Palliative Care
Dr Rachel Dawson

Objectives
 Increase your confidence in dealing with palliative care cases

Content
 Who is a palliative care patient?
 Presentation/ likely symptoms
 Palliative care emergencies


Help available
Medication – what, when & how much to use
 Setting up a syringe driver
 Case studies/ ethical dilemmas

Who Is a Palliative Care
Patient?

A patient for whom the objective of any treatment is to
 offer symptom relief only
For example –
- Any end-stage chronic illness; cancer, heart failure, renal failure, COPD, MS
….
- Dementia

- Old age
It is NOT just for cancer patients

Common Symptoms
(PEPSI COLA)
 Pain
 Drowsiness
 Breathlessness
 Nausea / Vomiting


Constipation
Anxiety/ Agitation / Restlessness/ Confusion – remember carer
 Dysphagia
 Other symptoms are more common in certain scenarios e.g. ascites in ovarian cancer

Palliative care Emergencies
 Hypercalcaemia
 Spinal cord compression
 SVC obstruction
 GI obstruction
 Haemorrhage – esp Upper GI
 ( Raised ICP)

Palliative Care Emergencies
– Hypercalcaemia
 Calcium > 2.6mmol/l


Suspect if known bony mets or any common tumour; Breast/ kidney/ myeloma/ lung or CRF
Symptoms – non-specific : thirst, constipation, N/ V, Abdo pain, anorexia
 Management – STOP any calcium (!) & admit for re-hydration & IV Pamidronate

Palliative Care Emergencies –
Spinal Cord Compression
 Incidence of ~5% of all cancer patients
– 70% occur in T spine


Always suspect if known bony mets/ common metastasising tumours
Symptoms include – pain / leg weakness/ constipation/ incontinence
 Management: ADMIT – IV
Dexamethasone, MRI & RTx

Palliative Care Emergencies –
GI Obstruction


Can occur with any cancer – not just physical obstruction
Symptoms include – V (faeculent),
Constipation (empty rectum), Abdo distension, Pain
 Management - ? Admit, ? NGT, Consider stopping prokinetic (dom/ met) & switch cyclizine/ haloperidol, buscopan. Soften stool
& consider dexamethasone

Palliative Care Emergencies –
SVC Obstruction



Rare – 75% are due to 1y lung cancer.
~3% lung cancers develop SVCO
Symptoms – periorbital oedema, SOB/ stidor, neck or arm swelling. Usually dilated veins can be seen on chest wall.
Management – Treat breathlesness/ anxiety with opioid +/- BZD. ADMIT – IV dexamethasone & RTx

Palliative Care Emergencies-
Haemorrhage
 Rare, but most common with upper GI
(Remember steroids)
 Usually fatal
 Need to anticipate / warn carer
 Management – Midazolam +/diamorphine to alleviate suffering

Palliative Care Emergencies
(7)
 Raised ICP – presents with drowsiness/ headache/ V. Can usually be anticipated. Mx= dexamethasone
16mg/day
 In essence emergency drugs include –
Diamorphine, Anti-emetic, Midazolam &
Dexamethasone

Help Available
-
-
-
-
-
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 COMMUNITY
District Nurses ->LCP
Macmillan Nurses
Hospice at home ->LCP
Consultants
Pharmacist – Twycross/
Pall care BNF
Bradford Cancer
Support ->benefits
-
-
-
 HOSPITAL
Consultants
Specialist nurses
2 nd opinion

Medication – What, When &
How Much to Use
 Analgesia
 Antiemetic
 Anticholinergics
 Sedatives/ Anxiolytics
 Anti-inflammatory
 Others – secretions, mouth care & constipation.

