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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 28 – Palliative care Chapter 28 Palliative care Andrea L. Zuckerman Further information NICE Improving supportive and palliative care for adults with cancer (2004) http://www.nice.org.uk Hospice information Tel: 0870 903 3903 http://www.hospiceinformation.info Woodruff, Doyle (2004) The IAHPC Manual of Palliative Care (2nd Edition) IAHPC Press http://www.hospicecare.com/manual/IAHPCmanual.htm Patient advice and support British Association of Cancer United Patients (BACUP) Tel:0800 800 1234 http://www.bacup.org.uk DIPEX Project: Patient experiences http://www.dipex.org P.1000
Palliative care in general practice ‘Any man’s death diminishes me because I am involved in mankind’ Devotions Meditation 17, John Donne (1572–1631). Palliative care starts when the emphasis changes from curing the patient and prolonging life to relieving symptoms and maintaining well-being or ‘quality of life’. GPs have 1 or 2 patients with terminal disease at any time, and get more personally involved with them than any others. The problems arising are a complex mix of physical, psychological, social, cultural, and spiritual factors involving both patients and carers. To respond adequately, good lines of communication and close multidisciplinary teamwork is needed. Local palliative care teams are invaluable sources of advice and support and frequently produce booklets with advice on aspects of palliative care for GPs. Symptom control must be tailored to the needs of the individual. A few basic rules apply:

  • Carefully diagnose the cause of the symptom
  • Explain the symptom to the patient
  • Discuss treatment options
  • Set realistic goals
  • Anticipate likely problems
  • Review regularly

The Gold Standards Framework aims to improve quality and of palliative care provided by the primary care team by developing practice-based organization of care of dying patients. The framework focuses on 7 key tasks—optimising continuity of care, teamwork, advanced planning (including out-of-hours), symptom control, and patient, carer and staff support. Evaluation data show the framework ↑, the proportion of patients dying in their preferred place, and improves quality of care as perceived by the practitioners involved. Further information Gold Standards Framework Tel: 020 7840 4673 E-mail gsf@macmillan.org.uk NICE Improving supportive and palliative care for adults with cancer (2004) http://www.nice.org.uk Hospice information Tel: 0870 903 3903 http://www.hospiceinformation.info Woodruff, Doyle (2004) The IAHPC Manual of Palliative Care (2nd Edition) IAHPC Press. http://www.hospicecare.com/manual/IAHPCmanual.htm Patient advice and support British Association of Cancer United Patients (BACUP) Tel: 0800 800 1234 http://www.bacup.org.uk Macmillan Cancer Relief Tel:0808 808 2020 http://www.macmillan.org.uk P.1001
Syringe drivers Although drugs to control the symptoms of terminal illness can usually be administered by mouth, occasionally that is not possible. Portable syringe drivers give a continuous subcutaneous infusion and can provide good control of symptoms with little discomfort or inconvenience to the patient. Indications:

  • The patient is unable to take medicines by mouth owing to nausea and vomiting, dysphagia, severe weakness, or coma
  • There is bowel obstruction and further surgery is inappropriate
  • The patient does not want to take regular medication by mouth

Drugs which can be used in syringe drivers Table 28.1 Mixing drugs in syringe drivers Provided there is evidence of compatibility, drugs can be mixed in syringe drivers. Diamorphine can be mixed with:

  • Cyclizine
  • Hyoscine hydrobromide
  • Hyoscine butylbromide
  • Midazolam
  • Dexamethasone
  • Levomepromazine
  • Haloperidol
  • Metoclopramide

Common problems with syringe drivers

  • If the syringe driver runs too slowly: Check it is switched on; check the battery; check the cannula is not blocked.
  • If the syringe driver runs too quickly: Check the rate setting.
  • Injection site reaction: If there is pain or inflammation, change the injection site.
Table 28-1 Drugs which can be used in syringe drivers
Indication Drugs
Nausea and vomiting Haloperidol 2.5–10mg/24h.
Levomepromazine 5–200mg/24h. (causes sedation in 50%)
Cyclizine 150mg/24h. (may precipitate if mixed with other drugs)
Metoclopramide 30–100mg/24h.
Octreotide 300–600mcg/24h. (consultant supervision)
Hyoscine hydrobromide 20–60mg/24h.
Respiratory secretions Hyoscine hydrobromide 0.6–2.4mg/24h.
Glycopyrronium 0.6–1.2mg/24h.
Restlessness and confusion Haloperidol 5–15mg/24h.
Levomepromazine 50–200mg/24h.
Midazolam 20–100mg/24h. (and fitting)
Pain control Diamorphine—-1/3–½ dose oral morphine/24h.
image Subcutaneous infusion solution should be monitored regularly both to check for precipitation (and discolouration) and to ensure the infusion is running at the correct rate.

