Symptom Control in the Last 48hrs Dr Bisharat El Khoury Consultant in Palliative Medicine NUH

Objectives Recognise patient is dying Planning end of life care-MDT Symptom management Psychological and emotional support Patient and family/ carers Each other

How do you recognise a patient is dying?

Recognising Death Profoundly weak Bed bound Very limited oral intake Drowsy/ semi-comatose Confused/ agitated Unable to swallow medication

Planning End of Life Care Wishes of family/ coping at home Planning for crisis – Anticipatory Prescribing Drug administration and prns Discuss 999/ resuscitation DNACPR

Main Aims of Treatment STOP unnecessary drugs STOP unnecessary intervention i.e. BP, pulse Manage symptoms Psychological support Patient Carers/ family Yourself

Management Continue to assess bladder, bowels

Indications for Using a Syringe Driver Essential meds if unable to take oral Semi-comatose Vomiting, swallowing difficulties Confused/ agitated

Symptoms Pain Nausea & Vomiting Terminal agitation Breathlessness Death rattle Haemorrhage

Pain Assess cause i.e. urinary retention Route of medication Ensure breakthrough analgesia available

Pain – If Not On Opioids Provide prn morphine 2.5-5mg sc up to 1hrly if needed Review after 24hrs – if 2+ doses start syringe driver

Pain-if On Opioids Convert 24hr PO morphine to 24hr CSCI morphine – divide by 2 Convert 24hr PO morphine to 24hr CSCI diamorphine – divide by 3 Convert 24hr PO oxynorm to 24hr CSCI oxycodone – divide by 2 Continue to give prn pain relief if needed (1/6 of total)

Pain Do not start Fentanyl patches Provide prn analgesia

Fentanyl and Equivalent Doses Compared to Oral Morphine 1:100 Fentanyl patches mcg/72hrs Morphine po Mg/24hrs 12 30 25 60 50 120 75 180 100 240

Fentanyl Patches in the Terminal Phase Leave patch on, continue to change every 72hrs Give doses of sub cut morphine for breakthrough pain If 2+ prns needed/ 24hrs give morphine by CSCI starting with sum of prn doses in last 24hrs

Renal Impairment e GFR < 30ml/min Stage 4/5 Chronic Kidney Disease There is no exact equivalence between opioids

Anticipatory Medication Renal Impairment - Pain Use smaller doses of opioids the patient is on ie 1/2mg oxycodone/ morphine po/sc Better to be familiar with the opioid Opioids of choice are Alfentanil and Fentanyl

Renal Impairment – Pain if not on regular opioid Alfentanil 100micrograms or Fentanyl 25micrograms prn If needing prns consider syringe driver with Alfentanil 500mcg or Fentanyl 100mcg

Alfentanil 1mg Alfentanil subcut is equivalent to 30mg oral morphine Hepatic metabolism inactive metabolites excreted in urine Rapid onset of action and used in procedure related pain Ensure prn dose

Fentanyl 1mg Fentanyl is equivalent to 150mg oral morphine Can use trans mucosal Fentanyl products earlier Fentanyl patch continue and use prns Ensure prn doses available

A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration. The pain was continuous, worsened with eating, was associated with nausea, and radiated to her back. She reported no vomiting, fever, diarrhea, or weight loss, and her vital signs were normal. Her abdomen was distended, diffusely tender on palpation, and tympanic on percussion on the upper half and dull on the lower half. Bowel sounds were missing on the left side, and a large mass was palpated in that area. Laboratory evaluation was unremarkable. Computed tomography (CT) showed massive dilatation of the stomach, and gas was seen distally on a CT scan. More than 4 liters of fluid was drained from the patient's stomach during the first 24 hours. Upper gastrointestinal endoscopy showed no evidence of peptic ulcer disease or cancer but did show hypertrophic pyloric stenosis. She underwent endoscopic balloon dilation of the pyloric sphincter, with immediate symptomatic relief and resolution of gastric dilatation. Within a few days, the patient returned to a normal diet, and 20 months later, she continued to do well.

Nausea & Vomiting Nausea - unpleasant feeling of need to vomit, often with autonomic symptoms Retching - rhythmic laboured movements of diaphragm and abdominal muscles Vomiting- forceful expulsion of gastric contents

Common causes of N&V - cancer

Correct The Correctable Cough - antitussive Gastritis - antacid Gastric irritant drugs - ie NSAID ? Stop Constipation - laxative Raised ICP - corticosteroid Hypercalcaemia - zometa

N & V End of Life If cause known and previous antiemetics working Continue and give parenterally

N & V End of Life If cause unknown or unrelieved by previous antiemetics Use levomepromazine broad spectrum Start 6.25-12.5mg po/sc o.n. and prn Can be given prn up to 1 hourly if needed If 2+ doses use CSCI

Nausea & Vomiting Give regularly and reassess Treat cause ie renal failure reduce opioids Consider CSCI – can be used for anti-emetic alone Seek advice

Terminal Agitation Change in behaviour Reduced awareness Mental distress/ anguish Fluctuating confusion Hallucinations/ paranoid ideas

