Download Palliative Care Symptom Management

Palliative Care
Symptom Management
The Symptom Management Guidelines have been developed for palliative care patients in the
Community. For symptom management of palliative care patients in the Hospital setting contact
Hospital Palliative Care Team if required.
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FEBRUARY 2015
Contents
Breathlessness/Dyspnoea ...................................................................................................................... 3
Constipation ........................................................................................................................................... 5
Diarrhoea ................................................................................................................................................ 9
Delirium .................................................................................................................................................. 9
Fatigue .................................................................................................................................................. 10
Mouth Discomfort/Xerostomia (dry mouth) and Stomatitis. .............................................................. 10
Nausea and Vomiting ........................................................................................................................... 12
Pain ....................................................................................................................................................... 13
Managing Palliative Care Emergencies ................................................................................................ 18
i.
Hypercalcaemia ......................................................................................................................... 18
ii.
Spinal Cord Compression .......................................................................................................... 18
iii.
Malignant Bowel Obstruction ................................................................................................... 18
iv.
Superior Vena Cava Obstruction ............................................................................................... 19
v.
Massive Haemorrhage .............................................................................................................. 19
References ............................................................................................................................................ 20
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Physical Control of Symptoms
Breathlessness/Dyspnoea
In palliative care, breathlessness is often multi-factorial therefore it is relatively rare to use a specific therapy
to treat one cause.
The experience of breathlessness may vary between people at the end of life, dependent both on the causes
of the symptom and the person's perceptions of the meaning of the symptom. The distress caused by
increasing breathlessness should not be underestimated and in order for this symptom to be effectively
addressed, the multi-dimensional nature of the symptom means that more than a physical/pharmacological
approach may be required.

Use algorithm – see following page.
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Physical Control of Symptoms
BREATHLESSNESS / DYSPNOEA
Prevent or manage the related problems of
dyspnoea:
 addressing fear and anxiety by active listening,
exploration of the meaning of breathlessness for
each individual.
 The use of positioning, breathing control, coping
strategies, adaptation and energy conservation.
Initial Management
Treatment of underlying causes -treating the cancer
itself, the complications of cancer (i.e. pleural effusions,
anaemia) and concurrent non-cancer causes (i.e. heart
or lung disease).
Did first line treatment fail or was it
inappropriate?
Pharmacological treatments
 Opioids - the aim is to ease the sensation of dyspnoea. Doses should
be monitored on an individual basis.
Morphine Elixir
If Morphine Naive
2.5 mg 4 hourly prn




If on slow release Morphine
Non-Pharmacological treatments
 Addressing fear and anxiety by active listening,
exploration of the meaning of breathlessness for
each individual.
 The use of positioning, breathing control, coping
strategies, adaptation and energy conservation.
 Increasing airflow by use of fan or opening a
window. Cold flannel on face.
 Referral to physio for assessment & support.
 Graduated exercise is helpful if patient is able.
2.5 – 5mg prn dose may be
adequate & should be trialled if the
patient is on higher opioid doses.
There is no hard evidence that prn
dose of >10mg is more effective.
Benzodiazepines - can be of benefit with anxiety and fear eg
Midazolam nasal spray or longer acting Lorazepam used to calm
episodes or used pre-emptively.
Nebulised bronchodilators (using spacers) - are effective for
reversible airway obstruction and should be considered for a trial
period.
Oxygen – can be considered in the presence of hypoxia.
Steroids – are of benefit if obstruction, lymphangitis or inflammation
are present or suspected. Evidence for benefit is weak.
Towards the end of life non-pharmacological interventions tend to become
less effective and a greater reliance on pharmacological approaches is
common.
* Intra-nasal midazolam 15mg/3ml in a spray bottle at a dose of 1-2 puffs
in each nostril up to hourly PRN.
Did second line treatment fail?
Yes
Ask for help
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Physical Control of Symptoms
Constipation
Constipation can be defined as the small, infrequent or difficult passage of hard stools.
Causes of constipation are many and varied, and can include reduced activity, poor oral intake, unfamiliar
surroundings, or be indirectly due to cancer e.g. hypercalcaemia, drugs such as opioids, or anti-cholinergics,
and/or concurrent medical problems e.g. haemorrhoids.
In palliative care a lot of patients are immobile, have small appetites, paralysis, are bed bound and receive
constipatory drugs.
Assessment
 Thorough history taking, (especially past & present bowel habit)
 Abdominal and rectal examination
 Recording of bowel habits by the patient or family.
 Refer to Bristol Chart on Page 36.
Management
 Prevention is the key eg. Prescribing laxatives with opioid use and give pt/carer permission to titrate the
dose
 If a cause can be identified then efforts should be made to rectify this.
 Consider switching opioids to less constipating eg methadone or fentanyl
Non-pharmacological intervention
 Increase fluids & encourage exercise if appropriate. Fruit juice, kiwi crush may be helpful in some
patients
 Provide with commode or raised toilet seat if required
 Encourage/provide privacy
Pharmacological intervention
 Intervention to be considered depends on desired outcome.
 Always prescribe laxatives prophylactically and regularly when opioids are prescribed.
Types of Laxatives and Uses
Type
Action
Simulant
Stimulate the peristaltic
movement.
Example
Administration Hints
senna (in Laxsol™)
Bisacodyl
Fleet™
Dulcolax™