Incorrect use of syringe drivers is a common cause of drug errors. P.1002
Pain and general debility Pain control Pain control is the cornerstone of palliative care. Cancer pain is multifactorial—be aware of physical and psychological factors. Principles of pain control p.172 Pain-relieving drugs p.174 Management of specific types of pain Table 28.2 Terminal restlessness Causes:

  • Pain/discomfort—urinary retention, constipation, pain which the patient cannot tell you about, excess secretions in throat.
  • Opiate toxicity—causes myoclonic jerking. The dose of morphine may need to be ↓ if a patient becomes uraemic.
  • Biochemical causes—↑Ca2+, uraemia— If it has been decided not to treat abnormalities, DON’t check for them.
  • Psychological/spiritual distress

Management

  • Treat reversible causes e.g. catheterization for retention, hyoscine to dry up secretions.
  • If still restless, treat with a sedative. This does NOT shorten life but makes the patient and any relatives in attendance more comfortable. Suitable drugs: haloperidol 1–3mg tds po; chlorpromazine 25–50mg tds po; diazepam 2–10mg tds po, midazolam or levomepromazine via syringe driver.

Weakness, fatigue, and drowsiness Almost a universal symptom. Reversible causes

  • Drugs—opiates, benzodiazepines, steroids (proximal muscle weakness), diuretics (dehydration and biochemical abnormalities), antihypertensives (postural hypotension)
  • Emotional problems—depression, anxiety, fear, apathy
  • Hyercalcaemia
  • Other biochemical abnormalities—DM, electrolyte disturbance, uraemia, liver disease, thyroid dysfunction
  • Anaemia
  • Poor nutrition
  • Infection
  • Prolonged bed rest
  • Raised intracranial pressure (drowsiness only)

Management

  • Treat reversible causes.
  • If drowsiness and fatigue persist, consider a trial of dexamethasone 4–6mg/d. or antidepressant. Although steroids make muscle wasting worse, they may improve general fatigue and improve mobility.
  • Psychological support of patients and carers—empathy, explanation.
  • Physical support—referral to physiotherapist, review of aids and appliances, review of home layout (possibly with referral to OT), review of home care arrangements.
  • Advice on modification of lifestyle.
Table 28-2 Management of specific types of pain
Type of pain Management
Bone pain
  • Try NSAIDs
  • Consider referral for palliative radiotherapy, strontium treatment (prostate cancer), or iv bisphosphonates (↓ pain in myeloma, breast and prostate cancer)
  • Refer to orthopaedics if any lytic metastases at risk of fracture, for consideration of pinning
Abdominal pain
  • Constipation is the most common cause— p.1007
  • Colic—try loperamide 2–4mg qds or hyoscine hydrobromide 300mcg tds s/ling. Hyoscine can also be given via syringe driver.
  • Liver capsule pain—use dexamethasone 4–8mg /d, titrating dose down to the minimum that controls pain
  • Gastric distention—may be helped by an antacid ± an anti-foaming agent (e.g. Asilone). Alternatively, a prokinetic may help e.g. domperidone 10mg tds before meals.
  • Upper Gl tumour—coeliac plexus block may help. Refer to palliative care team.
  • Consider drug causes—NSAIDs are a common iatrogenic cause
  • Acute/subacute obstruction— p.1004
Neuropathic pain
  • Often burning/shooting and may not respond to simple analgesia
  • Titrate to the maximum tolerated dose of opioid
  • If inadequate, add a nerve pain killer e.g. amitriptyline 10–25mg nocte increasing as needed every 2wk. to 75–150mg. Alternatives include carbamazepine, gabapentin, phenytoin, sodium valproate, and clonazepam.
  • If pain is due to nerve compression caused by tumour, dexamethasone 8mg od may help
  • Other options: TENS; acupuncture; nerve block
Rectal pain
  • Topical drugs e.g. rectal steroids
  • TCAs e.g. amitriptyline 10–100mg nocte
  • Anal spasms—glyceryl trinitrate ointment 0.1–0.2% bd
  • Referral for local radiotherapy
Muscle pain
  • Paracetamol and/or NSAIDs
  • Muscle relaxants e.g. diazepam 5–10mg od, baclofen 5–10mg tds, dantrolene
  • Physiotherapy, aromatherapy, or relaxation
  • Heat pads
Bladder spasm
  • Try oxybutinin 5mg tds or tolterodine 2mg bd
  • Amitriptyline 10–75mg nocte is often effective
  • If catheterized, try instilling 20mls of intravesical bupivacaine 0.25% for 15min. tds
Acute pain of short duration e.g. dressing changes
  • Try a short-acting opiate e.g. meptazinol 200mg po given 20min. prior to procedure

