Download FACTSHEET 16 ON PALLIATIVE CARE EMERGENCIES IN

Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
FACTSHEET 16 ON PALLIATIVE CARE
EMERGENCIES IN PALLIATIVE CARE
See also Cambridgeshire Community Services policy for anticipatory prescribing for
patients with a terminal illness (‘Just in Case’)
http://www.cambridgeshireandpeterboroughccg.nhs.uk/downloads/CATCH/Just_in_Case_
Policy.pdf
Palliative care emergencies encompass not only situations that are imminently life
threatening, but also those that could result in impaired quality of life for the remainder of
the patient’s life, or for the family in their bereavement.
When planning the care of your patient:
be aware of potential “emergencies”
e.g. patient with vertebral metastasis/metastases likely to develop spinal cord
compression.
be aware of patient’s wishes, in the event of emergency – check for documentation
in regard to preferred priorities for care (PPfC), advance decision to refuse
treatment (ADRT), resuscitation status (DNACPR)
be aware of family/carer wishes
e.g. to be with patient whatever happens.
focus on anticipating emergency and planning appropriately in advance.
e.g. green towels and sedation for haemorrhage: emergency contact number.
‘Emergencies’ considered in this factsheet are:
haemorrhage
stridor
choking
psychiatric emergency
spinal cord compression
superior vena cava obstruction
raised intra cranial pressure
hypercalcaemia
Drugs most frequently prescribed in an emergency
diamorphine injection 5mg or 10 mg ampoule diluted with water for
subcutaneous administration
midazolam injection 5mg/ml 2ml ampoule for subcutaneous or buccal
administration
lorazepam 1mg tablet for sublingual (prescribed as ‘Genus’ brand) or oral use
haloperidol injection 5mg/ml 1ml ampoule for subcutaneous administration
glycopyrronium injection 200microgram/ml – 1ml ampoule for subcutaneous
administration
Water for injection
Page 1 of 6 Factsheet 16
Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
Haemorrhage
predisposing factors :
cancer related
chemotherapy related
biochemical
pharmacological
tumour invasion
abnormal clotting, platelet dysfunction
reduced platelet count
uraemia, hepatic dysfunction
NSAIDS, anticoagulants, SSRI’s
haemoptysis, carotid ‘blow-out’ gastro-intestinal
bleed
consider in advance:
discussing issues of resuscitation
use of sedation, prophylactically and in the acute situation
whether family would/or would not want to be present
NB catastrophic haemorrhage (e.g. carotid blow-out) can cause (almost) instantaneous
death with no time for any treatment – stay with the patient.
Suggested treatment:
have a supply of dark towels readily available
severe haemorrhage lasting minutes/hours is frightening for patients and carers –
sedation should be readily available and rapidly administered.
benzodiazepine – preferably midazolam intravenously/buccal 5mg repeated as
necessary to maintain drowsiness.
The subcutaneous route is not effective where there is peripheral “shutdown” due
to blood loss.
in a patient’s home/care home rectal diazepam 10mg is an alternative, but if
appropriate individual arrangements for availability of midazolam may be made.
Stridor
The high-pitched sound of breathing (in and out) when partial laryngeal/major airway
obstruction is present e.g.in tumours of head and neck or mediastinum.
Problems arise due to exhaustion from laboured breathing and anoxia:
in a hospital environment intervention (bronchoscopy, laser therapy,
chemotherapy) may be considered.
in a patient’s home/care home consider whether referral for intervention
appropriate: pre-emptive planning for either tracheostomy or sedation will require
detailed discussion
alleviate anxiety with benzodiazepine – midazolam 5mg subcutaneously
maximum hourly
or diazepam 5mg orally (maximum 20mg per day)
Page 2 of 6 Factsheet 16
Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
Choking
Inability to breathe due to acute obstruction of the pharynx, larynx or trachea. Can be due
to local tumour, more often due to neurologically mediated swallowing difficulties – Motor
Neurone Disease, skull base metastases.
Discuss the situation with patient and carers:
acknowledge fears
discuss possible interventions (involve speech therapist in assessment where
appropriate).
Acute situation:
where available midazolam 5 to10mg
can be given
+/- diamorphine 5mg
subcutaneously or intravenously
rectal diazepam (10mg) if no other treatment available
If prolonged/repeat bouts of choking: anti secretory agents (glycopyrronium 200
micrograms ampoule administered subcutaneously as required 4 hourly) may be helpful.
Psychiatric Emergencies
Patients presenting with extreme anxiety/apprehension will usually respond to
benzodiazepines and a calming environment.
lorazepam 500micrograms sublingually/orally repeated as necessary to
maximum 4mg in 24 hours
midazolam 2.5 to 5mg buccal/subcutaneously repeated as necessary to
maximum 30mg in 24 hours
diazepam 5mg orally repeated as necessary to maximum 20mg in 24 hours
Agitation may require haloperidol 5mg repeated if necessary to 10mg maximum
subcutaneously as bolus (reduce in the elderly to half dose).
