home.community: symptomatic relief of malignant ascites

Transcription

1 home.community: symptomatic relief of malignant ascites Lynne Lewis RN PG Dip Hsc Jackie Thompson RN

2 Background Information Malignant ascites is a prognostic indicator evident once diagnosed, patients have a medium survival time of twenty weeks (Sangisetty, Milner 2011) Recurrent Malignant Ascites causes unpleasant symptoms and significantly reduces the patients quality of life

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4 Background Information cont.. Repeated abdominal paracentesis is widely used and effective procedure It provides good symptom relief in the short term Accumulation and fluid volume is difficult to predict

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6 Symptoms of Ascites Increased abdominal girth Dyspnoea Flank pain Orthopnoea Early feeling of fullness after food Heart burn

7 Collaborative Approach Home drainage requires a team approach by a group of health professionals Oncologists,Interventional Radiologist, Palliative Care Consultant, GP, District Nurses, Community Palliative Care Nurses There is a shared care arrangement between District Nurses and Franklin Hospice

8 Patient Suitability FBC Serum plasma Basic haemostasis screen Co morbidities Enough subcutaneous tissue Do they require 1-3 taps only

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12 Bob s Journey

13 Diagnosis June Diagnosed with Cholangiocarcinoma & pulmonary metastases March CT diagnosed progressive disease to lung and peritoneum with mixed response from gemcitabine, capecitabine and cefuximab

14 Approach to Disease Took a pragmatic approach to disease and decision making around treatment Did not want to know prognosis Bob elected not to discuss issues around death and dying

15 Bobs Journey 11 th June Admission to hospital with increasing abdominal distension, query bowel obstruction Underwent USS which showed a large volume of malignant ascites Paracentesis 6.5L drained Late June Re-admitted with abdominal cellulitis post paracentesis 5L drained 3 rd July Returned to oncology day stay for peritoneal drainage

16 Continued; Bob frustrated with frequent drainage as a inpatie Discussion was held with patient regarding insertion of a permanent catheter Palliative Consultant liaised with Interventional radiologist A portacath was inserted Bob was discharged home

17 End of life Care The portacath was accessed 10 times over 6 weeks 21 st August - Syringe driver was commenced with Midazolam10mgs, Morphine 20mgs, Nozinan 12.5mgs PRN: Morphine 5mgs & Midazolam 5mgs 26 th August Bob passed away peacefully at home with his wife

18 Jack s Journey

19 Diagnosis Adenocarcinoma of the pancreas with hepatic metastases June /12 history backpain, anorexia, nausea, weight loss & jaundice Referred by PCT 29/07/2011 following insertion of biliary stent & paracentesis 5 L drained

20 Approach to Disease Wanted to know only limited information His wife communicated for him His emotions were concealed Limited social support

21 Jacks Journey Commenced IV gemcitabine 16/08/2011 he discontinued this 2/7 21/09/2011 admitted to hospital with lethargy, anorexia & abdominal distension, - 8L drained 24 th re-admitted with abdominal distension; portacath inserted for community paracentesis

22 Continued; Paracentesis procedure was carried out three times in the community over a 6 week period Anticipatory drugs Midazolam 2.5mgs, Oxycodone 20mgs, Nozinan 6.25 mgs Syringe driver was commenced on the 5 th Dec 2011,patient requested an admission to local hospital he died three days later

23 Positive feedback from families No travel stress Home comforts Treated when he felt like it More visitors Not surrounded by sickness and sad stories Consistent caring faces Less Clinical, less doctors felt less acutely sick Clear communication channels

24 Conclusion In our locality paracentesis has been shifted from a hospital in patient procedure to the community. Moving these goal posts for patients with malignant ascites has enabled them to maintain an improved quality of life.

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26 References Sangisetty, L, Milner ( 2011). Malignant ascites: A review of prognostic factors, pathophysiology and therapeutic measures. World Journal of Gastrointestinal Surgery 2012 Sabatelli,J, Glassman,M, Kerns,S, Hawkins, I (1994). Permanent indwelling peritoneal access device for the management of malignant ascites. Cardiovascular Intervention Radiology. Fleming.N, Alvarez-Secord,A,etal ( 2009). Indwelling catherters for the management of refractory Malignant Ascites: A systematic literature overview and retrospective Chart review. Journal of Pain and Symptom Management Counties Manukau District Health Board (2011) Intraperitoneal Port Accessing for Peritoneal Drainage Procedure Keen, A, Fitzgerald.D, Bryant.A, Dickinson, H. ( 2010) Management of drainage for malignant ascites in gynaecological cancer. Review. The Cochrane Collaboration. Dr Linda Huggins Palliative Care Consultant Middlemore Hospital Auckland lynne@franklinhospice.org.nz