End of life care

Dr Maelie Swanwick

Consultant in Palliative Medicine

Derby Hospitals NHS Foundation Trust

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 family’s bereavement

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

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

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

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

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

Types of pain

• VisceralDull, aching, diffuse, continuous, colickyeg liver capsular pain, bowel spasm

• BoneLocalised, bone tendernesseg bony metastases, fractures, arthritis

• NerveBurning, prickling, shootingAllodynia, hyperalgesia, hyperpathiaeg nerve root infiltration, post-herpetic neuralgia

• MyofascialLocalised muscle pain

Types of pain

• VisceralDull, aching, diffuse, continuous, colickyeg liver capsular pain, bowel spasm

• BoneLocalised, bone tendernesseg bony metastases, fractures, arthritis

• NerveBurning, prickling, shootingAllodynia, hyperalgesia, hyperpathiaeg nerve root infiltration, post-herpetic neuralgia

• MyofascialLocalised muscle pain

Types of pain

• VisceralDull, aching, diffuse, continuous, colickyeg liver capsular pain, bowel spasm

• BoneLocalised, bone tendernesseg bony metastases, fractures, arthritis

• NerveBurning, prickling, shootingAllodynia, hyperalgesia, hyperpathiaeg nerve root infiltration, post-herpetic neuralgia

• MyofascialLocalised muscle pain

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

Morphine

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

sedation, N&V 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

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

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

Nausea & vomiting

• Tailor anti-emetic to presumed cause

• Clear instructions on administration

• Appropriate route and formulation

• 2nd line anti-emetic

Breathlessness

• Very common problem

• Causes varied, both malignant and non-malignant

• Holistic management– drug measures– non-drug measures

“Death rattle”

• Retained secretions in the upper airway

• Distressing for carers to hear, usually not bothering patient

• Postural drainage

• “Drying” agents– Anticholinergic drugs

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

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

Dosage guidelines

DRUG Dose range CommentDiamorphine 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

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

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

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, DN’s & Macmillan

nurses providing practical and emotional support

Progress

• Initially some improvement in pain but not fully pain controlled

• S/E’s 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

• 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 DN’s to administer• Died at home

Out of hours palliative care – the C’s

• Communicate

• Co-ordinate

• Control symptoms

• Continuity

• Carer support

• Care in the dying phase

• Continued learning

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

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

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

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

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

• 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

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.