End of life care

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End of life care

• Dr Maelie Swanwick
• Consultant in Palliative Medicine
• Derby Hospitals NHS Foundation Trust

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Principles of palliative care

• 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 familys
  bereavement

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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

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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

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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

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Principles of management

• 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

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Common symptoms at the end of life

• Symptom burden in the last year of life
  remarkably similar despite diagnosis
• Fatigue
• Pain
• Breathlessness
• Nausea and vomiting
• Principles of palliative care are not restricted
  to cancer patients nor to the last few days of
  life

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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

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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

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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

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Analgesia

• Consider the cause
• WHO analgesic ladder
• Step 1 Paracetamol /- NSAIDS /- adjuvant
• Step 2 Weak Opioids Step 1
• Step 3 Strong Opioids Step 1
• Adjuvant drugs
• Antidepressants amitriptyline
• Anticonvulsants carbamazepine, gabapentin
• Antiarrhythics mexilitine
• Dexamethasone

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Morphine

• The opioid of choice in the UK
• Pre-empt common S/Es including constipation,
  sedation, NV 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

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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

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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

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Nausea vomiting

• Tailor anti-emetic to presumed cause
• Clear instructions on administration
• Appropriate route and formulation
• 2nd line anti-emetic

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Breathlessness

• Very common problem
• Causes varied, both malignant and non-malignant
• Holistic management
• drug measures
• non-drug measures

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Death rattle

• Retained secretions in the upper airway
• Distressing for carers to hear, usually not
  bothering patient
• Postural drainage
• Drying agents
• Anticholinergic drugs

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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

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Drugs for sc use
DRUG NAME Licensed Acceptable
Diamorphine Y Y
Cyclizine N Y
Metoclopramide N Y
Levomepromazine Y Y
Haloperidol N Y
Midazolam N Y
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Dosage guidelines
DRUG Dose range Comment
Diamorphine 5mg Pain
Cyclizine 100 150mg Nausea vomiting
Haloperidol 2.5 5mg 5 10mg Nausea vomiting Restlessness or confusion
Hyoscine butylbromide 20 60mg Secretions
Levomepromazine 12.5- 50mg Low dose antiemesis Higher doses for sedation
Midazolam 10 60mg Anxiolytic, sedation
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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

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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

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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,
  DNs Macmillan nurses providing practical and
  emotional support

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Progress

• Initially some improvement in pain but not fully
  pain controlled
• S/Es 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

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• 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 DNs to
  administer
• Died at home

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Out of hours palliative care the Cs

• Communicate
• Co-ordinate
• Control symptoms
• Continuity
• Carer support
• Care in the dying phase
• Continued learning

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Out of hours palliative care

• Anticipate problems
• Adequate supplies of medication
• Advice to patient and carers
• 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

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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

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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

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Events leading to admission..

• 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

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What may help..

• 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

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• 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

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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.