Analgesia
 Tailor analgesic choice to type of pain – may need a combination
 Give clear instructions
 Gradually increase dose
 Give regular dosage +/- PRN
 Consider potential SE & co-prescribe
 Follow up to ensure ok

Analgesia – Types of Pain





‘Standard’ = WHO Analgesic ladder = Opioid
Bony pain – consider NSAID, RTx,
Bisphosphonates
Neuropathic – Opioids, Gabapentin,
Pregabalin
Abdo Spasm – Anticholinergics
Muscular – NSAID, Baclofen, BZD’s

Analgesia - Types
 Non-opioids: Paracetamol, NSAID
 Weak Opioid : Codeine,
Dihydrocodeine, Tramadol
 Strong Opioids : Morphine (1 st line),
Diamorphine, Fentanyl, Oxycodone,
Hydromorphone, Methadone
 Others – Ketorolac; Ketamine

Analgesia – choice


Choose on basis of type of pain, route of delivery & previous analgesia used
1 st line build up ladder to morphine.
 Start regular oromorph eg 5-10mg qds + prn.
 Review amounts used & convert to MST. Can then convert to diamorphine as necessary.
 Switch to oxycodone/ hydromorphone / fentanyl if morphine SE
 REMEMBER to co-prescribe + PRN

Antiemetic



Likely to be used a co-prescription or to reduce established nausea.
Try simple meds 1 st line
1 st line = Cyclizine, Stemetil, Metoclopramide
 Consider other choices if co-existing symptoms e.g. Haloperidol, Dexamethasone
 Can use combinations.
 Doses may be higher eg 60-100mg metoclopramide over 24hrs.
 Avoid Metoclopramide if obstruction

Agitation/ Anxiety
 Consider reversible causes inc pain
 Consider non-drug treatments
 Consider underlying depression
 Medication: Haloperidol, BZD’s
 Shortacting BZD’s eg lorazepam s/l
 Sedating BZD’s eg Midazolam s/c
 Sedatives eg Phenobarbitol

Other meds


Secretions – consider hyoscine patch or s/c
Constipation – try & avoid with coprescribing
- Prescribe regular laxatives
- Remember Co-danthrusate/ docusate

- Seek nurse advice/ involvement
Mouth Care – consider saliva sprays/ gel

Other meds - dexamethasone
Has multiple uses at different doses & compatible in syringe drivers
 Anorexia - 2-4mg/ d
 Raised ICP – 16mg/d
 Gut obstruction – 4-8mg/d
 Hiccoughs – 4-12mg/d
 Anti-inflammatory – 4 –16mg/d

Medication example
If opioid naïve a good starting point for oral route:


Oramorph PRN & convert OR 10mg MST bd, then review. PLUS…
Cyclizine 50mg tds. PLUS…
 Movicol1 sachet 2-4x per day
 Review regularly & if problems – seek help

 When
Syringe Drivers –
When, What , How
- Try & anticipate
- Team decision
- Can always be stopped
- Ensure family aware.
- Communicate well
- STOP all other meds

 What
-
-
-
-
-
Diamorphine (510mg if naïve)
Cyclizine (150mg) &/or Metoclopramide
(60mg)
WFI
+/- Midazolam – 20-30mg/24hrs initailly
Ensure stat doses available & instructions to increase after 24hrs if necessary.
Special instructions eg GI haemorrhage.

 How
-
Inform/ Involve family in decision
Inform DN’s or H at H
- Prescribe meds
-
- Write up instructions – Syringe driver & stat sheet. Be clear.
Inform LCD – fax
Ensure follow up in place

Other considerations
 Always ensure the person still wishes to remain at home.



Keep family informed & advise re action to take in event of death
Benefits – DS1500
Level 6 care/ Continuing care – poor prognosis
 LCD/ OOH form
 DNR form for transport

Cases

Conclusion
 Hopefully confidence increased
 Information packs include:
- Handout
- Yorkshire cancer network booklet
- Dose comparisons of Strong Opioids
- Syringe driver compatability info
- Local pharmacy info
- Forms – DNR, Level 6, LCD, Syringe driver,
PEPSI COLA + DS1500 advice.
 Marie Curie Talks