Download End of life care

End of life care
Dr Maelie Swanwick
Consultant in Palliative Medicine
Derby Hospitals NHS Foundation Trust
Principles of palliative care
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Regards death as a normal process
Neither hastening nor postponing death
Provides relief from pain and other symptoms
Integrates psychological and spiritual aspects of
pain
• Offers a support system for the patient and family
during the illness and in the family’s bereavement
How do you recognise a
palliative patient ?
• Disease trajectories less predictable with
chronic organ failure compared with cancer
• Clinical indicators
– General eg weight loss, physical decline,
reduced performance status seen in all
– Specific
• The surprise question
• Patient choice or need
How do we recognise the dying
patient
• Indicators of irreversible decline, gradual
but progressive
– Profound weakness
– Drowsy and disorientated
– Diminished oral intake, difficulty taking
medication
– Poor concentration
– Skin colour and temperature changes
Why is it important to recognise
the palliative patient
• To allow the doctor and patient to make
appropriate decisions
– Treatment
– Place of death
– Most of the final year of life is spent at home
yet most people are admitted to hospital to die
– Most dying people would prefer to die at home,
around 25% do so
– More than 50% cancer patients die in hospital
Principles of management
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Relieve physical symptoms promptly
Consider multifactorial nature of symptoms
Remember the psychosocial/spiritual
Avoid unnecessary medical intrusion
Stop unnecessary drugs
Continuity of care
Anticipate problems
Common symptoms at the end of
life
• Symptom burden in the last year of life
remarkably similar despite diagnosis
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Fatigue
Pain
Breathlessness
Nausea and vomiting
• Principles of palliative care are not restricted to
cancer patients nor to the last few days of life
Types of pain
• Visceral
Dull, aching, diffuse, continuous, colicky
eg liver capsular pain, bowel spasm
• Bone
Localised, bone tenderness
eg bony metastases, fractures, arthritis
• Nerve
Burning, prickling, shooting
Allodynia, hyperalgesia, hyperpathia
eg nerve root infiltration, post-herpetic neuralgia
• Myofascial
Localised muscle pain
Types of pain
• Visceral
Dull, aching, diffuse, continuous, colicky
eg liver capsular pain, bowel spasm
• Bone
Localised, bone tenderness
eg bony metastases, fractures, arthritis
• Nerve
Burning, prickling, shooting
Allodynia, hyperalgesia, hyperpathia
eg nerve root infiltration, post-herpetic neuralgia
• Myofascial
Localised muscle pain
Types of pain
• Visceral
Dull, aching, diffuse, continuous, colicky
eg liver capsular pain, bowel spasm
• Bone
Localised, bone tenderness
eg bony metastases, fractures, arthritis
• Nerve
Burning, prickling, shooting
Allodynia, hyperalgesia, hyperpathia
eg nerve root infiltration, post-herpetic neuralgia
• Myofascial
Localised muscle pain
Analgesia
• Consider the cause
• WHO analgesic ladder
– Step 1
– Step 2
– Step 3
Paracetamol +/- NSAIDS +/- adjuvant
Weak Opioids + Step 1
Strong Opioids + Step 1
• Adjuvant drugs
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Antidepressants – amitriptyline
Anticonvulsants – carbamazepine, gabapentin
Antiarrhythics – mexilitine
Dexamethasone
Morphine
• The opioid of choice in the UK
• Pre-empt common S/Es including constipation,
sedation, N&V and visual hallucinations
• Renally excreted so start with low dose in renal
impairment or the elderly
• Give preferably PO but can be given SC
• Long and short-acting preparations
• Adequate breakthrough analgesia
Morphine conversion
• 3mg PO morphine = 1mg sc diamorphine
• Eg 30mg MST bd for pain control
In 24 hours = 60mg morphine.
