Acute problems in palliative care
Dr Chantal Simon, Dr Karen O’Reilly, Dr Robin Proctor and Dr John Buckmaster on dealing with acute problems in this challenging area
Dr Chantal Simon, Dr Karen O'Reilly, Dr Robin Proctor and Dr John Buckmaster on dealing with acute problems in this challenging area
Some acute events in advanced disease must be treated as emergencies. Although unnecessary hospital admission may cause distress for patients and carers, missed emergency treatment of reversible conditions can be disastrous.
Questions to ask
• What is the problem?
• Can it be reversed?
• What effect will reversal have on this patient's overall condition?
• Could active treatment maintain or improve this patient's quality of life?
• What is the ‘right' thing to do?
• What does the patient want?
• What do the carers want?
Emergencies in advanced disease
• Depending on the general state of the patient, make a decision on whether to treat the hypercalcaemia or not.
• If a decision is made not to treat, provide symptom control and don't check the serum calcium again.
• Active treatment: depends on level of symptoms and Ca2+:
– if asymptomatic, with corrected calcium of less than 3mmol/l, they should be monitored
– if symptomatic and/or corrected calcium of more than 3mmol/l, arrange immediate treatment with pamidronate via oncologist or palliative care team.
• Give analgesia.
• Unless in a very terminal state, confirm the fracture on X-ray and refer to orthopaedics or radiotherapy urgently for consideration of fixation (long bones, wrist, neck of femur) and/or radiotherapy (rib fractures or vertebral fractures).
This includes haematuria, haemoptysis, GI bleeding or wounds.
Make a decision whether the cause of the bleed is treatable or a terminal event.
• Active treatment: call for emergency ambulance support. Lie flat. Gain IV access and give fluids if available.
• No active treatment: stay with patient, give sedative medication (midazolam 10- 40mg subcutaneously or IM or diazepam 10-20mg pr). Support the carers. Consider diamorphine 2-10mg subcutaneously if the patient is in pain.
• Consider reversible causes: anaemia, pneumonia, pleural effusion, exacerbation of COPD, heart failure, pulmonary embolism, superior vena cava obstruction.
• Palliative measures: morphine 2.5-5mg prn (or increase background opioid dose
by 30-50%) or consider diamorphine/ morphine syringe driver with midazolam 5-10mg/24h.
Spinal cord compression
• Presents with back pain worse on movement and neurological symptoms such as constipation, weak legs and incontinence of urine.
• Prompt treatment (less than 48 hours from first neurological symptoms) is needed if there is any hope of restoring function. Treat with oral dexamethasone 16mg/d and refer urgently for radiotherapy unless in final stages of disease.
Breakthrough of pre-existing, opioid-responsive pain: give a stat dose of opioid, this being one-sixth of the total opioid dose in the last 24 hours. Acts in less than 30 minutes. Repeat if ineffective.
To convert 24-hour doses:
• oral morphine 90mg = subcutaneous diamorphine 30mg (3:1)
• oral morphine 90mg = subcutaneous morphine 45mg (2:1)
• Fentanyl ‘25' patch = subcutaneous diamorphine 30mg.
• If respiratory rate is 8/min or greater and patient is easily rousable and not cyanosed, review if their condition worsens. Consider reducing or omitting the next opioid dose.
• If respiratory rate is under 8/min, and/or patient is unconscious or barely rousable and/or cyanosed, dilute a standard ampoule containing naloxone 400µg to 10ml with sodium chloride 0.9%. Give 0.5ml (20µg) IV every two minutes until respiratory status is satisfactory to a maximum of 10mg naloxone. If respiratory function still doesn't improve, question the diagnosis.
Note: further boluses may be necessary once respiratory function improves, as naloxone is shorter-acting than morphine.
• Ensure the airway is clear and turn the patient into the recovery position. Prevent onlookers from restraining the fitting patient. Treat fitting with diazepam 5-10mg IV or pr.
• If the patients has more than one seizure without regaining consciousness, or fitting continues for more than 20 minutes, repeat diazepam every 15 minutes until fitting is controlled. Admit, unless a very terminal condition.
• Support the carers.
• Consider checking BM.
• Depending on clinical state, consider referral for further investigation if this is the patient's first fit.
Terminal restlessness or agitation
Causes include pain or discomfort, myoclonic jerks secondary to opioid toxicity, biochemical causes (increased Ca2+ or uraemia), psychological or spiritual distress.
• Treat reversible causes, such as catheterisation for retention, hyoscine to dry up secretions.
• If still restless, treat with a sedative. This does not shorten life but does make the patient and any relatives in attendance more comfortable.
• Suitable drugs: haloperidol 1-3mg tds po; diazepam 2-10mg tds po, midazolam (10-100mg/24h via syringe driver or 5mg stat) or levomepromazine (12.5-50mg/24h via syringe driver or 6.25mg stat).
This is an extract from Emergencies in Primary Care published by Oxford University Press, edited by Dr Chantal Simon, Dr Karen O'Reilly, Dr Robin Proctor and Dr John Buckmaster.
To order a copy go to www.oup.co.uk or click on the link on the right of this screen