Emergencies in palliative care

Dr Pete NightingaleFRCGP,DCH,DTM+H,DRCOG,C

ert Med Ed,Cert Pal Care.Macmillan GP

Last hours of living

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

caregiversawareness of patient choicesknowledgeable, skilled, confident

rapid response likely events, signs, symptoms of the dying process

Situations to be considered

1. Delirium at the end of life2. Sudden unexpected deterioration:

diagnoses to consider3. Haemorrhage4. Spinal cord compression5. Pathological fracture6. Upper airway or SVC obstruction7. Hypercalcaemia

Case 1 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 FailureB Dose of opioid too highC HypercalcaemiaD Diabetes

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

Hypercalcaemia (2) Constipation Tiredness and lethargy Muscle weakness Confusion Coma “generally unwell”

Hypercalcaemia (3) ADMIT IF ILL Measure serum calcium RehydrateI/V bisphosphonate (pamidronate or

zoledronic acid)

Case 2 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

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? 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: 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

Kramer JA Palliative Medicine (1992) 6 202-211

Spinal cord compression-typical history

% patients complaining

% found on examination

Then sudden onset of Central back pain WEAKNESS 76% 87% vertebral 6-7 weeks tenderness SPINCTER 0% 57% 80%-95% DISTURBANCE SENSORY DEFICIT 51% 78%

PATIENTS DO NOT ALWAYS COMPLAIN - SUSPECT AND ASK

KEY MESSAGE

Ask about symptoms in high risk groups (? Give high risk

patients information)

Why does it matter? 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 205 (68%)

Hospice 4 (1%)

DGH 64 (21%)

Oncology treatment centre

28 (9%)

During referral process: 214 (78%) seen by GP 235 (78%) seen by DGHat some stageFirst presentation to oncology centre reduced delay

and improved neurological outcome D. J Husband BMJ (1998) 317 18-21

KEY MESSAGE

In the presence of symptoms/signs, discuss

with/refer to oncology early (within 24h)

Spinal cord compressionSuspect: Ask for symptoms of radicular pain,

sensory change, weakness Check power, reflexes, sensory levelIf symptoms/signs: Give dexamethasone 12-16mg

immediately Discuss with oncologist ASAP (w/i

24h)

Case 3 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 DVT B Haemorrhage into the leg C Pathological Fracture D Hypercalcaemia

Pathological fracture Ca breast, prostate, myeloma Lytic (destructive) metastases Weight bearing bones ≥ one-third cortex lost Limb pain ↑ with weight bearing

Pathological fracture Little/no trauma Sudden and severe pain ↑ with smallest movement Limb deformity Local swelling/bruising/tenderness

Case 4 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

SVC Obstruction 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 I/V dexamethasone 12mg (thrombolysis/LMWH) Radiotherapy stents

Case 5 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 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 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 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 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

KEY DECISION: 1. is this reversible? 2. or is the patient dying?

Sudden, unexpected deterioration 2 KEY QUESTIONS: 1. Does the underlying diagnosis

suggest short prognosis?2. Is there a history of decline in

function with no other explanation?

3. 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) high calcium spinal cord compression, Dehydration (poor intake, vomiting, diarrhoea, diuretics) Haemorrhage (especially NSAIDS/steroids) hypo or hyperglycaemia, severe anaemia, medication error, infection

Recognising dying 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:-1. Bedbound2. Only able to take sips3. Semicomatose4. Unable to take medication orally

TimeOnset of incurable cancer -- Often a few years, but

decline usually < 2 months

“Cancer” Trajectory, Diagnosis to Death

Function

Death

High

Low

Cancer

Possible hospice enrollment

Organ System Failure Trajectory

Time

Function

Death

High

Low

Begin to use hospital often, self-care becomes difficult

~ 2-5 years, but death usually seems “sudden”

Heart Failure TerminalPhase

Initiation / Extension of Supportive Care

Practical Clinical ApproachPractical Clinical Approach

• Progressive oedema, renal failure or hyponatraemia with no reversible cause.

• Deterioration despite optimal therapy.

• Patient wishes. C.Ward, Heart 2002, 87:294-298

Intuitive Approach‘Would I be surprised if the patient died over the next 12 months?’

Prognostic Indicator Guidance (PIG)

Potential Problems

• Intrinsically difficult, complex approximation

• Innacuracies are inevitable

• Can be wrong- patients feel that they are ‘living beyond their sell by date’

PIG

Potential Positives

• Greater equity for non-cancer patients such as heart failure

• Earlier supportive care

• Better access to services, respite, day care etc

• Enable more to ‘live well until they die’

Case 7 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: 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: 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 happensORDER OF PRIORITIES:1. Appear calm2. Stay with the patient3. Stem/disguise blood loss as much as

possible4. Summon assistance5. Consider crisis medication (if

easy/available/not detracting from overall care)

6. Ensure aftercare

Our management options are determined by clinical context: Patients general condition Disease and prognosis Patients’ and families wishes Burden of treatment Distress of symptoms

To summarise: 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