Palliative Care – Case 1
You are on call and a seventy eight year old man is admitted with acute confusion. He has
known prostate cancer with bony metastasis. It has recently escaped hormonal control and
is advancing. He has deteriorated significantly over the last few days at home and has had
increasing pain, particularly in his hips and spine. He started vomiting yesterday and has
vomited three times since. He has a constant feeling of background nausea. His GP has
reviewed him at home, as has his Macmillan nurse. They have increased his morphine
sulphate a couple of times over the last week.
Drugs List:
Diclofenac
Morphine Sulphate S.R
Oramorph
Paracetamol
Simvastatin
Aspirin
Calcichew
Digoxin
Citalopram
50mg t.d.s
60mg b.d (Increased recently. 7 days ago was 30mg b.d.)
5 mg as required.
1g q.d.s
20mg o.d
75mg o.d
1 tab b.d.
125mcg daily
20mg
On examination you find him to be dehydrated and cachectic. He has periods where he is
lucid but becomes muddled easily. He is found to be in AF at a rate of 66bpm. He has
tenderness over the L4-5 area with the slightest touch and over the left hip. He is vague
and falls asleep easily. His wife describes that he seems jerky and is seeing animals at the
end of the bed (these are not present.) He is fully mobile and prone to wandering. B.P
95/50
Initial blood tests:
Hb 97 Wcc 15.4 Plt 78. Na 127 K 4.1 Urea 27 Cr 250. Calcium 3.12 (corrected)
Issues for Discussion
Consider all his symptoms and what you would do to improve these.
How you would adjust his medication, and why?
What other things would you like to do?
Palliative Care – Case 2
Whilst covering the surgical ward a 44 year old lady (Carol) is admitted with a new diagnosis
of carcinoma of the colon. She was diagnosed one month ago and unfortunately had liver
metastasis on diagnosis.
The CT scan at the time revealed a large lesion and she
commenced chemotherapy immediately after diagnosis. She presented to A and E with
signs and symptoms of bowel obstruction.
It was considered appropriate to operate.
Unfortunately during surgery she was found to have wide spread peritoneal seedlings.
There were many adhesions, and the bowel was stuck to the bladder and the uterus at
several places. The surgeons were unable to bypass the multilevel obstruction.
Carol has two children 6 and 10 and a husband, who is a bus driver.
Issues for Discussion
What are the key problems here and how could you manage them?
What issues should be discussed with Carol and her family?
She is managed with medical symptom control. Despite no changes being required in her
medication over the next 5 days she becomes less rousable. She is awake for short periods
of time and has sips of fluid from a syringe.
When is it appropriate to start the end of life pathway and what are its advantages?