FACTSHEET 16 ON PALLIATIVE CARE EMERGENCIES IN PALLIATIVE CARE See also Cambridgeshire Community Services policy for anticipatory prescribing for patients with a terminal illness ( Just in Case ) http://www.cambridgeshireandpeterboroughccg.nhs.uk/downloads/catch/just_in_case_ Policy.pdf Palliative care emergencies encompass not only situations that are imminently life threatening, but also those that could result in impaired quality of life for the remainder of the patient s life, or for the family in their bereavement. When planning the care of your patient: be aware of potential emergencies e.g. patient with vertebral metastasis/metastases likely to develop spinal cord compression. be aware of patient s wishes, in the event of emergency check for documentation in regard to preferred priorities for care (PPfC), advance decision to refuse treatment (ADRT), resuscitation status (DNACPR) be aware of family/carer wishes e.g. to be with patient whatever happens. focus on anticipating emergency and planning appropriately in advance. e.g. green towels and sedation for haemorrhage: emergency contact number. Emergencies considered in this factsheet are: haemorrhage stridor choking psychiatric emergency spinal cord compression superior vena cava obstruction raised intra cranial pressure hypercalcaemia Drugs most frequently prescribed in an emergency diamorphine injection 5mg or 10 mg ampoule diluted with water for subcutaneous administration midazolam injection 5mg/ml 2ml ampoule for subcutaneous or buccal administration lorazepam 1mg tablet for sublingual (prescribed as Genus brand) or oral use haloperidol injection 5mg/ml 1ml ampoule for subcutaneous administration glycopyrronium injection 200microgram/ml 1ml ampoule for subcutaneous administration Water for injection Page 1 of 6 Factsheet 16
Haemorrhage predisposing factors : cancer related chemotherapy related biochemical pharmacological tumour invasion consider in advance: abnormal clotting, platelet dysfunction reduced platelet count uraemia, hepatic dysfunction NSAIDS, anticoagulants, SSRI s haemoptysis, carotid blow-out gastro-intestinal bleed discussing issues of resuscitation use of sedation, prophylactically and in the acute situation whether family would/or would not want to be present NB catastrophic haemorrhage (e.g. carotid blow-out) can cause (almost) instantaneous death with no time for any treatment stay with the patient. Suggested treatment: have a supply of dark towels readily available severe haemorrhage lasting minutes/hours is frightening for patients and carers sedation should be readily available and rapidly administered. benzodiazepine preferably midazolam intravenously/buccal 5mg repeated as necessary to maintain drowsiness. The subcutaneous route is not effective where there is peripheral shutdown due to blood loss. in a patient s home/care home rectal diazepam 10mg is an alternative, but if appropriate individual arrangements for availability of midazolam may be made. Stridor The high-pitched sound of breathing (in and out) when partial laryngeal/major airway obstruction is present e.g.in tumours of head and neck or mediastinum. Problems arise due to exhaustion from laboured breathing and anoxia: in a hospital environment intervention (bronchoscopy, laser therapy, chemotherapy) may be considered. in a patient s home/care home consider whether referral for intervention appropriate: pre-emptive planning for either tracheostomy or sedation will require detailed discussion alleviate anxiety with benzodiazepine midazolam 5mg subcutaneously maximum hourly or diazepam 5mg orally (maximum 20mg per day) Page 2 of 6 Factsheet 16
Choking Inability to breathe due to acute obstruction of the pharynx, larynx or trachea. Can be due to local tumour, more often due to neurologically mediated swallowing difficulties Motor Neurone Disease, skull base metastases. Discuss the situation with patient and carers: acknowledge fears discuss possible interventions (involve speech therapist in assessment where appropriate). Acute situation: where available midazolam 5 to10mg can be given +/- diamorphine 5mg subcutaneously or intravenously rectal diazepam (10mg) if no other treatment available If prolonged/repeat bouts of choking: anti secretory agents (glycopyrronium 200 micrograms ampoule administered subcutaneously as required 4 hourly) may be helpful. Psychiatric Emergencies Patients presenting with extreme anxiety/apprehension will usually respond to benzodiazepines and a calming environment. lorazepam 500micrograms sublingually/orally repeated as necessary to maximum 4mg in 24 hours midazolam 2.5 to 5mg buccal/subcutaneously repeated as necessary to maximum 30mg in 24 hours diazepam 5mg orally repeated as necessary to maximum 20mg in 24 hours Agitation may require haloperidol 5mg repeated if necessary to 10mg maximum subcutaneously as bolus (reduce in the elderly to half dose). Paranoia and/or aggressive behaviour occasionally occur, especially in patients with cerebral disease. Patients are often very fearful and distressed and despite advanced disease show unexpected mobility and strength. The situation is distressing also for family and professional carers. Exceptionally: To gain control, (preventing harm to self or others), haloperidol 10mg intramuscularly, should be administered. (This may require restraint to enable administration of medication). NB small doses of benzodiazepines without an antipsychotic may aggravate the situation. Advice from psychiatrist and/or palliative care team should be sought and regular antipsychotic medication may be required. Page 3 of 6 Factsheet 16
Metastatic Spinal Cord Compression (MSCC) 10% of all cancer patients develop MSCC. Be aware of the possibility in any patient with vertebral metastasis particularly in cancer of lung, breast, prostate, kidney, multiple myeloma or non-hodgkin lymphoma. NICE guidance states the following action for any cancer patient: Contact the MSCC (Metastatic Spinal Cord Compression) coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases: pain in the middle (thoracic) or upper (cervical) spine progressive lower (lumbar) spinal pain severe unremitting lower spinal pain spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) localised spinal tenderness - nocturnal spinal pain preventing sleep Contact the MSCC (Metastatic Spinal Cord Compression) coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency: neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction - neurological signs of spinal cord or cauda equina compression. Currently, in Cambridgeshire, the Metastatic Spinal Cord Compression Coordinator is the oncology Registrar on-call in the local cancer centre contactable through the hospital switchboard. (Addenbrookes Hospital 01223 245151) More than 25% patients develop paraplegia in less than 48 hours from presentation. Median survival after compression has occurred and impairment/loss established is 7-10 months, but up to 30% of patients live with their disability for more than a year. Superior Vena Cava Obstruction (SVCO) SVCO is due to compression, obstruction or thrombosis impairing central venous return - if active intervention is appropriate hospital admission will be required for assessment and possible chemotherapy/radiotherapy, stenting etc NB Local Cancer Network guidelines for Superior Vena Cava Obstruction should be consulted. SVCO occurs most frequently in cancer of lung (70% of cases) or lymphoma (8%) Page 4 of 6 Factsheet 16
Symptoms: dyspnoea facial/upper body/ arm swelling and/or skin mottling headaches/ muzziness cough dysphagia After treatment, average survival is 8 months. If a patient is either bed bound/terminal/refusing intervention, or after discussion with oncologist no further treatment is available, all symptom control/care measures should be given and nursing support arranged (seek specialist advice) Raised Intracranial Pressure May arise from: Cerebral metastases most commonly bronchus, breast, testicular teratoma, malignant melanoma, non-hodgkin Lymphoma Primary intracranial tumour astrocytoma, meningioma, oligodendroglioma, glioblastoma. Symptoms may include: Signs: headache, (worst on wakening), nausea +/- vomiting, drowsiness, convulsion, visual disturbance. papilloedema, bradycardia, raised blood pressure, cranial nerve lesions. If suspected discuss with oncologist/palliative care specialist. Hypercalcaemia 20% of all patients with malignant disease will develop hypercalcaemia: this occurs most commonly in breast cancer, renal cell cancer, myeloma, squamous cell tumours and lymphoma N.B. treating, or repeatedly treating hypercalcaemia in advanced/advancing disease may not be beneficial in terms of quality of life. Symptoms may include: Thirst, polyuria, anorexia, nausea, headache, constipation, mental blunting, cardiac dysrhythmia, deterioration in pain control if suspected FIRST consider whether further intervention is appropriate/acceptable (discuss with palliative care specialist) if further intervention required request admission for treatment for patients not undergoing interventional treatment, full symptomatic treatment should be continued IF ANY UNCERTAINTY REGARDING MANAGEMENT SEEK SPECIALIST ADVICE Page 5 of 6 Factsheet 16
General palliative care references include: Palliative Care Formulary, Fourth Edition (PCF4) Edits: Robert Twycross and Andrew Wilcock available via Palliativedrugs.com Palliative Adult Network Guidelines Third Edition (also available as an App) Edits: Max Watson, Caroline Lucas, Andrew Hoy, Ian Back, Peter Armstrong Specific references for factsheet 16: NICE Guidance Nov 2008 Metastatic spinal cord compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression Page 6 of 6 Factsheet 16