Transcript Symptom Control in Palliative Care

Symptom Control in Palliative
Care
Cathy Corden
GP VTS ST1
Case Study 1
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Mrs AB 68 year old lady
Ca breast with metastatic disease
Worsening pain in back, cannot get
comfortable at all
Nauseous, lethargic and her
daughter feels she has become
more confused recently.
On paracetamol 1 gram qds,
codeine 30mg qds
Case Study 1
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What are the main issues in this case?
What investigations might you want to
carry out?
Is there anything else you would want to
know to help make decisions?
If all investigations normal, what would
be the next management steps for pain
control?
Spinal Cord Compression
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Back pain most often thoracic
Weakness of lower limbs
Sensory level
Urinary symptoms
Up to 5% cancer sufferers
Ca prostate, breast, bronchus,
myeloma
Spinal Cord Compression
http://intqhc.oxfordjournals.org/content/19/6/377.full
Spinal Cord Compression cont
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GP can start dexamethasone
16mg/day whilst referring urgently
to oncology/spinal centre
MRI scan
Radiotherapy
Spinal surgery
Hypercalcaemia
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10-20% advanced cancer
Myeloma, breast, renal, squamous
cell carcinomas
Nausea, vomiting, confusion,
constipation, thirst, fits, coma.
More commonly caused by
parathyroid hormone-related
peptide secreting tumour rather
than lytic metastases
Hypercalcaemia cont
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Symptoms appear when calcium
rises quickly and over 3.0 mmol/L
Admit for fluids and IV
bisphosphonates
May require PO bisphosphonates to
reduce recurrence rates.
Bony metastases
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Significant pain
Pathological fractures
Analgesia
Radiotherapy
Bisphosphonates
Surgical inj steroids/anaesthetics
WHO analgesic ladder
Opioid Analgesia
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Immediate release e.g. oramorph.
Work within 20mins and last 4
hours.
Modified release e.g. Zomorph, MST
MR.
Start 10 mg immediate release 4
hourly and increase by 30-50%
every 3 days until pain relief
achieved/SEs. Beware elderly pts.
Opioid Analgesia
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Once stable pain control transfer to
modified release preparation.
Need immediate release preparation
for breakthrough pain. Should be
1/6 total dose e.g. if taking 60 mg
MST bd would need 20 mg
oramorph 4 hourly.
Remember the laxative, antiemetic
Case Study 2
Mrs CD 56 year old lady
Metastatic ovarian carcinoma
Continuous vomiting last 4 days
Intermittant bowel obstruction. Last opened
bowels 3 days ago. Abdominal pain
On MST 60 mg bd, oramorph prn,
metoclopramide 10mg tds PO
Wishes not to go back to hospital as does
not want NG tube/prolonged hospital stay
Case Study 2
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You decide to set up a syringe
driver at home.
What are the common reasons for
using syringe driver?
What medications could you choose,
what dosages?
As a GP how do you order syringe
drivers? What is the important info
needed on prescription?
Syringe Drivers
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Persistent
vomiting
Reduced level
consciousness
Weak
Dysphagia
Forgets to take
PO medication
Last days of life
Pain Control
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Diamorphine s/c
To convert from oral morphine to
s/c diamorphine ratio is 3:1
On MST 60 mg bd, 40 mg oramorph
in 24 hours therefore total
morphine 160 mg. Diamorphine
dose in 24 hours would be just over
50mg.
Vomiting
www.yorkshire-cancer-net.org.uk/
Ordering Syringe Drivers
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Medication in words and numbers if
controlled drugs
Made up to 15 ml with water for
injection
To run over 24 hours
Aseptic services – part of pharmacy
D/W district nurses
Need to sign pink form for DN to set
up driver.
Syringe Drivers
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Diamorphine can be combined with any of
the following in a driver:
Cyclizine
Haloperidol
Hyoscine Hydrobromide
Hyoscine Butylbromide
Levomepromazine
Metoclopramide
Midazolam
Case Study 3
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79 year old gentleman
Ca bronchus
Struggling with dyspnoea. His wife
tells you that he has been
deteriorating rapidly last two days
and is now very agitated.
On home oxygen
Case Study 3
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What are the common causes of
dyspnoea in someone who is
palliative?
How would you manage a patient
such as this? Consider:
- dyspnoea
- agitation
Dyspnoea
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Uncomfortable awareness of breathing.
Frightening.
Common in end stage COPD, cardiac
failure, cancer, neurological conditions
Rule out COPD exacerbation, PE,
pulmonary oedema, pneumonia, SVCO,
anaemia, pleural effusion, ascites, lung
mets, lymphangitis carcinomatosa
Superior Vena Caval Obstruction
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SOB
Swelling face,
arms
Collateral veins
Dizziness
Visual changes
Headache
Urgent referral
with high dose
dexamethasone
http://www.bmj.com/content/315/7121/1525.extract
Dyspnoea
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O2
Optimise bronchodilators in COPD
Use fan/open window to ease
sensation
Position upright
Physiotherapy
Good oral care
Dyspnoea
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Oramorph 2.5 mg 4 hourly. Titrate
up. Not used enough for dyspnoea
for fear of respiratory depression.
However very effective.
Diamorphine s/c
Midazolam 2.5 mg s/c anxiety/fear
suffocation.
Agitation
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Pain
Urinary retention
Constipation
Anxiety
Uncomfortable positioning
Nausea/vomiting
SE medication
Cerebral irritation
Agitation
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Once all above reversible causes
have been excluded likely terminal
agitation.
Levomepromazine 12.5-25.0 mg s/c
4-6 hourly, 25-150 mg s/c 24
hours.
Midazolam 2.5-5.0 mg s/c 4 hourly,
10-60mg s/c 24 hours.
References
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Oxford Handbook of Palliative Care
Derby Hospitals: Syringe Driver
Combinations from CASU
www.bathgped.co.uk/presentations
www.yorkshire-cancer-net.org.uk/