Equivalent dose of sc diamorphine
60/3 = 20mg diamorphine
Pain problems at home
• Pain may worsen
• New pains may emerge
• Route of administration may not be
effective
• Adequate supplies of breakthrough
analgesia
• Alternative analgesia
Nausea & vomiting
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Tailor anti-emetic to presumed cause
Clear instructions on administration
Appropriate route and formulation
2nd line anti-emetic
Breathlessness
• Very common problem
• Causes varied, both malignant and
non-malignant
• Holistic management
– drug measures
– non-drug measures
“Death rattle”
• Retained secretions in the upper airway
• Distressing for carers to hear, usually
not bothering patient
• Postural drainage
• “Drying” agents
– Anticholinergic drugs
Terminal agitation
• Up to 75% patients develop delirium or
agitation during the last few days of life
• Is it reversible, treat cause if possible
• Reassurance to family
Drugs for sc use
DRUG NAME
Licensed
Acceptable
Diamorphine
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Y
Cyclizine
N
Y
Metoclopramide
N
Y
Levomepromazine
Y
Y
Haloperidol
N
Y
Midazolam
N
Y
Dosage guidelines
DRUG
Diamorphine
Cyclizine
Dose range
5mg +
100 – 150mg
Comment
Pain
Nausea & vomiting
Haloperidol
2.5 – 5mg
5 – 10mg
Nausea & vomiting
Restlessness or confusion
Hyoscine
butylbromide
Levomepromazine
20 – 60mg
Secretions
12.5- 50mg
Low dose – antiemesis
Higher doses for sedation
Midazolam
10 – 60mg
Anxiolytic, sedation
64 yr old man with recurrent
bowel cancer
• Complained of:
– Lower back and left buttock pain
– Pain radiates down left leg with altered sensation
– Intermittent abdominal colicky pain with constipation
and vomiting
• On examination:
– Prolapsed stoma with empty stoma bag
– Distended tympanic abdomen
– Painful non-erythematous swelling of left buttock
Problems
• Pain
– From pelvic tumour invading ilium
– Neuropathic pain down left leg from pelvic tumour invading sacral
plexus
– Bowel colic from intermittent partial bowel obstruction
• Body image
– Large herniated stoma and buttock swelling
• Intermittent partial bowel obstruction
– Nausea and vomiting
– Constipation
Treatment
• Pain
– Radiotherapy tried initially
– Oral morphine titrated upwards for tumour pain
– Amitriptyline initially caused too many S/E, so tried
carbamazepine
• Bowel obstruction
– Stool softeners and avoided stimulant laxatives or prokinetic
antiemetics
– Dexamethasone to relieve partial obstruction
– Cyclizine for nausea
• Body image
– Multidisciplinary approach with stoma nurses, DN’s & Macmillan
nurses providing practical and emotional support
Progress
• Initially some improvement in pain but not fully
pain controlled
• S/E’s limited opiate dose, switch to oxycontin had
a similar effect
• NSAID added
• Increasing weakness
• Frequent vomits of partially digested food, nil
from stoma
• Difficulty taking anything orally
• Became drowsy, confused with myoclonic jerks
• Renal impairment secondary to the reduced intake
and vomiting led to opiate toxicity
• Started on the LCP
• Oral medication stopped
• Syringe driver was used with a reduced dose of
opiate
• Hyoscine butylbromide and cyclizine added to
reduce the vomits
• Additional sc opiate, midazolam, buscopan
prescribed and left at the house for the DN’s to
administer
• Died at home
Out of hours palliative care –
the C’s
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Communicate
Co-ordinate
Control symptoms
Continuity
Carer support
Care in the dying phase
Continued learning
Out of hours palliative care
• Anticipate problems
• Adequate supplies of medication
• Advice to patient and carers
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Are they in the picture ?
What might they expect
What they can do
Who to call in an emergency, what to do in an
emergency
Starting a syringe driver at home
• FP10 – quantity of diamorphine in 15ml
WFI “via syringe driver over 24 hrs”
• Number of syringes to be prescribed
• Total quantity of diamorphine
• Syringes ordered from Derby City Hospital
pharmacy
• Taxied to the patients home
84yr old man with end-stage
heart failure
• Lives with elderly wife
• Frequent admissions after waking in the
night very dyspnoeic
• Admitted to MAU, transferred to cardiology
ward
• Only home for 1 - 5 days before
readmission
Events leading to
admission..
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Slips off pillows
Increasing breathlessness panics him and wife
“Nothing to try” at home to ease dyspnoea
Wife calls NHS Direct, ambulance sent as “cardiac
patient”
• Treated as “acute heart failure” by paramedics and
medical team on MAU
• Reverts back to usual meds on cardiol ward
What may help..
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Conversation with patient about end of life issues
Low dose oramorph 1-2mg qds for dyspnoea
Recliner chair to keep him higher at night
Home oxygen to try initially if wakes, with
instructions to try a dose of oramorph
• GP spoken to directly, helpfully informed out of
hours Doctors service
• Community support from GP, DN and Macmillan
nurse
• Wife and son had written instructions
regarding treatment plan during the night
• Telephone numbers to contact clearly
written and left by the phone
• Regular contact from the DN, GP and
Macmillan nurse to support her
And did it help..
• Remained at home for 8 weeks before being
readmitted to a palliative care bed where he
died with his family around him.