Lubricant
Lubricate the anorectum and
have a stimulant effect.
glycerine


Softeners
Change consistency of faeces.
Not the laxative of choice where
peristaltic action impaired e.g.
stroke, Parkinsons, impaction,
bowel obstruction.
Lactulose™ - needs to be
taken with adequate
water.Lax-sachets™ similar to an osmotic as it
draws water but does not
affect the electrolyte
balance. Coloxyl

Contraindicated in
suspected obstruction.
Can increase abdominal
pain.
If given rectally must be
inserted at least 4cm into
the rectum against the
mucous membrane of
the rectum, not into the
faeces – blunt end first.
Insert into the faeces –
pointed end first
Avoid using lubricant
with suppositories.
At least 125mls of water
needs to be taken at the
time of administration.
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Physical Control of Symptoms
Types of Laxatives and Uses
Type
Action
Bulkforming
agent
Provides fibre which adds bulk
to the stool.
Example
Administration Hints
Psyllium husk ( Konsyl-D)


Must be taken with a
significant amount of
water.
Tends to be used to
“maintain regularity” and
is not appropriate to
treat constipation due to
opioids.
Hospices of Northland Generalist Palliative Care Guidelines – Revised Electronic Version April 2010
Practice Point: All laxatives require a reasonable water intake to produce the best effect – especially the
osmotic laxatives such as Lactulose, softeners and bulk-forming laxatives such as metamucil. Optimise the
existing laxative regime rather than an automatic switch from one laxative to another especially in patients
who are frail & are eating or drinking less.
 Use algorithim – see following page.
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Physical Control of Symptoms
CONSTIPATION
Yes
Are faeces easy and
comfortable to pass?
Is constipation a risk?
Yes
No
Reassess
daily
No
PREVENTION OF CONSTIPATION
Maintain fluids and diet.
Encourage gentle mobility.
If having constipating drugs e.g. opioids, amitriptyline
use:
Laxsol 2 tabs nocte - 4 tabs b.d. Liquid preparations need to
be considered if tablets are a problem.
Dehydration, or immobility: titrate laxative to maintain
passage of a comfortable stool.
Maintain daily bowel record.
INTERVENTION:
Glycerine and Dulcolax suppositories, one of each via rectum,
being careful not to place in stool.
Increase softener and stimulant in daily regime.
Lax-achets – 2-8 sachets per day
Yes
Is the rectum full?
IF NECESSARY:
Microlax enema one or two via rectum. Consider fleet enema.
May require manual evacuation under sedative cover. e.g.
midazolam 5 mg subcutaneously.
No
PREVENTION:
See above.
Exclude obstruction.
Is stool unlikely to be the cause?
(abdominal x-ray early)
Yes
Consider appropriate management of
bowel obstruction (see management of
bowel obstruction section).
No
Is the colon
full?
Yes
If colic present consider oil enema, overnight
follow up mane with fleet enema.
If colic not present increase laxative.
Consider Lax- sachets – up to 8/day then review.
In impaction up to 8/day can be given in <6hours.
RETURN TO BEGINNING
Reassess every three days and ask
for advice if necessary
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Physical Control of Symptoms
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Physical
Control of Symptoms
Diarrhoea
Causes of diarrhoea must be sought and reversed. Infection, malabsorption and constipation/obstruction
with overflow are the most common and potentially reversible. Overuse of laxatives is also a common
occurrence. Patients undergoing chemotherapy and radiotherapy may also develop diarrhoea. Comorbidities such as ulcerative colitis or irritable bowel syndrome may also be present.
Management
 Modify diet
 Assess & treat overflow from constipation if present. Encourage fluid intake and use of Lax-sachets
2-8 sachets/day or may need manual removal followed by laxatives.
 If non-infective treat with loperamide or codeine phosphate.
 Review drugs – consider antibiotics, modify laxative
 Consider bulking agents
 Prescribe appropriate anti-diarrhoeal agent eg loperamide, codeine
 Seek specialist advice for control of co-morbidities, enzyme replacement eg pancrease
Delirium
Delirium is one of the most common neuropsychiatric problems in patients with end stage disease and a
