Macmillan GP adviser Dr Charles Campion-Smith offers tips on anticipating a dying patient's wishes
1. Ensure the diagnosis is accurate.
Don't fall into the trap of just treating ‘cancer pain' with opiates, or ‘cancer vomiting' without thinking of the cause. Is the pain due to metastases that might need radiotherapy? Is the vomiting due to hypercalcaemia, gastric compression, urinary tract infection or drugs?
2. Good pain relief requires regular dosing rather than a vague ‘as required' direction.
Start cautiously, using four-hourly morphine mixture, adjusting the dose to prevent pain breakthrough. Then consider swapping to a slow-release preparation. If pain is unrelieved – with three or more doses of breakthrough analgesia or reports of moderate or severe pain on three occasions over 24 hours – then increase the baseline analgesia dose by 30-50%.
3. Always prescribe for breakthrough pain.
Calculate the doses accurately; for acute pain in someone already on an opiate, ordinary doses of diamorphine will do very little. The usual breakthrough dose is about one-sixth the daily total analgesic dose, so needs updating as analgesia requirements increase.
4. Plan for what might happen.
Look out for:
• increased or new symptoms
• inability to take oral medication
• urinary retention
• spinal cord compression.
Give the patient and carer clear information about what to look out for and what to do. Ensure appropriate drugs are already prescribed and equipment such as a syringe driver or urinary catheter pack is easily available.
Discuss with carers how to access care at different times. Specifically advise that calling 999 is very seldom appropriate and may result in resuscitation and admission.
Rehearse the final days and hours of life with them. Consider using the excellent Liverpool Care Pathway booklet Coping with dying – understanding the changes which occur before death (available from www.mcpcil.org.uk/liverpool_care_pathway).
5. Remember that acute breathlessness is often accompanied by panic or fear.
Sublingual lorazepam – an ‘off-label' use – 0.5mg to 1mg can be quick and effective. For chronic breathlessness, low-dose morphine, using a fan or opening the windows and simple relaxation exercises can help.
6. Ask about patients' wishes and record these as an anticipatory care plan.
It helps to know that wishes about place of care and advanced decisions about resuscitation have been recorded and passed on. Ensure everyone involved in a patient's care knows of any care plans. If you are seeing a patient you don't know, make an effort to find out about any advanced care plans and take note of these.
7. Avoid giving exact prognoses – you will almost always be wrong.
If a patient asks, listen to what he or she thinks and then decide whether to correct any major misapprehensions. Talking in ‘days', ‘weeks' or ‘months' can give patients and families some indication, but always remind them of the unreliability of even these predictions.
8. Be willing to ask difficult questions.
‘Are you frightened?' can be a useful question that allows fears and anxieties to be discussed. Don't give empty reassurance.
9. Be willing to ask for help.
Specialist palliative care advice in most areas is available 24 hours a day. There is a good chapter on palliative prescribing in the BNF and symptom-control algorithms with the Liverpool Care Pathway.
10. Work as a team – including the family and your local pharmacist.
Share problems, support each other and review the care you have given. Don't forget to recognise when you have done a great job together. Or think about how things can be better next time.
Dr Charles Campion-Smith is a GP in Dorset and a GP adviser for Macmillan Cancer Support
Competing interests None declared.
Dr Campion-Smith would like to thank fellow Macmillan GPs Dr Prue Mitchell, Dr Lucy Thompson, Dr Angela Steele and Dr Jonny Rae for their input. Macmillan GPs are funded with protected time to improve the quality of cancer and palliative care provided by primary health care teams within the local health economy.
Older patient receiving palliative care Elderly patient
