1. Palliative Care Dr Rachel Dawson

2. Objectives Increase your confidence in dealing with palliative care cases

3. Content Who is a palliative care patient? Presentation/ likely symptoms Palliative care emergencies Help available Medication – what, when & how much to use Setting up a syringe driver Case studies/ ethical dilemmas

4. Who Is a Palliative Care Patient?

5. A patient for whom the objective of any treatment is to offer symptom relief only For example – - Any end-stage chronic illness; cancer, heart failure, renal failure, COPD, MS …. - Dementia - Old age It is NOT just for cancer patients

6. Common Symptoms (PEPSI COLA) Pain Drowsiness Breathlessness Nausea / Vomiting Constipation Anxiety/ Agitation / Restlessness/ Confusion – remember carer Dysphagia Other symptoms are more common in certain scenarios e.g. ascites in ovarian cancer

7. Palliative care Emergencies Hypercalcaemia Spinal cord compression SVC obstruction GI obstruction Haemorrhage – esp Upper GI ( Raised ICP)

8. Palliative Care Emergencies – Hypercalcaemia Calcium > 2.6mmol/l Suspect if known bony mets or any common tumour; Breast/ kidney/ myeloma/ lung or CRF Symptoms – non-specific : thirst, constipation, N/ V, Abdo pain, anorexia Management – STOP any calcium (!) & admit for re-hydration & IV Pamidronate

9. Palliative Care Emergencies – Spinal Cord Compression Incidence of ~5% of all cancer patients – 70% occur in T spine Always suspect if known bony mets/ common metastasising tumours Symptoms include – pain / leg weakness/ constipation/ incontinence Management: ADMIT – IV Dexamethasone, MRI & RTx

10. Palliative Care Emergencies – GI Obstruction Can occur with any cancer – not just physical obstruction Symptoms include – V (faeculent), Constipation (empty rectum), Abdo distension, Pain Management - ? Admit, ? NGT, Consider stopping prokinetic (dom/ met) & switch cyclizine/ haloperidol, buscopan. Soften stool & consider dexamethasone

11. Palliative Care Emergencies – SVC Obstruction Rare – 75% are due to 1y lung cancer. ~3% lung cancers develop SVCO Symptoms – periorbital oedema, SOB/ stidor, neck or arm swelling. Usually dilated veins can be seen on chest wall. Management – Treat breathlesness/ anxiety with opioid +/- BZD. ADMIT – IV dexamethasone & RTx

12. Palliative Care Emergencies- Haemorrhage Rare, but most common with upper GI (Remember steroids) Usually fatal Need to anticipate / warn carer Management – Midazolam +/- diamorphine to alleviate suffering

13. Palliative Care Emergencies (7) Raised ICP – presents with drowsiness/ headache/ V. Can usually be anticipated. Mx= dexamethasone 16mg/day In essence emergency drugs include – Diamorphine, Anti-emetic, Midazolam & Dexamethasone

14. Help Available COMMUNITY - District Nurses ->LCP - Macmillan Nurses - Hospice at home ->LCP - Consultants - Pharmacist – Twycross/ Pall care BNF - Bradford Cancer Support ->benefits HOSPITAL - Consultants - Specialist nurses - 2 nd opinion

15. Medication – What, When & How Much to Use Analgesia Antiemetic Anticholinergics Sedatives/ Anxiolytics Anti-inflammatory Others – secretions, mouth care & constipation.

16. Analgesia Tailor analgesic choice to type of pain – may need a combination Give clear instructions Gradually increase dose Give regular dosage +/- PRN Consider potential SE & co-prescribe Follow up to ensure ok

17. Analgesia – Types of Pain ‘Standard’ = WHO Analgesic ladder = Opioid Bony pain – consider NSAID, RTx, Bisphosphonates Neuropathic – Opioids, Gabapentin, Pregabalin Abdo Spasm – Anticholinergics Muscular – NSAID, Baclofen, BZD’s

18. Analgesia - Types Non-opioids: Paracetamol, NSAID Weak Opioid : Codeine, Dihydrocodeine, Tramadol Strong Opioids : Morphine (1 st line), Diamorphine, Fentanyl, Oxycodone, Hydromorphone, Methadone Others – Ketorolac; Ketamine

19. Analgesia – choice Choose on basis of type of pain, route of delivery & previous analgesia used 1 st line build up ladder to morphine. Start regular oromorph eg 5-10mg qds + prn. Review amounts used & convert to MST. Can then convert to diamorphine as necessary. Switch to oxycodone/ hydromorphone / fentanyl if morphine SE REMEMBER to co-prescribe + PRN

20. Antiemetic Likely to be used a co-prescription or to reduce established nausea. Try simple meds 1 st line 1 st line = Cyclizine, Stemetil, Metoclopramide Consider other choices if co-existing symptoms e.g. Haloperidol, Dexamethasone Can use combinations. Doses may be higher eg 60-100mg metoclopramide over 24hrs. Avoid Metoclopramide if obstruction

21. Agitation/ Anxiety Consider reversible causes inc pain Consider non-drug treatments Consider underlying depression Medication: Haloperidol, BZD’s Short-acting BZD’s eg lorazepam s/l Sedating BZD’s eg Midazolam s/c Sedatives eg Phenobarbitol

22. Other meds Secretions – consider hyoscine patch or s/c Constipation – try & avoid with co- prescribing - Prescribe regular laxatives - Remember Co-danthrusate/ docusate - Seek nurse advice/ involvement Mouth Care – consider saliva sprays/ gel

23. Other meds - dexamethasone Has multiple uses at different doses & compatible in syringe drivers Anorexia - 2-4mg/ d Raised ICP – 16mg/d Gut obstruction – 4-8mg/d Hiccoughs – 4-12mg/d Anti-inflammatory – 4 –16mg/d

24. Medication example If opioid naïve a good starting point for oral route: Oramorph PRN & convert OR 10mg MST bd, then review. PLUS… Cyclizine 50mg tds. PLUS… Movicol1 sachet 2-4x per day Review regularly & if problems – seek help

25. Syringe Drivers – When, What, How When - Try & anticipate - Team decision - Can always be stopped - Ensure family aware. - Communicate well - STOP all other meds

26. What - Diamorphine (5-10mg if naïve) - Cyclizine (150mg) &/or Metoclopramide (60mg) - WFI - +/- Midazolam – 20-30mg/24hrs initailly - Ensure stat doses available & instructions to increase after 24hrs if necessary. - Special instructions eg GI haemorrhage.

27. How - Inform/ Involve family in decision - Inform DN’s or H at H - Prescribe meds - Write up instructions – Syringe driver & stat sheet. Be clear. - Inform LCD – fax - Ensure follow up in place

28. Other considerations Always ensure the person still wishes to remain at home. Keep family informed & advise re action to take in event of death Benefits – DS1500 Level 6 care/ Continuing care – poor prognosis LCD/ OOH form DNR form for transport

29. Cases

30. Conclusion Hopefully confidence increased Information packs include: - Handout - Yorkshire cancer network booklet - Dose comparisons of Strong Opioids - Syringe driver compatability info - Local pharmacy info - Forms – DNR, Level 6, LCD, Syringe driver, PEPSI COLA + DS1500 advice. Marie Curie Talks