major source of distress for patients and their carers. This may be present as a hypo or hyper active state.
The course of delirium may fluctuate over a number of hours and shows diurnal variation. Symptoms
include:
 Disorientation
 Fear and dysphoria
 Memory impairment
 Reduced attention span
 Altered sleep wake cycle
Delirium may be classified as hyperactive, hypoactive or mixed.
Risk factors include: drugs, infection, metabolic disturbances, hypoxia, dementia, co-morbidities,
advanced disease especially with brain involvement and pain. In the frail & elderly constipation & poor
mobility may also be triggers for delirium. A good work-up is necessary to find a cause, correct the
reversible and offer management. It is important to have a high suspicion of hypoactive delirium as such
patients may not receive the appropriate attention as do those with hyperactive delirium. Delirium may
also be part of the terminal phase.
Management
 Pharmacological intervention
 Review drugs including opioids
 Correct metabolic disturbances eg hypercalcemia or infection
 Start anti psychotics – haloperidol, risperidone, quetiapine or olanzepine
 Acute Agitation/paranoia –use parenteral Haloperidol or Methotimeprazine +/- a Benzodiazepine for
sedation, but note that benzodiazepines alone may worsen symptoms in non terminal patients.
 If terminal, prescribe ongoing sedation with Midazolam for sedation +/- antipsychotic eg
levomepromazine (Nozinan)
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Physical
Control of Symptoms
Non Pharmacological intervention
Explanation to patient and family of all that is being undertaken is mandatory.
 Ensure there is a safe environment
 Prevent sensory overload
 Psychological interventions — reassurance, orientating aids (clock, personal belongings, presence of
family), emotional support (touch, empathy), clarification, validation and repetition during lucid periods
 Family and/or carer support is vital.
Fatigue
Fatigue is the term used to encompass physical weakness (asthenia) and mental tiredness. It may be
experienced and expressed as easily tiring, generalised weakness or mental tiredness. It is a very
common accompaniment of end stage cancer or end organ diseases. It is often assumed that it is an
evitable consequence of approaching death. However reversible situations must be excluded. It is also
important to exclude the cause of localised weakness that could result from stroke, spinal cord damage
or nerve root damage.
Management
 Establish cause – eg, hypercalcaemia, dehydration, infection
 Review drug regime – eg B.blockers
 Correct metabolic abnormalities if appropriate – Dehydration
Non Pharmacological Interventions
 Give dietary advice and support, increase calorific intake if appropriate
 Adapt activities of daily living to coincide with times of maximal energy
 Arrange for help from loved ones, home care, hospice, district nursing as appropriate
 Exercise – gradual exercise is helpful & can keep patients & families motivated
Pharmacological Interventions
 Corticosteroids
- mechanism of action is unclear (studies suggest a modest energy enhancing effect in cancer
patients only)
- benefit may decrease after 4-6 weeks – regular review of benefits must be carried out and
slow weaning off carried out when there is no further benefit.
- see dose as in anorexia/cachexia (Section 3.1.2).
- methylphenidate may occasionally be used under Specialist guidance.
Mouth Discomfort/Xerostomia (dry mouth) and Stomatitis.
Good mouth care and oral hygiene is essential to the wellbeing of patients debilitated by advanced
disease. Please follow algorithm
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Physical Control of Symptoms
.
PREVENTATIVE MEASURES:
 12 hourly brushing with toothpaste, rinse well. Ensure
dentures are cleaned and soaked e.g. Sterident.
 12 hourly mouthwash (remove dentures if present)
IS THE MOUTH
HEALTHY?
Yes
(intact mucosa, clean, moist and
pain free)
No
IS ULCERATION
PRESENT?
IS INFECTION PRESENT? - YES
 Treat if appropriate
Viral - consider acyclovir
Bacterial - anaerobic use metronidazole orally.
- aerobic use flucloxicillin
 If painful apply Bonjela (cholinesalicylate), use Difflam
mouthwash
Yes
No
IS THE MOUTH DIRTY?
(coated tongue, mucosa or
teeth; oral debris).
CANDIDA?
Yes
Yes
No
No

