The dying cancer patient Flashcards
what are the principles of palliative care and when its used
accessible throughout journey
applicable early in course of illness in conjunction with active therapy
symptom control
enchances QOL, may positively influence the course of illness
alternative to disease modifying or life sustaining treatment of
questionable value at end of life
how did palliative care originate
• Origins in the hospice movement – care of the dying pt right at the end of their lives
features of palliative care
• Recognition and relief of pain and other symptoms
• Recognition and relief of psychosocial suffering, including
appropriate care and support for relatives and close
friends
• Recognition and relief of spiritual / existential suffering - work with chaplain
• Sensitive communications between professional carers,
patients, relatives, and colleagues
• Inter-professional / multi-disciplinary team caring where
possible
• Helping patients achieve their wishes at the end of life
what are the benefits of palliative care
• Improved quality of life
• Reduced depression
• Improved pain and symptom control
• Increased patient and family satisfaction
• Reduced utilisation of aggressive interventions at the end
of life (CPR, ITU, dialysis, tracheostomy…)
• Increased survival in patients with advanced Non Small
Cell Lung Cancer
study with non-SCLC and palliative care
randomised pts to best onch treatment with or without palliative
pal – better pain, symptom control management, qol, less depression used less aggressive treatment at end of life, better survival rate, pts and families more satisfied
what is end of life care
care in final weeks
–months; some definitions include final year of life
what is terminal care
hours to days
distinction between end of life care and palliative care
You don’t have to be dying to receive palliative care
• Patients are often fearful of being referred to
palliative care as they think this means they are
about to die
what is care of the last days of life
NICE
dying in the last 2-3 days of life
what is the relationship between palliative, end of life and terminal care
palliative care encompasses all of it
what is involved in terminal care
psychosocail support of pt and family
symptom managemnet
spiritual care
what is involved in end of life care
ongoing medical treatment as appropriate hospice care/home supports condition is non-curative wks/mo to live symptom management spiritual care psychosocial support
what is involved in palliative care
introduction to palliatve approach living with life limiting illness with any progress symptom management maximising QOL palliative chemo/radio palliative surgery maximising community supports psychosocial support
who gives general palliative care
– GPs / district nurses, junior
doctors / ward nurses / CSW
why do people need specialist palliative care
when their symptoms are harder to control
who gives specialist palliative care
Community specialist palliative care teams (community
specialist palliative care nurses= ‘Macmillan nurses’)
• Hospice inpatient units
• Hospital specialist palliative care teams , specialist palliative
care consultants, specialty registrars, junior doctors (F1 to
F3), clinical nurse specialists
role of community specialist nurse
Contact with pots ion home- phone contact, visit no more than once a week, unless get more complicated) no hands on care – district nurse do hands on nurse care
summarise hospice palliative care
in patient units
50% discharge, 50% die – not just a place where people go to die
Hospice – short stay unit – max 2wk
look after pt for EOL care and symptom control – admitted for symptom control then go home when better
how many people die in England /yr
500000
age of deaths
2/3 >75yrs
what are the causes of majority of deaths
follow period of chronic illness: • Cardiovascular disease • Cancer • Chronic respiratory disease • Stroke • Neurological disease • Dementia
time progression of cancer
pt will continue func on good level and then there is a point where they deteriorate which continues at a rapid rate – fairly predictable
time progression of organ failure eg COPD
func decline at gradual – punctuated by dips which are infective exacerbation of COPD for example – AB recover, not up to baseline – keep gradually decline – have to determine which dip not going to jump back to baseline
time progression of fraility eg dementia
fluctuate along and then get better again – more gradual decline over time
when is palliative care involved on a patient’s journey
can encounter palliative care
throughout
• Palliative care not just for imminently dying
patients
• Palliative care for cancer patients who will be cured
• Palliative care for cancer patients with progressive
disease
• Palliative care for dying patients
how can palliative care help during cancer treatment
symptom control • Pain • Nausea and vomiting • Constipation • Breathlessness • Treatment of side effects from chemo e.g. peripheral neuropathy, vomiting/ nausea Pain control post radical radiotherapy causing severe oesophagitis and dysphagia Palliation of sub acute/ bowel obstruction while having chemotherapy
physical symptoms in cancer
fatigue pain breathlessness anorexia cough constipation depression nausea insomnia anxiety
palliative care in advanced metastatic disease
• Treatment of nausea and vomiting secondary to hypercalcaemia • Palliation of headaches and nausea secondary to brain metastases
how do you know that someone is dying
All reversible causes have been treated and, despite this, the patient is not getting any better Progressively bed bound • Increasingly drowsy • Decreasing communication • Decreasing oral intake • Progressive loss of swallow progressively unable to talk
is it always appropriate to treat reversible things
things – if going to die in next day – not going to treta pleural effuision with chest drain because painful – what are you going to achieve by treating this. Sometimes tricky for ward teams to determine the ceiling of care
what needs to be done when you recognise that a patient is dying
a senior decision/recognition that they are
dying and that the focus of care should be comfort
and symptom control
urgently to discuss with the patient and
family about what is going on - especially if pt can’t communicate
stop all unnecessary/painful interventions
e.g. blood tests, iv cannulation, blood pressure
monitoring
• Check that the patient has a DNACPR form and
clear ceilings of care documented
survey - what is important to patients in their final days
. Be kept clean. named decision maker nurse that they feel comfortable with know what to expect about physical condition have someone that will listen maintain dignity trust physician have financial affairs in order be free of pain maintain sense of humour
what do you do when family ask if it will be tonight
o Should know if they should spend the night or go home
o Really hard to get it right about prognosis
o Don’t know but want to give them an idea
o Plan for the worst and hope that better – better to do things too soon than too late
o Things can change really quickly
o People can stabalise/get worse
o Prepare for short frame or longer one
o If told def die in 12hrs and then still there in 4days = hard to cope with
o need to be reminded to look after themselves
what is important in the final days
The patient and their symptoms
• Do they have spiritual needs that can be met now?
