Loose clothing
– Electric recliner chair
– Using pursed lips to
breathe out
– Leaning forward
– Adaptations and aids
Pharmacological Management
• Opioids
– Oral morphine (normal release) 2.5mg (if Opioid
naive/elderly)
– Gradual titration upwards according to response
• Benzodiazepines
– Lorazepam 0.5-1mg sublingual (SL) - rapid relief during
panic attacks
– Diazepam (oral) for longer term management
– Midazolam 2.5mg subcutaneous if oral/SL intolerable
Above medication are respiratory sedatives, therefore should be
monitored carefully. However in the terminal stages of illness the
benefits usually out-weigh the risks.
Pharmacological Management
• Oxygen therapy only where
appropriate (mixed evidence, check
sats, liaise with MDT)
• Steroids
• Bronchodilators
• Antibiotics
• Blood transfusion
Breathlessness…
How does it feel?
Key Messages
BREATHLESSNESS
• Both pharmacological and non-pharmacological
management are important but the relative contribution
of these approaches varies according to prognosis.
• Dyspnoea is a subjective symptom – it is the perception
of breathlessness and is not objectively measurable,
unlike breathlessness which can be observed.
• Drug treatments predominate in the terminal phase
Psychological Management of
Breathlessness
Clinical Psychologist
Aims for Today
• Experiential exercise
• Emotional impact of breathlessness
• Overview of psychological interventions
Vicious Circle
• E.g. wake up coughing…
I feel awful, this must
be serious
I cant get my breath
Fear of dying
Chest tightens, breathing
quickens, palpitations, sweaty,
dizzy
Role of psychology
•
•
•
•
•
•
Very detailed assessment of the problem
Formulation
Whole person approach
Space to explore the problem more
Psycho-education, self help materials
Work with individual, family, carers etc
Possible Interventions
• Anxiety management (e.g. gentle relaxation exercises,
diaphragmatic breathing, exposure to feared situations)
• Working with low mood (e.g. activity scheduling and
pacing, diaries, lethargy cycle)
• Exploring beliefs (illness beliefs, perceptions of control,
challenging unhelpful beliefs, finding alternative ways of thinking,
behaviour experiments)
• Sleep
• Adjustment and loss
• Health Behaviour Change
Or importantly…
• Listening, containing, and not trying to fix it
Questions, and a final exercise
Case study
…Feedback from Group 2
Nausea and Vomiting
Causes of Nausea and Vomiting
•
•
•
•
•
•
•
Gastrointestinal - Stasis; obstruction
Metabolic - Renal failure; hypercalcaemia
Drugs - Opioids; antibiotics etc…
Toxic - Chemotherapy; infection
Brain metastases - Raised ICP
Psychosomatic - Anxiety; fear
Pain
Non-pharmacological Management
• Calm environment, away from sight/ smell of
food
• Snacks and small palatable meals
• Consider complementary therapies (sea bands,
aromatherapy)
• Refer to dietitian
• Psychological input for anxiety-related eg CBT
for anticipatory nausea
Emetic pathways
Pharmacological management
• Gastric stasis
metoclopramide
• Metabolic/ chemical
haloperidol
• Increased ICP
cyclizine, steroids
• Bowel obstruction
metoclopramide if no
colic, cyclizine if colic
• Uncertain cause
levomepromazine
Nausea and vomiting game…
Lunch
Case Study
….Feedback from Group 3
Pain
Bradford and Airedale tPCT Pain
Assessment Tool
• Have you used it?
• Advantages/ disadvantages
Examples of pain assessment tools
• Abbey (cognitive/ communication
difficulties)
• McGill (complex pain)
• Picture/ number scales (easy to use)
Causes of Pain
• The illness/disease e.g. soft tissue, visceral, bone,
neuropathic
• Cancer Treatment e.g radiotherapy
• Disease Related Debility e.g constipation, muscle
tension/spasm
• A Concurrent Disorder e.g osteoarthritis, diabetes
Characteristics Examples
Adjuvant
Analgesics
somatic
•Well localised
•Typically dull or
aching
•Metastatic bone pain
•NSAIDS
•Muscle relaxants
•corticosteroids
visceral
•Poorly localised
•Deep, squeezing,
pressure like
•Pancreatic cancer
•Primary tumour
invading tissue
•Intra-peritoneal
metastases
•Antispasmodics
•corticosteroids
neuropathic
•Often severe
•Burning or
electric shock-like
•Common at site
of sensory loss
aching
nerve damage arising
from radiation, chemo
or surgery
Antidepressants
Antiepileptics
(corticosteroids)
Management of Pain
Explanation and good communication
• Modification of the pathological process radiotherapy, chemotherapy, hormone therapy, Surgery
• Modification of way of life and environment - avoid
pain precipitating activities, walking aids, hoists
• Non-Drug Methods - heat pads, TENS, Massage,
Complementary therapies,
• Analgesics (to discuss further)
• Anaesthetic Interventions - nerve blocks, epidural
injections
W.H.O Analgesic Ladder
Opioids for Moderate to
Severe Pain
e.g morphine +/- adjuvants
STEP 3
Opioids for Mild to
Moderate Pain
e.g. codeine +/- adjuvants
Non-Opioid Analgesics
STEP 2
e.g. Paracetamol / NSAIDS
+/- adjuvants
STEP 1
PAIN
PERSISTS
OR
INCREASES
PAIN
PERSISTS
OR
INCREASES
Opioid game…
What else affects pain
perception?