Tongue and Teeth: clean with ½ tsp sodium bicarbonate and ½ tsp salt in
one cup of warmed water. Soak dentures overnight in chlorine releasing
solution e.g. Sterident or Nystatin.
Mucosa: effervescent solution (e.g. soda water or cider water)

IS THE MOUTH
DRY?
 Treat cause
Yes
No
IS THE MOUTH
STILL PAINFUL?
No
If candidal overgrowth (white patches or coating):
 Using ½ tsp of Sodium Bicarbonate and ½ tsp salt
mixed with a cup of warm water, clean mouth (use
as mouthwash) ensuring dentures are removed prior
to mouthwash.
 Use solution to brush teeth and tongue.
 Oral nystatins drops QID - ensure dentures are
removed when taking this. Swish around mouth (as
this works on contact only), and then swallow.
 Fluconazole 50 mg daily for five days (If severe or
not responding to Nystatin) .


- dehydration (if appropriate)/infection/anxiety.
- consider medication change
Local measures: frequent sips of water and regular mouthwash/use
atomizer spray with water/ice cubes to suck/frozen fruit juice/pineapple
chunks or juice/moisten lips with aqueous cream / oral lubrication.
Consider: Artificial saliva e.g. Biotene oral gel

Yes
Topical analgesics: Benzydamine (Difflam) mouthwash/choline
salicylate gel (Bonjela) dispersible aspirin mouthwash
 Consider: Candidal infection (may cause a red, painful mouth without
patches) - see above
 Use soft toothbrush or foam sponge toothbrushes
 Zylocaine viscous.
RETURN TO BEGINNING
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Physical Control of Symptoms
Nausea and Vomiting
These are common symptoms in palliative care. The causes are many and several may be present at any
one time.
Important considerations in the management of nausea & vomiting.
 Attempt to establish a cause
 Reverse the cause if possible eg hypercalcamia, constipation, UTI
 Use a ‘broad spectrum’ antiemetic (see table below) whilst the possible cause/causes is being
established.
o Domperidone and metoclopramide 10mg tds a/c or qid if prokinesis is to be encouraged
o levomepromazine (Nozinan) – 6.25mg nocte
o When there is more clarity around the cause choose the appropriate anti-emetic or
combination of anti-emetics. Eg inner ear /peritoneal origin may respond best to anti
muscarinic/histminic approach.
 Subcutaneous route of administraton
 Consider other drugs – eg anxiolytics if anxiety induced, gastric protection if gastric irritation is
suspected.
 Seek specialist advice as control of nausea & vomiting may be complex and difficult.
 Prescribe regular medication and prn doses.
The following table gives an indication of receptor site affinities for the anti-emetis commonly used in
palliative care.
14-16
Receptor site affinities of selected antimetics
Dopamine Histamine
D2H1antagonist antagonist
a
Metoclopramide
++
0
Domperidone
a
Acetylcholine
(muscarinic)
antagonist
0
5HT2antagonis
t
0
5HT3antagonis
t
(+)
5HT4antagonis
t
++
++
0
0
0
0
0
0
0
0
0
+++
0
Cyclizine
0
++
++
0
0
0
Hyoscine hydrobromide
0
0
+++
0
0
0
b
+++
0
0
0
0
0
++
+++
++
+++
0
0
Ondansetron
Haloperidol
b
Levomepromazine
c
(methotrimeprazine)
Pharmacological activity: 0 none or insignificant, + slight, ++ moderate, +++ marked
a. Domperidome & Metoclopramide both have prokinetic activity and encourage gastric emptying. Metoclopramide
crosses the blood-brain barrier and exerts a central effect but may cause dystonic reactions, decreased mental acuity
and drowsiness. Domperidone may therefore be a better option for patients who are on antidepressants, antipsychotics or the elderly.
b. Haloperidol 1.5 – 3mg nocte is the drug of choice for ‘chemically’ induced nausea including that caused by opioids.
c. Nozinan (methotrimeprazine) 6.25mg nocte has affinities for several receptor sites and is a good first line broad
spectrum anti-emtic.
Regular follow up is necessary and combinations of drugs may be required to achieve as much receptor
activity as possible.
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Physical Control of Symptoms
