Transcript Emergencies in palliative care

Emergencies in palliative care
Dr Pete Nightingale
FRCGP,DCH,DTM+H,DRCOG,Cert
Med Ed,Cert Pal Care.
Macmillan GP
Last hours of living
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everyone will die
< 10% suddenly
> 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
Two roads to death
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
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7.
Delirium at the end of life
Sudden unexpected deterioration:
diagnoses to consider
Haemorrhage
Spinal cord compression
Pathological fracture
Upper airway or SVC obstruction
Hypercalcaemia
Case 1
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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?
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)
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Constipation
Tiredness and lethargy
Muscle weakness
Confusion
Coma
“generally unwell”
Hypercalcaemia (3)
ADMIT IF ILL
 Measure serum calcium
 Rehydrate
I/V bisphosphonate (pamidronate or
zoledronic acid)
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Case 2
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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
Can’t get out of bed
Still being sick
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What diagnoses are you
considering?
What key questions will you
ask to make a more accurate
clinical assessment?
What action will you take?
What do you think is most
appropriate action?
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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
Spinal cord compression in
cancer
Spinal cord compression:
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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
Spinal cord compression-typical
history
% patients
complaining
Central back pain
 vertebral
tenderness
80%-95%
Then sudden onset of
WEAKNESS
% found on
examination
76%
87%
SPINCTER
DISTURBANCE
0%
57%
SENSORY DEFICIT
51%
78%
6-7 weeks
PATIENTS DO NOT ALWAYS COMPLAIN - SUSPECT AND ASK
Kramer JA Palliative Medicine
(1992) 6 202-211
KEY MESSAGE
Ask about symptoms in high risk
groups (? Give high risk patients
information)
Why does it matter?
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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
KEY MESSAGE
Diagnosis, referral and treatment
in less than 24h improves
outcome.
First presentation is to:
General practitioner
Hospice
DGH
Oncology treatment
centre
205 (68%)
4 (1%)
64 (21%)
28 (9%)
During referral process:
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214 (78%) seen by GP
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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)
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)
Case 3
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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
Which is most likely?
A
B
C
D
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DVT
Haemorrhage into the leg
Pathological Fracture
Hypercalcaemia
Pathological fracture
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Ca breast, prostate, myeloma
Lytic (destructive) metastases
Weight bearing bones
≥ one-third cortex lost
Limb pain ↑ with weight bearing
Pathological fracture
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Little/no trauma
Sudden and severe pain
↑ with smallest movement
Limb deformity
Local swelling/bruising/tenderness
Case 4
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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?
Which is most likely?
A Anxiety
 B Pleural Effusion
 C SVC obstruction
 D Infection
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SVC Obstruction
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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
Treatment of SVCO
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I/V dexamethasone 12mg
(thrombolysis/LMWH)
Radiotherapy
stents
Case 5
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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
Terminal Restlessness and
Agitation
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As death approaches
affects between 40-80% of patients
motor restlessness,
fear, anxiety,
mental confusion with/without
hallucinations
or a combination of these symptoms.
Terminal Restlessness and
Agitation
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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
Terminal Restlessness and
Agitation 2
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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)
Acutely disturbed or
aggressive patients
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If young consider 5mg haloperidol sc/im
with possible lorazepam 1-2mg sc/im
If elderly halve these doses but possibly
repeat after 30minutes
Case 6
A 55 yr old man with a
glioblastoma has suddenly
deteriorated at home.
How would you assess and
manage this?
Sudden, unexpected
deterioration
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KEY DECISION:
is this reversible?
or is the patient dying?
Sudden, unexpected
deterioration 2
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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?
Is this a reversible situation?
Have I excluded correctable causes?:
 Reversible renal failure (pelvic tumours obstructing ureters,
vomiting causing dehydration)
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high calcium
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spinal cord compression,
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Dehydration (poor intake, vomiting, diarrhoea, diuretics)
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Haemorrhage (especially NSAIDS/steroids)
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hypo or hyperglycaemia,
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severe anaemia,
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medication error,
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infection
Recognising dying
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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
Case 7
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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?
Catastrophic haemorrhage:
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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
Managing risk of catastrophic
haemorrhage:
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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
Crisis haemorrhage:if it happens
ORDER OF PRIORITIES:
1.
Appear calm
2.
Stay with the patient
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Stem/disguise blood loss as much as
possible
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Summon assistance
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Consider crisis medication (if
easy/available/not detracting from overall
care)
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Ensure aftercare
Our management options are
determined by clinical context:
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Patients general condition
Disease and prognosis
Patients’ and families wishes
Burden of treatment
Distress of symptoms
To summarise:
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Time is short for these patients
Always step back and look at the bigger
picture
Keep comfort and patient/family wishes
foremost
Don’t let the burden exceed the benefit
For ca breast, prostate, lung and myeloma,
remember SCC, hypercalcaemia and
pathological fractures