Emergencies in palliative care Dr Pete Nightingale FRCGP,DCH,DTM+H,DRCOG,Cert 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 caregivers awareness of patient choices knowledgeable, skilled, confident rapid response likely events, signs, symptoms of the dying process

Situations to be considered 1. Delirium at the end of life 2. Sudden unexpected deterioration: diagnoses to consider 3. Haemorrhage 4. Spinal cord compression 5. Pathological fracture 6. Upper airway or SVC obstruction 7. 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 Failure B Dose of opioid too high C Hypercalcaemia D 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 Rehydrate I/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) Spinal cord compression-typical history

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 practitioner205 (68%) Hospice4 (1%) DGH64 (21%) Oncology treatment centre 28 (9%) During referral process: 214 (78%) seen by GP 235 (78%) seen by DGH at some stage First presentation to oncology centre reduced delay and improved neurological outcome D. J Husband BMJ (1998)

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 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. Bedbound 2. Only able to take sips 3. Semicomatose 4. Unable to take medication orally

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 happens ORDER OF PRIORITIES: 1. Appear calm 2. Stay with the patient 3. Stem/disguise blood loss as much as possible 4. Summon assistance 5. 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