Non Pharmacological Intervention
 Consider elements that may affect nausea — smells, dirty mouth, past experiences recalling episodes
of vomiting.
 Regular mouthcare including the treatment of oral thrush
 Education of family to provide small attractive meals.
 Ginger and ginger drinks do have anti-nausea effect.
Pain
Pain is a multi-dimensional feature occurring in up to 90% of patients who receive palliative care,
including those with a non-malignant pathology. It requires constant assessment, management review
with attention to detail and prescribing that is tailor made to each particular patient. It requires constant
diagnosis of possible causes, the correction of reversible causes, and the search for the most appropriate
medication. If uncontrolled, pain has a huge impact on a patient’s quality of life, limiting sleep, rest,
mobility, social interaction, work, activities and family life therefore contributing to suffering.
Assessment
Each pain described requires an in-depth history taking eg the site, quality, severity, timing and triggering
factors need to be explored, including the drugs that have been used and their effect. Other features
such as anxiety, reactions to life events, concerns, and family realities must also be extracted.
A good physical examination will help determine the site and type of pain.
The types of pain can be:
1. Somatic – pain in solid body parts..
2. Visceral – this usually involves the organ capsule and apart from opioids may respond well to the use
of an anti-inflammatory medication.
3. Neuropathic – because the pain is transmitted via injured or affected nerves this pain may require
adjuvant drugs apart from opioids of which Methadone may be the better option. (see below)
4. Incident pain – this pain occurs when triggered by positional change, cough or another precipitant.
It may occur in the absence of a background pain and may be quite challenging to control with drugs
only.
5. Break through pain – transient increase in pain.
6. Colicky pain is intermittent pain that occurs with increased organ activity of smooth muscle in the
bladder, uterus or bowel. This requires specific anti-spasmodic medication and can include opioids.
7. Other pain types include headaches from increased intra-cranial pressure, central pain generated
from intracerebral tumours or damage, and sphincter pain such as bladder spasm and anal tenesmus.
Management of Pain
The management of pain should follow basic steps which can be effective in up to 90%
of patients. Specialist palliative care services or Specialist pain services provide ongoing support and
specialist input when this is necessary.
The WHO ladder of Analgesia has been the guide in pain relief. It involves three steps
 Mild pain generally controlled by non-opioids or NSAID’s
 Moderate pain generally controlled by ‘mild’ opioids +/- NSAID’s
 Severe pain necessitating use of ‘strong’ opioids +/- NSAID’s
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Physical Control of Symptoms
Important Considerations
 An NSAID may be used as an initial drug as can paracetamol (+/- codeine) especially in the case where
there is inflammatory element to the pain. It should then be considered at every step together with the
use of opioids and other drugs.Consider the role of gastro protection with a PPI.
 Consider the co-prescripion of a PPI with NSAID use for gastro-protection
 Pain in palliative care patients is chronic and requires regular medications together with prn doses for
breakthrough episodes.
 Most analgesics can be given orally unless this route is compromised by nausea, vomiting, dysphagia or
malabsorption.
 As pain escalates, the opioid dose must be titrated upwards to reflect the increase in pain.
 At every step, the inclusion of co-analgesic drugs should be considered. This is especially important in
the case of neuropathically generated pain.
Opioids