Paranoia and/or aggressive behaviour occasionally occur, especially in patients with
cerebral disease. Patients are often very fearful and distressed and despite advanced
disease show unexpected mobility and strength. The situation is distressing also for
family and professional carers.
Exceptionally:
To gain control, (preventing harm to self or others), haloperidol 10mg intramuscularly,
should be administered. (This may require restraint to enable administration of
medication).
NB small doses of benzodiazepines without an antipsychotic may aggravate the situation.
Advice from psychiatrist and/or palliative care team should be sought and regular antipsychotic medication may be required.
Page 3 of 6 Factsheet 16
Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
Metastatic Spinal Cord Compression (MSCC)
10% of all cancer patients develop MSCC. Be aware of the possibility in any patient with
vertebral metastasis particularly in cancer of lung, breast, prostate, kidney, multiple
myeloma or non-Hodgkin lymphoma.
NICE guidance states the following action for any cancer patient:
“Contact the MSCC (Metastatic Spinal Cord Compression) coordinator urgently (within
24 hours) to discuss the care of patients with cancer and any of the following symptoms
suggestive of spinal metastases:
– pain in the middle (thoracic) or upper (cervical) spine
– progressive lower (lumbar) spinal pain
– severe unremitting lower spinal pain
– spinal pain aggravated by straining (for example, at stool, or when coughing or
sneezing)
– localised spinal tenderness
- nocturnal spinal pain preventing sleep
Contact the MSCC (Metastatic Spinal Cord Compression) coordinator immediately to
discuss the care of patients with cancer and symptoms suggestive of spinal metastases
who have any of the following neurological symptoms or signs suggestive of MSCC, and
view them as an oncological emergency:
– neurological symptoms including radicular pain, any limb weakness, difficulty in walking,
sensory loss or bladder or bowel dysfunction
- neurological signs of spinal cord or cauda equina compression.”
Currently, in Cambridgeshire, the Metastatic Spinal Cord Compression Coordinator is the
oncology Registrar on-call in the local cancer centre – contactable through the hospital
switchboard. (Addenbrookes Hospital 01223 245151)
More than 25% patients develop paraplegia in less than 48 hours from presentation.
Median survival after compression has occurred and impairment/loss established is 7-10
months, but up to 30% of patients live with their disability for more than a year.
Superior Vena Cava Obstruction (SVCO)
SVCO is due to compression, obstruction or thrombosis impairing central venous return if active intervention is appropriate hospital admission will be required for assessment
and possible chemotherapy/radiotherapy, stenting etc
NB Local Cancer Network guidelines for Superior Vena Cava Obstruction should be
consulted.
SVCO occurs most frequently in cancer of lung (70% of cases) or lymphoma (8%)
Page 4 of 6 Factsheet 16
Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
Symptoms:
dyspnoea
facial/upper body/ arm swelling and/or skin mottling
headaches/’muzziness’
cough
dysphagia
After treatment, average survival is 8 months.
If a patient is either bed
bound/terminal/refusing intervention, or after discussion with oncologist no further
treatment is available, all symptom control/care measures should be given and nursing
support arranged (seek specialist advice)
Raised Intracranial Pressure
May arise from:
Cerebral metastases – most commonly bronchus, breast, testicular teratoma,
malignant melanoma, non-Hodgkin Lymphoma
Primary intracranial tumour – astrocytoma, meningioma, oligodendroglioma,
glioblastoma.
Symptoms may include:
headache, (worst on wakening), nausea +/- vomiting, drowsiness, convulsion,
visual disturbance.
Signs:
papilloedema, bradycardia, raised blood pressure, cranial nerve lesions.
If suspected discuss with oncologist/palliative care specialist.
Hypercalcaemia
20% of all patients with malignant disease will develop hypercalcaemia: this occurs most
commonly in breast cancer, renal cell cancer, myeloma, squamous cell tumours and
lymphoma N.B. treating, or repeatedly treating hypercalcaemia in advanced/advancing
disease may not be beneficial in terms of quality of life.
Symptoms may include:
Thirst, polyuria, anorexia, nausea, headache, constipation, mental blunting, cardiac
dysrhythmia, deterioration in pain control
if suspected FIRST consider whether further intervention is appropriate/acceptable
(discuss with palliative care specialist)
if further intervention required – request admission for treatment
for patients not undergoing interventional treatment, full symptomatic treatment
should be continued
IF ANY UNCERTAINTY REGARDING MANAGEMENT
SEEK SPECIALIST ADVICE
Page 5 of 6 Factsheet 16
Cambridgeshire Palliative Care Guidelines Group
Review Date: September 2016
General palliative care references include:
‘Palliative Care Formulary’, Fourth Edition (PCF4)
Edits: Robert Twycross and Andrew Wilcock available via Palliativedrugs.com
Palliative Adult Network Guidelines Third Edition (also available as an App)
Edits: Max Watson, Caroline Lucas, Andrew Hoy, Ian Back, Peter Armstrong
Specific references for factsheet 16:
NICE Guidance Nov 2008 Metastatic spinal cord compression: diagnosis and
management of adults at risk of and with metastatic spinal cord compression
Page 6 of 6 Factsheet 16