1. PALLIATIVE CARE EMERGENCIES Julie Davies, Clinical Nurse Specialist, St Luke’s Community Services Sue Shaw, Clinical Nurse Specialist, St Luke’s Community Services

2. Definition Palliative care emergencies include situations that are imminently life threatening, but also those that could result impaired quality of life for the rest of the patient’s life, or for the family in their bereavement.

3. General Principles Anticipate Who is at risk? Plan Communication Preparation Avoid Correct the correctable Prophylaxis

4. Considerations What is the problem? Can it be reversed? What effect will reversal of symptom have on a patient’s overall condition? Could active treatment maintain or improve this patient’s quality of life? What does the patient want? What do the carers want?

5. Major Emergencies Hypercalcaemia Spinal Cord Compression Superior Vena Cava Obstruction Haemorrhage Sepsis in neutropaenic patient

6. Hypercalcaemia Raised serum calcium (above 2.9mmolL) If left untreated is generally fatal (renal failure and arrhythmias) Most commonly but not exclusively seen in multiple myeloma and breast cancer and also non-small cell lung and bowel cancer Bone metastases are commonly, but not always present

7. Presenting Features Nausea Anorexia and vomiting Constipation Thirst and polyuria leading to dehydration Drowsiness Confusion and coma Cardiac arrhythmias

8. Management Discuss situation with doctor, patient, family appropriateness of treatment Check serum calcium, urea & electrolytes and albumen levels Rehydration – IV fluids IV bisphosphonates (pamidronate, zoledronate) Monitor serum calcium levels after treatment

9. Spinal Cord Compression Vertebral metastasis +/- collapse Tumour growing into the epidural space Tumour within the spinal cord

10. Clinical Features Back pain often described as a ‘band like pain’ – often worse on coughing or straining Stiffness, weakness, numbness, pins and needles usually starts in the feet and works its way up – often ‘like walking on cotton wool’ Urinary sphincter symptoms hesitancy, incontinence, perianal numbness and altered bowel habit are late features Examination often reveals defined areas of sensory loss and brisk or absent reflexes

11. Management The longer the delay in investigations and treatment the higher the risk of poor outcome Acute Oncology can be contacted on 01752 432283 Urgent referral for investigations – usually MRI scan Oral/IV Dexamethasone 16mg/day If appropriate radiotherapy Sometimes surgery Post treatment – rehab/physio If paraplegic important to recognise need for urinary catheterisation and bowel management regime

12. Superior Vena Cava Obstruction (SVCO) Occlusion from thrombosis Extrinsic pressure by tumour Direct tumour invasion of vessel wall More commonly seen in patients with Ca bronchus and Lymphoma. Small percentage in other cancers Other non malignant causes – goitre, aortic aneurysm

13. Clinical Features Symptoms Tracheal oedema and dyspnoea Cerebral oedema with headache, worse on stooping Visual changes Dizziness and syncope Swelling of the face, particularly periorbital oedema Neck swelling Oedema of arms and hands

14. Superior Vena Cava Obstruction (SVCO)

15. Clinical Features contd Symptoms Rapid breathing Periorbital oedema Cyanosis Non-pulsatile distension of neck veins Dilated collateral superficial veins of upper chest Oedema of hands and arms

16. Management Symptom relief paramount Management of dyspnoea with opioids and sometimes benzo-diazepines High dose dexamethasone 16mg/day Radiotherapy to the mediastinum Sometimes a metal stent is inserted into the SVC

17. Haemorrhage Causes Tumour/tumour invasion/fungating tumour Treatments such as steroids, NSAIDs causing gastric irritation/erosion Generalised clotting insufficiency or anticoagulants

18. Management Non-acute Tranexamic acid Adrenalin soaks on wounds PPIs eg Omeprazole, Ranitidine Possible radiotherapy

19. Management contd Acute Consider, if high risk of haemorrhage, to prepare the family/patient/carers by giving full explanation. Suggest being prepared with dark coloured towels/blanket etc Anticipate Midazolam s.c. or buccal or rectal Diazepam Catastrophic haemorrhage can cause almost instantaneous death with no time for treatment. May be a terminal event so stay with patient.

20. Sepsis in neutropaenic patient All clinical staff should be aware of potential for patients undergoing oncological treatment to become neutropaenic (rationale) and develop life threatening systemic infection Could this be a severe infection? Neutropaenia is a indicator Temperature>38.3 - <36 Respiratory rate > 20 per minute Heart Rate > 90 per minute Acute Confusion/reduced conscious level Glucose > 7.7 (unless DM) 2 or more of these signs could suggest sepsis

21. Management Admission to acute oncology unit for investigation and treatment (possibly sepsis 6 if appropriate) Intravenous antibiotics Lactate Oxygen Fluids Blood Cultures Urine output On-going monitoring of blood results until neutrophil count recovers

22. remember/think While unnecessary hospital admission may cause distress for the patient and carers, missed emergency treatment of reversible symptoms can be disastrous. IF ANY CONCERNS, SEEK ADVICE AND ACT IMMEDIATLEY.