Morphine
Methadone
Fentanyl
Oxycodone
Co-analgesic drugs







NSAID’s for inflammation
CorticoSteroids
Tricylic anti-depressant eg Amitriptyline
Anti-convulsant eg Gabapentin, Na Valproate
Benzodiazepines for muscle relaxation, anxiety
Antibiotics for infection
Bisphophonates in bone pain (approved for breast
cancer & myeloma)
Side effects may limit drug tolerance or escalation. If the opioid is effective consider drugs or other
measures to counteract these side-effects before switching the opioid eg
 Haloperidol for hallucinations
 Nozinan or Meloclopramide. Haloperidol for emesis
 Laxatives for constipation (required in most cases)
 Opioid rotation may become necessary to control pain or minimize side-effects. The following flow
chart provides some simple steps as guidelines towards the better choice of opioid. Conversion doses
on the other hand are not straightforward and may require specialist advice (see flow chart).
 Regular review is necessary and non-drug measures must be considered and explained eg rest,
relaxation, distraction, adequate sleep, adaption of life style.
 Unrelieved pain or pain escalation may require investigation and referral to specialist services including
radiotherapy.
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Physical Control of Symptoms
Algorithm for Opioid Use
Pain requiring opioids
Constipation/bowel obstruction
Renal impairment
no
yes
morphine
Laxatives?
+/- switch
Fentanyl +
Oxycodone prn
Fentanyl +
Morphine prn
(methadone may
Effective
Effective
be less constipating)
Not effective
Effective but hallucinations
Is the pain
neuropathic?
Not effective –
colic persists
Effective
Boney
pain?
Oxycodone
Switch to methadone
and add adjuvants
Add NSAID and
consider switch to
methadone / RT
Return to morphine/use
methadone optimise
laxatives
Page 15
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Physical Control of Symptoms
Morphine
 Oral morphine is available in the long acting form (m-Eslon or LA Morph) and the quicker/short
acting form (Sevedol tabs or Liquid in several strengths).
 The usual starting dose for morphine when used for pain is 2.5 – 5mg 4hrly prn if the pain is
intermittent or 10mg 12hrly if the pain is constant.
 PRN doses must always be prescribed and the dose of these must increase if the total dose of
regular morphine is increasing. As a general rule, the prn dose must be at least 1/6 of the total
daily morphine dose. In some cases eg incident pain, the intensity of the episodes far outruns
the level of pain at rest and requires higher PRN doses.
 Laxatives must always be prescribed regularly with morphine unless contraindicated eg.
Ilieostomy. Aniti-emetics may be required and should be prescribed on an as needed basis.
Drowsiness may be an initial side-effect which may wear off after a few days.
 If or once the oral route becomes difficult, morphine sulphate is available for subcutaneous use.
The oral to subcut dose must be halved due to increased bio availability.
 Subcutaneous morphine may be given intermittently every 3hrs prn for episodic pain or
continuously via a syringe driver. Morphine sulphate mixes well with most other medications
when given via this manner.
 Consider the use of an adjuvant drug for pain
 If the pain is not morphine responsive or if side-effects become intolerable or uncontrollable
consider the addition of an adjuvant drug or switch to another opioid. (see flow chart).
Methadone (best under specialist guide)
 Methadone is available as tablets, liquid or ampoules.
 Toxicity sedation and respiratory depression can be sudden and after 4-5 days of accumulation
 The starting dose of methadone is usually 2.5mg 12hrly for constant pain or 2.5mg prn 3-4 hrly
for intermittent pain, but maximum of 7.5 mg per 24 h for PRN)
 PRN doses are the same as the regular and may be given 4hrly, however methadone levels may
accumulate and it is therefore necessary to review the total daily dose of Methadone on the
second or third day if drowsiness or other side-effects develop.
 Requires regular monitoring (4-5 day intervals) when commencing methadone
 Specialist advice is usually required to titrate methadone to higher doses.
 Methadone may be given i.m or subcutaneously if the oral route is compromised. The
conversion from oral to the subcutaneous route is 80%. Caution must be executed with higher
doses.
Fentanyl
 Fentanyl is available as transdermal patches of varying strengths starting from 12.5mcg/hr
patches, or in the injectable form which can be given subcutaneously and is used to titrate
against pain levels in an inpatient setting eg. 600mcg of subcutaneous Fentanyl in 24hrs is
equivalent to the 12.5mcg/hr patch and converts to between 30-60mg of total daily oral
morphine.
 There is no quick acting Fentanyl currently available in NZ that may be self administered.
Breakthrough pain is best controlled with oral Morphine.
Page 16
FEBRUARY 2015
Oxycodone
 Oxycodone is available in 2 forms – the long acting controlled release, 12hrly MR (modified
release) tablets and the quick acting form (oxycodone immediate release).
 Oxycodone is twice as potent as morphine mg for mg.
 Oxycodone is 80% bioavailable so oral to s/c should respect a20 % reduction in dose for
equivalence.
 The indications for converting to oxycodone is the lower side-effect (eg hallucinations) profile it
may have in some patients.
 Pain that is not sensitive to morphine is not responsive to oxycodone but its potentially lower
side effect profile may allow better tolerance and escalation of the drug.
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Physical Control of Symptoms
Managing Palliative Care Emergencies
Situations in palliative care that require urgent attention and a level of suspicion.
i.
Hypercalcaemia
The features of hypercalcamia include the following:
 Nausea, vomiting, malaise
 Increasing pain
 Increasing confusion, delirium and drowsiness
 Polyuria
 Constipation
One should have a level of suspicion if these or some of these symptoms are present especially in
cases where there are known boney metastases. Squamous cell lung cancers and renal cancers can
commonly produce non-metastatic hypercalcaemia.
These patients need investigation and must be referred to specialist services.
ii.
Spinal Cord Compression
This requires urgent attention or must be suspected if the following are present in patients with
known or suspected boney metastases.
 Increasing or changing back pain +/- boney tenderness
 Sensory changes in the limbs, perineum, eg paraesthesia, numbness
 Constipation, urinary hesitancy/retention
 Faecal and/or urinary incontinence
 Weakness effecting lower limbs, upper limbs or both
On examination there may be a sensory level, sensory abnormalities, reduced reflexes and
decreased muscle power. Referral is urgent and management includes high dose steroid & urgent
radiotherapy (16 mg od).
iii.
Malignant Bowel Obstruction
Several conditions may give rise to this. After surgical intervention is excluded, medical management
is possible for control of symptoms and possible reversible of the obstruction.
Bowel obstruction must be considered when there is:
 No bowel motion or passage of flatus for several days
 Nausea & vomiting
 Colicky gripey pain +/- background abdominal pain
 Abdominal distention
 Generalized malaise, fatigue
 Dehydration
Specialist referral is necessary.
Management includes high dose steroid, subcutaneous administration of anti-emetic, analgesics and
anti-muscarinics.
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Physical Control of Symptoms
iv.
Superior Vena Cava Obstruction
Requires to be considered especially in lung cancer, particularly small cell.