P.1003
P.1004
Dysphagia, nausea, and vomiting Nausea and vomiting are common in patients with advanced cancer. Consider cause and mechanism before choosing an antiemetic (Table 28.3). Remember hypercalcaemia as a cause of persistent nausea. Don’t forget non-drug measures to ↓ nausea e.g.

  • avoidance of food smells and unpleasant odours
  • diversion
  • relaxation
  • acupressure/acupuncture

For prophylaxis of nausea and vomiting—use po medication; for established nausea or vomiting—consider a parenteral route (e.g. syringe driver) as persistent nausea may ↓ gastric emptying and drug absorption. Review antiemetic therapy daily. Obstruction/subacute obstruction of the bowel Often of complex origin with functional and mechanical elements. Presents with:

  • Vomiting—often faeculent with little preceding nausea
  • Constipation
  • Abdominal distention

Examination reveals an empty rectum. Treatment options

  • If surgery is an option, then refer for a surgical opinion.
  • If the patient is otherwise well, consider referral to an oncologist—ovarian and colonic cancers often respond to chemotherapy.
  • Otherwise, treatment is symptomatic:
  • Dexamethasone 4–8mg/d.—antiemetic and minimizes obstruction
  • If colic is a problem, stop prokinetics (metoclopramide/domperidone) and start an antispasmodic (e.g. hyoscine 300mcg tds po)
  • For pain, give an opiate—if there is a risk of malabsorption, give by syringe driver
  • Aim to abolish nausea and keep vomiting to a minimum (may be impossible to abolish vomiting) with cyclizine, haloperidol, or levomepromazine
  • If vomiting cannot be controlled, consider referral for venting gastrostomy
  • Keep stool soft
  • Consider referral to palliative care for antisecretory agents (e.g. octreotide).

Dysphagia May be due to physical obstruction (by tumour bulk) or functional obstruction (neurological deficit).

  • Treat the cause if possible e.g. celestin tube for oesophageal tumour
  • If the patient is hungry and wishes to be fed, consider referral for a percutaneous endoscopic gastrostomy (PEG)
  • If the patient does not wish to have a PEG, ask whether s/he would like subcutaneous fluids and treat symptomatically with mouth care, anxiolytics, analgesia, and sedation.
Table 28-3 Choice of antiemetic
Mechanism of vomiting Antiemetic
↑/CP
  • Dexamethasone 8–16mg/d.
  • Cyclizine 50mg bd/tds
  • Levomepromazine 6–25mg/d.
Anxiety, fear, or pain
  • Benzodiazepines e.g. diazepam 2–10mg/d. or midazolam sc
  • Cyclizine 50mg bd/tds
  • Levomepromazine 6–25mg/d.
Motion/position
  • Cyclizine 50mg tds po/sc/im
  • Hyoscine po (300mcg tds) or transdermally (1mg/72h.)
  • Prochlorperazine po (5mg qds) or buccal (3–6mg bd)
Endogenous toxins/drugs
  • Ondansetron (particularly for chemotherapy induced vomiting) 8mg bd po or 16mg od pr
  • Haloperidol 1.5–5mg nocte (particularly for opiate induced vomiting, hypercalcaemia, or renal failure). An antiemetic is usually necessary only for the first 4–5d. of opiate therapy.
  • Alternatives include: metoclopramide; cyclizine; levomepromazine
Gastric stasis*
  • Domperidone 10mg tds or metoclopramide 10mg tds (particularly if multifactorial with gastric stasis and a central component)
Gastric irritation
  • PPls e.g. lansoprazole 30mg od or omeprazole 20mg od
  • Antacids
  • Misoprostol 200mcg bd—if caused by NSAIDS
Constipation
  • Laxatives/suppositories/enemas
Intestinal obstruction
  • See opposite
Cough induced
  • p.1011
Unknown cause
  • Cyclizine 50mg tsd
  • Levomepromazine 6–25mg/d.
  • Dexamethasone 4–8mg daily po/sc
  • Metoclopramide 10mg tds po
*Vomits of undigested food without nausea soon after eating.