• The family
• Communication with the family
• Do they understand what is going on and the
urgency?
• Compassion
common symptoms in last hours/days of life
pain
agitation
noisy breathing - upper airway secretions
nausea - not that common an issue, will affect how give med, need to think about but not common
considerations of medicine at end of life
Many people die peacefully needing no medical
intervention
• Many cancer patients will have had pain, and be on
regular oral analgesia,
• When unable to swallow –need analgesia via a different
route
• Similarly if they have been vomiting,
• need to continue antiemetic via different route
• Otherwise, nausea not a particularly common symptom
pain management
o Drugs parenterally – subcut – don’t want cannular more painful SC less painful than IM
o Therefore need opioids – if opioid naïve and normal renal func – give morphine sulphate 2,5mg sc prn – then titrate up
o If impaired renal fun – avoid morphine – oxycodone 1mg
distress/agitation at end
o Common in dying
o Terminal agitation – people agitated but not necessarily dying – used in hospicies a lot – just before dye become agitated and distressed
o Need to exclude easily reversible – pain/urinary retention
o Marked in young pots/previously psych distress
o Existential thing – scared
Sometimes very marked in young patients or those
with previous psychological distress
• Helped by some drugs
management of distress/agitation
• Midazolam 2.5mg sc prn (short acting
benzodiazepine)
• May need bigger doses e.g. 5mg sc prn
• May need syringe driver if need >2 doses (continuous subcutaneous
infusion csci)
• 2
nd line drug is levomepromazine
• Higher dose than for vomiting i.e. levomepromazine
12.5mg sc
• Ask for help from the Specialist Palliative Care Team
describe noisy upper airway secretions
‘Death rattle’
• Usually in unconscious patient - chest clear, all comes from upper airways
• Distressing for families - o Explaining to family helps and saying that they don’t think opt is aware
chest clear and all comes from upper airway – reposition pt, avoid suctioning, may be gently if something in mouth
management of noisy upper airway secretions
Repositioning • Avoid suctioning • Glycopyrronium 0.2mg sc • Hyoscine hydrobromide/hyoscine butylbromide • Can use syringe driver
treatment for N and v
- Haloperidol 0.5mg sc prn
- Levomepromazine 3.125mg-6.25mg sc prn
- Both can be used in a syringe driver
- Eg Haloperidol 2- 5mg sc / 24 hours
- Levomepromazine 6.25mg-25mg sc / 24 hours
what are anticipatory drugs
o Written up for pts who think dying
o So that pts who are dying might get the symptoms and we know the drugs available
o Should be prescribed at point recognised dying
o On as required chart in case something crops up – in case something develops in the coming hours
o When going home – prescribed in advance, put in house a few weeks in advance if pt doesn’t want to return to hospital and ceilings fo care recognise
o Days to hours in hospital
what are THE anticipatory drugs
• Morphine 2.5mg sc prn (pain)
• Midazolam 2.5mg sc prn (agitation)
• Glycopyrronium 200 mcg sc prn (respiratory
secretions)
• Haloperidol 0.5 mg sc prn (nausea/vomiting)
challenges of looking after someone dying of cancer
Really hard for doctors to see our patients die
• We need to support them and their families
• Often our compassion is the best support
• Very hard to go into the room where the patient has just
died and their family is there grieving
• Families really appreciate it when doctors do that and it may
well be one of the things they remember
• Although you may not influence the eventual outcome,
what you say/do makes a real difference
• Easy for families to feel abandoned
• Doctors (and nurses) too need support