Breathlessness (caused by laryngeal oedema)
Choking sensation
Neck and facial swelling
Headache / or feeling of fullness in the head
Trunk and arm swelling
May have visual changes
Dizziness
Upper trunk venous engorgement
On examination there may be delated non-pulsatile neck veins, dilated collateral veins of chest and
arms and engorged conjunctive, peri-orbital oedema.
Specialist referral is necessary.
Management includes high dose steroids, radiotherapy, chemotherapy and in some cases metal
stenting into the SVC.
v.
Massive Haemorrhage
The potential to be an extremely distressing event.
Patients at risk generally fall within the disease categories listed below:
 Head and beck cancers
 Cancer of the bronchus
 Gastrointestinal cancer
Management includes discussion with patient and families regarding the possibility that this may
occur. The use of s/c medications such as midazolam need to be available. Practical information
around the availability of dark towels to help protect and clean is also suggested.
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Physical Control of Symptoms
References
Best Practice Vol 3 Issue 1, (1999). Management of Constipation in Older Adults. Available online
www.joannabriggs.edu.au.
Costello, H. (2002). Living with cancer related breathlessness. The Cancer Society of NZ Wellington Division
Inc.
nd
Doyle, D., Hanks, G., & MacDonald (1998).Oxford Textbook of Palliative Medicine (2 edition) Oxford: Oxford
University Press.
Hoyal, C., Grant, J., Chamberlain, F., Cox, R., & Campbell, T. (2002). Improving the management of
breathlessness using a clinical effectiveness programme. International Journal of Palliative Nursing, Vol 8(2).
th
Maddocks, I, (2001) Palliative Care: A Guide for General Practitioners (8 ed.) Dawpark: South Australia.
MacLeod, R., Vella-Brincat, J., & Macleod, A. (2002). The Palliative Care Handbook. Guidelines for Clinical
Management and Symptom Control, Hutcheson, Bowman & Stewart.
Regnard, C. & Hockley, J (1995). Flow diagrams in Advanced Cancer and Other Diseases. London: Hodder
Headline PLC.
Thomas, K.(2003). Caring for the Dying at Home. Companions on the Journey. Oxford: Radcliffe Medical Press.
Twycross, R., & Wilcock, A. (2004). Symptom Management in Advanced Cancer. (3rd edition). Oxford:
Radcliffe Medical Press.
World Health Organisation (1956) Cancer Pain Relief, WHO, Geneva.
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