P.1005
Drugs with antimuscarinic effects antagonize prokinetic drugs and therefore, where possible, should not be used concurrently. Use of a syringe driver p.1001 P.1006
Other Gl problems Anorexia

  • Treat nausea, mouth problems, pain, and other symptoms
  • ↓ psychological distress and treat depression
  • Advise small, appetising meals, frequently, in comfortable surroundings

Drugs that may be helpful

  • Alcohol pre-meals
  • Metoclopramide or domperidone 10mg tds pre-meals—to prevent feeling of satiety caused by gastric stasis
  • Dexamethasone 2–4mg od or prednisolone 15–30mg od

Mouth problems General measures

  • Review medication making the mouth sore or dry
  • Treat oral infections: oral thrush—fluconazole 50mg od for 7d. and soak dentures in Milton fluid for ≥ 12h. to prevent reinfection
  • Mouthwashes—saline, betadine, oraldene, corsodyl, difflam (for pain)
  • 1/4-1/2 ascorbic acid 1g effervescent tablet/d.—place on tongue and allow to dissolve
  • Mouth care—refer to DN for advice; use a toothbrush to keep the tongue clean

Specific measures

  • Painful mouth—difflam mouthwash ± xylocaine spray
  • Ulcers or painful areas—adcortyl in orabase paste topically qds after eating and nocte
  • Oral cancer pain—topical NSAIDs e.g. piroxicam melt
  • Chemotherapy induced ulcers—sucralfate suspension
  • Dry mouth
    • Review medication which might be causing dry mouth e.g. antidepressants, opioids
    • Salivary stimulants—iced water, pineapple chunks, chewing gum, boiled sweets or mints
    • Saliva substitutes e.g. glandosane spray
  • Radiotherapy induced dryness—pilocarpine
  • Excessive salivation—amitriptyline 10—100mg nocte, hyoscine or glycopyrronium via syringe driver.

Ascites Depending on clinical state, consider referring for chemotherapy if appropriate or treat symptoms:

  • Give analgesia for discomfort
  • Refer to the general physicians or surgeons for paracentesis if the patient is well and/or peritoneo-venous shunt if recurrent
  • Try diuretics—furosemide 20–40mg od or spironolactone 100–200mg od and/or dexamethasone 2–4mg daily
  • Try support stockings and/or massage for leg oedema
  • ‘Squashed stomach syndrome’—try prokinetics e.g. domperidone or metoclopramide 10mg tds.

P.1007
Hiccup A distressing symptom. Treatment is often unsatisfactory.

  • General measures: Rebreathing with a paper bag; pharyngeal stimulation by drinking cold water or taking a teaspoonful of granulated sugar.
  • Peripheral hiccups: Caused by irritation of the phrenic nerve or diaphragm. Try metoclopramide (10mg tds), antacids containing dimethicone (e.g. gaviscon), dexamethasone (4–12mg/d.), or ranitidine (150mg bd).
  • Central hiccups: Due to medullary stimulation e.g. ↑ICP, uraemia. Try chlorpromazine (10–25mg tds/qds), dexamethasone (4–12mg/d.), nifedipine (10mg tds), or baclofen (5mg bd).