Terminal Agitation Associated with progressive multi-organ failure Generally not reversible Medication usually necessary 85% patients prior to death

Causes of Terminal Agitation Psychological Fear Unfinished business Biochemical Liver/ renal failure Raised calcium Hypoxia Physical Pain Full bladder Full rectum Hypoxia/ breathlessness Cerebral metastases

Management of Terminal Agitation Treat cause General measures Nursing the patient-reassure, environment, safety Carers-explanation Review drugs/ reduce medication Treat symptom Midazolam (high doses can sometimes worsen if used alone) Levemepromazine

Drugs Commonly Used Midazolam Levomepromazine Haloperidol

Drug Treatment Antipsychotics are the drug of choice BZD if given alone can make agitation worse

Levomepromazine Phenothiazine antipsychotic, anti-emetic Half life 16-30hrs Analgesic properties Sedating

Levomepromazine Highly anxious pts who are overwhelmed Pain exacerbated with onset of delirium

Levomepromazine Typical breakthrough sc doses 6.25-12.5mg to 12.5-25mg Syringe driver start 12.5-25mg/24hrs Maximum dose 300mg/24hrs

Midazolam BZD Half life 2-5hrs Reduces neuronal activity Single stat dose 2-3x more potent than diazepam

Midazolam CSCI 10-30mg to 30-60mg/24hrs Start 20-30mg/24hrs if fitting/ on antiepileptics Breakthrough doses 2.5-5mg to 5-10mg can be give hrly and with antipsychotic

Midazolam Can make agitation worse if used alone If needing higher doses use an antipsychotic

Breathlessness Subjective difficulty in breathing associated with high levels of anxiety and fear (different from tachypnoea and hyperventilation) OHPC 2005

Breathlessness Explanation/ relaxation Repositioning Fan If O2 sat< 90% use oxygen 2-4l/min

Breathlessness Common in palliative care 40-80% Complicated pathopysiology Do not assume it is caused by cancer If due to cancer ? treat cancer Look for reversible causes

Reversible causes ? Bronchopneumonia Anaemia Pleural effusion COPD PE SVCO Heart failure

                   

Patients Experience Common trigger for panic Intermittent – exertion, bending, talking Restriction of ADL/ social life Feelings anxiety, pain, impending death

Terminal Breathlessness Explanation to family/ carers Use opioid with sedative- anxiolytic CSCI Diamorphine/ morphine + midazolam If agitated add levomepromazine/ haloperidol

Drug Treatment -Opioids Reduce ventilatory response so reducing respiratory effort and SOB Also reduce tidal volume and RR Generally more beneficial for pts SOB at rest

Opioid Naive Start low 2.5-5mg sc/po morphine Titrate to response and effect If 2+ doses in 24hrs prescribe regularly Always provide prns

Patients on opioids Use PRN dose – may need less or more Some patients may tolerate CSCI with morphine/ diamorphine better

Anxiolytics To reduce panic/ anxiety – use prn also Diazepam 1-2mg po Lorazepam 0.5-1mg sl/po Midazolam 2.5-5mg stat Midazolam 5-10mg/ 24hrs CSCI

Respiratory Symptoms Severe acute stridor Bleed into bronchus or trachea Noisy tachypnoea

Oxygen Use if hypoxic Decreases work of breathing Consider fan/ open window

Death Rattle Secretions in hypopharynx-oscillation If patient not distressed treatment for carers/staff Explanation important

Death Rattle Support-explanation Postural drainage Suction

Death Rattle Main treatment Buscopan/ Hyoscine butylbromide Give promptly-no effect on existing secretions Maximum dose 300mg/24hrs

Death Rattle Stat dose buscopan 20mg sc up to hrly If 2+doses in 24hrs start CSCI 40-80mg buscopan/ 24hrs Continue to give prns if needed

Catastrophic Bleed Stay with patient Prepare-green/ red towels Occasionally medication

Psychological Support How long? Loss control-explanation Fear-feeling safe/ valued Spirituality

Psychological Support Prepare-drugs, catheter, driver etc Recognising own emotions/ support each other

Bereavement Follow up support Risk factors Discussion/ learning/ audit

Case Study 87yr woman lung ca dying at home, supportive family, symptoms well controlled Current meds: oramorph 5mg tds, paracetamol, cyclizine 50mg tds

Swallowing becomes difficult – what do you suggest?

Prepare family CSCI diamorphine 5mg, cyclizine 150mg/24hrs

The next day she becomes unsettled and c/o abdominal pain – what could be happening?

Urinary retention – the pain and agitation settle on catheterisation

Later she becomes agitated and verbally aggressive Later she becomes agitated and verbally aggressive. The family admit this has been happening for short periods over the last few days.

Case Study Explanation Unable to get medication she is admitted to QMC and dies the next day CSCI diamorphine 5mg, levomepromazine 12.5mg, midazolam 10mg/24hrs

Contacts Hayward House 0115 969 1169 and ask switchboard to ring palliative care doctor on call Direct line 0115 962 7619