Social:
• Does the patient have
support?
• What resources are
available?
• What are the patients
stressors?
• Does pain affect social
roles?
• What does the patient do
for leisure / relaxation?
Spiritual:
• How is pain seen?
• Challenge
• Enemy
• Value
• Loss
• Punishment
• Weakness
• Strategy
• Relief
Coffee
Case study continued…
• Mick is admitted to hospital with increasing
shortness of breath, pyrexia and general
deterioration
• He was commenced on IV antibiotics and
IV fluids
• He is now drowsy, struggling to take oral
medication, has excess chest secretions
and is occasionally agitated
• Beth asks if he can come home
Case study continued
– What is happening?
– What will you do?
Analgesia in the last days of
life
• Morphine /diamorphine (SC infusion)
– 10-20mg/24hr if opioid naïve
– Or 50% / 30% of previous 24hr oral morphine dose
– Review daily and adjust dose
– Prescribe 1/6 of 24hr dose as prn SC injection
• Fentanyl transdermal patch
– Continue previous dose if comfortable
– Metabolism not affected by renal failure
Seek advice from palliative care team if symptoms
not controlled
Causes of terminal agitation
What could the CAUSE be?
Physical discomfort?
– Urinary retention
– Faecal impaction
– New pain (increase opioid or add NSAID)
– Sore pressure areas (consider topical
opioid, NSAID or local anaesthetic)
Managing Terminal Agitation
Neurological problems
• Fits, myoclonic jerks, motor restlessness
– Midazolam
• Hallucinations
– Haloperidol or Levomepromazine
Remember that opioids, antipsychotics and
antihistamines (eg Cyclizine) often cause
these problems
Pharmacological management
of terminal agitation
• Midazolam
– Very sedative
– Starting dose 10mg/24hr and 2.5mg prn
– Maximum 80mg/24hr
• Haloperidol
– 5mg/24hr for nausea, may need more for confusion
• Levomepromazine
– More sedating than Haloperidol
– 25-100mg/24hr
– Can combine with Midazolam
Excess secretions
Non-pharmacological Management
Noisy respiratory secretions, infections,
pulmonary oedema
Management (may include):
•
•
•
•
Explanation to relatives
Re-position patient
Frequent oral care
Review appropriateness of fluids
Excess secretions
Pharmacological Management
• Hyoscine Butylbromide (Buscopan)
20mg SC stat followed by infusion 60mg –
120mg/24hrs
• Furosemide 40mg SC or IV if pulmonary
oedema suspected
• Note that oropharyngeal suction is rarely needed
or necessary
Care after death
• Be aware of
cultural/religious
requirements
• Warn family if postmortem
necessary
• Plan bereavement support
• Support for each other as
professionals
Multi-professional Working
From this…
Out of
Hours
District
Nurse
GP
Allied
Health
Professional
Hospice
at Home
Discharge
coordinators
Hospital
consultant
Ambulance
service
Specialist
Palliative
Care
patient
Benefits
advisors
Pharmacy
Social Work
Volunteers
Family /
carers
Hospice
Continuing
Care
…to this
District Nurse
Out of Hours
GP
Hospice at Home
Allied health professionals
Discharge coordinators
Hospital consultant
Ambulance service
PATIENT
Pharmacy
Benefits advisors
Volunteers
Social Work
Family / carers
Specialist Palliative Care
Hospice
Continuing Care
Need Advice?
Community services…
• Bradford Community Palliative Care Team
01274 323511 (08.30 -17.00 Monday – Friday)
• Out of hours: 24 hour advice from on-call consultant via
Marie Curie Hospice 01274 337000
• Airedale Community Palliative Care Team
01535 642308 (08.30 - 17.00 Monday – Friday )
• Out of hours: 24 hour advice from on-call consultant via
Manorlands Hospice 01535 642308
Need Advice?
Hospital services….
• Bradford Hospital Palliative Care Team
01274 364035 (08.00 – 17.00 Monday – Friday)
Out of hours: 24 hour advice from on-call consultant via
Marie Curie Hospice 01274 337000
• Airedale Hospital Palliative Care Team
01535 295016 (08.30 – 17.00 Monday – Friday)
Out of hours: 24 hour advice from on-call consultant via
Manorlands Hospice 01535 642308
References
• Corner, J & Bailey, C (1995) Cancer Nursing –
Care in Context, Oxford; Blackwell
• Yorkshire Cancer Network (2009) Symptom
Management Guidelines, YCN
• Doyle et al (2005), Oxford Textbook of
Palliative Medicine
• Solano et al (2006) A comparison of symptom
prevalence… Journal of Pain & Symptom
Management. Vol 31. issue 1. pp58-69