Palliative care for patients with brain cancer
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1 Palliative care for patients with brain cancer Lyn Cave Clinical Nurse Specialist Palliative Care Hospital2Home (H2H) Dr Jayne Wood Clinical Lead Palliative Care The Royal Marsden and Royal Brompton Palliative Care Service Women's cancers Breast cancer introduction 1
2 Aim of Session Consider symptom control issues affecting end of life care in patients with brain tumours Role of Hospital2Home (H2H) Specialist Palliative Care
3 3 The Royal Marsden Pain
4 Approaches to Pain WHO, 1996 Moderate - severe pain Mild pain Non-opioids +/- adjuvant Mild moderate pain Weak opioids +/- non-opioid +/- adjuvant Other: Psychological support Radiotherapy Chemotherapy Surgery Spinal analgesia Neural blockade Strong opioids +/- non-opioid +/- adjuvant Adjuvant analgesics: NSAIDs Steroids Antidepressants Antiepileptics Antiarrythmics Anaesthetics Muscle relaxants Bisphosphonates
5 Corticosteroids Mechanism of action - peripheral: non selective COX inhibition, reduction of inflammatory mediators, peritumoral oedema - central: mechanism not defined INDICATION Administration: po/iv/sc Neurological Dex 16mg/d Soft tissue infiltration Dex 8-16mg/d raised intracranial pressure spinal cord compression nerve compression or infiltration head and neck tumours abdominal and pelvic tumours Contra-indication - No absolute - Side effects are often dose limiting Capsular stretching Dex 8-16mg/d liver metastases, other visceral metastases
6 6 The Royal Marsden Nausea/Vomiting
7 Causes Brain metastasis Raised ICP Anticipatory Emotional/psychological/ spiritual Metabolic disturbance: Uraemia Electrolyte disturbance Hormone imbalance Oral thrush Cough Treatment related: Chemotherapy Radiotherapy Opioids Antibiotics Gastric stasis Constipation Bowel obstruction
8 Management Treat Non-drug Acupuncture Calm atmosphere Small snacks Bland foods Drugs Regular administration Appropriate route Titrate adequately NB some drugs lower seizure threshold!
9 9 The Royal Marsden Seizures
10 Seizures at the End of Life If patient is known to have seizures and taking anti-epileptic medication: DO NOT stop the medication? Liquid medication or consider an alternative route Midazolam 30mgs over 24 hours via syringe pump Avoid seizure lowering medication Midazolam 10mgs prn if seizure lasts more than 5 minutes If seizures continue consider increasing midazolam or discuss with palliative care team as may need alternative (phenobarbitone) Some anti epileptic meds have a long half life and in an unconscious patient may continue to be effective for 2-3 days after the last po dose
11 Management of tumour-associated seizures Exclude other diagnoses e.g panic attacks Be prepared to accept less than perfect seizure control Generalised seizures usually respond better to Anti Epileptic Drugs (AEDs) than partial seizures Ensure patient and family are well informed about how to manage patient if seizure occurs Consider buccal midazolam as family members can administer if necessary
12 12 The Royal Marsden Hospital2Home & Coordinate My Care
13 Coordinate My Care Coordinate My Care (CMC) is a free service that can help to record patients views and wishes within an electronic personalised care plan The care plan can be viewed and updated by doctors, nurses and emergency services to share information about patient care, including where patient would like to be cared for and things they may want to avoid Patients details are only entered when they have given consent. If a person has lost the ability to make their own choices then a decision can be made in their best interests by a doctor or nurse after discussion where possible with the person s family and carers CMC record can only be accessed by health professionals emergency and Out of Hours health services
14 Hospital2Home Service (H2H) H2H programme developed to enable patients with life limiting disease where the aim of treatment is palliation only to be cared for in their preferred place and to improve communication between the hospital and community H2H service is a palliative care intervention, an approach to co-ordinating care using home-based case conferencing, based on a successful research project undertaken in Australia (Abernethy, 2006)
15 H2H Service Patients are offered a telephone service at the point of discharge where the Primary and Specialist Palliative Care Teams who will be responsible for managing the patient s care in the community will be telephoned to update them and discuss plan for future care. OR Face to Face meeting at patient s home to which the GP, DN, Community Palliative Care Clinical Nurse Specialist and anyone else involved in the patients care are invited. Patients can decline the service altogether
16 Aims of H2H intervention Patient and carer have opportunity to be involved in discussions regarding medical, nursing, social and psychological needs and to discuss and develop a plan of care for the future Ensure everyone has the same information Where possible identify a Key worker Discuss responsibilities and role of HCP s + contact numbers Possible issues for the future e.g bowel obstruction, management of seizures, blood transfusions, titration of steroids Medication Discuss Co ordinate My Care Record + update Do Not Attempt Resuscitation (DNAR) Preferred place of care and death Re-referral criteria if appropriate Review dates
17 17 The Royal Marsden Last Hours and Days of Life
18 End of Life Care 1/3-2/3 patients with cancer die in hospital This is likely to increase Often have unmet needs Appropriate training lacking Initiatives and strategies developed and implemented: End of Life Care Strategy (DH, 2008) Advance Care Planning Liverpool Care Pathway
19 Diagnosing dying: last hours to days of life Less mobile - bed/chairbound Increasingly drowsy for much of the day semi-conscious/less alert (Kinder & Ellershaw 2003) No longer able to take oral drugs/little or no oral intake Limited attention span disorientated Increased confusion/agitation Reduction in urine output (Stone et al 2001) Changes in pulse and respiratory rate Change in skin colour Ellershaw J BMJ 2003 Collis E BMJ 2013 Wilcock A PCF 4
20 Care of the dying patient Was this patient s condition expected to deteriorate in this way? Is further life prolonging treatment inappropriate? Have potentially reversible causes of deterioration been excluded? Multi-professional diagnosis Continuous review Ellershaw J BMJ 2003 Collis E BMJ 2013
21 Aims of anticipatory prescribing Prevent possible delays in the control of symptoms Avoid crises NB seizures Avoid unnecessary distress for patients and relatives Prevent inappropriate hospital admission
22 Anticipatory prescribing guidelines for Palliative Care adult patients Pain/Breathlessness Morphine Sulphate 2.5-5mg sc prn up to a maximum of every hour. Respiratory secretions Glycopyrronium 400mcgs sc as needed up to a maximum of tds Nausea + vomiting Haloperidol 1-2.5mgs sc prn up to maximum tds. Levomepromazine mg sc prn up to maximum tds NB Can lower seizure threshold Terminal restlessness - Midazolam 2.5mgs sc prn up to hourly Terminal haemorrhage/convulsions Midazolam 10mgs sc/im prn for seizure or life threatening bleed, once only. Diluent Water for Injections
23 23 The Royal Marsden Challenges
24 Challenges for Palliative Care More people living longer with chronic disease Palliative care needs becoming more complex Variable integration of palliative care with other services Variable disease trajectories Outcome measurement Specialist Palliative Care
25 Response to the Neuberger Review:- One chance to get it right DH, June 2014 How health and care organisations should care for people in the last days of their life Leadership alliance for the care of the dying people (21 organisations): established following Neuberger review of LCP, July priorities for care Early recognition, communication and regular review Sensitive communication Patient/those closest to them involved in decision making Needs of families/those closest met Individualised care plans
26 Review of objectives Consider symptom control issues affecting end of life care in patients with brain tumours Role of Hospital2Home (H2H) Specialist Palliative Care
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