Constipation Very common symptom. Causes:

  • Immobility
  • Poor diet
  • Poor fluid intake
  • Old age
  • Drugs—particularly opiates and antidepressants

Constipation can herald spinal cord compression. If suspected, do a full neurological examination. Management

  • Pre-empt constipation by putting everyone at risk on aperients.
  • Treat with regular stool softener (e.g. magnesium hydroxide) ± regular bowel stimulant (e.g. senna) or alternatively use a combination drug (e.g. co-danthrusate).
  • If that is ineffective, add glycerine suppositories (hard stool) or bisocodyl suppositories (soft stool).
  • If still not cleared, refer to the district nurse for microlet enemas ± high phosphate or arachis oil enemas.
  • Once cleared, leave on a regular aperient with instructions to ↑ aperients if constipation recurs.

Diarrhoea Less common than constipation but can be distressing for the patient and difficult for the carer—especially if incontinence results. Management

  • Screen for infection.
  • Ensure no overflow diarrhoea 2° to constipation.
  • Ensure no excessive/erratic laxative use.
  • Consider giving pancreatic enzyme supplements e.g. creon 25000 tds prior to meals if malabsorption.
  • Consider prednisolone enemas/foam (e.g. colifoam) for radiotherapy induced diarrhoea.
  • Otherwise, treat symptomatically with codeine phosphate 30–60mg qds or loperamide 2mg tds/qds.

Gut fistulae Connections from the gut to other organs—commonly skin, bladder, or vagina. Bowel fistulae are characterized by air passing through the fistula channel. Management

  • If well enough for surgery, refer to a surgeon.
  • If not fit for surgery, consider referring to palliative care for octreotide.

P.1008
Neurological and orthopaedic problems Raised intracranial pressure Occurs with 1° or 2° brain tumours. Characterized by

  • Headache—worse on lying
  • Vomiting
  • Confusion
  • Diplopia
  • Convulsions
  • Papilloedema

Management

  • Unless a terminal event, refer patients urgently to neurosurgery for assessment. Options include insertion of a shunt or cranial radiotherapy.
  • If no further active treatment is appropriate, start symptomatic treatment—raise the head of the bed, start dexamethasone 16mg/d. (stop if no response in 1wk.), analgesia.

Spinal cord compression Affects 5% of cancer patients—70% in thoracic region. Presentation can be subtle. Maintain a high level of suspicion in all cancer patients who complain of back pain, especially those with known bony metastases or tumours likely to metastasize to bone. Presentation

  • Often back pain, worse on movement, appears before neurology.
  • Neurological symptoms can be non-specific—constipation, weak legs, incontinence of urine.

Management Prompt treatment (<24—48h. from 1st neurological symptoms) is needed if there is any hope of restoring function. Once paralysed, <5% walk again. Treat with oral dexamethasone 16mg/d. and refer urgently for radiotherapy, unless in final stages of disease. Bone fractures Common in advanced cancer due to osteoporosis, trauma as a result of falls, or metastases. Have a low index of suspicion if a new bony pain develops. In the elderly, fracture of a long bone can present as acute confusion. Management

  • Analgesia
  • Unless in a very terminal state, confirm the fracture on X-ray and refer to orthopaedics or radiotherapy urgently for consideration of fixation (long bones, wrist, neck of femur) and/or radiotherapy (rib fractures, vertebral fractures).

Hypercalcaemia Most common with:

  • Myeloma (>30%)
  • Breast cancer (40%)
  • Squamous cell cancers.

P.1009
Presentation Symptoms are non-specific:

  • Thirst
  • Polyuria and polydipsia
  • Constipation
  • Nausea and vomiting
  • Abdominal pain
  • ↑ appetite
  • Depression
  • Fatigue
  • Confusion

Always suspect hypercalcaemia if someone is iller than expected for no obvious reason. Untreated hypercalcaemia can be fatal. Management Depending on the general state of the patient, make a decision whether to treat the hypercalcaemia or not. If a decision is made not to treat, provide symptom control and don’t check the serum calcium again. Active treatment depends on the level of symptoms and hypercalcaemia:

  • Asymptomatic patient with corrected calcium <3mmol/l:: Monitor
  • Symptomatic and/or corrected calcium >3mmol/l:
    • Arrange treatment with pamidronate via oncologist/palliative care team immediately.
    • Check serum calcium 7–10d. post-treatment. 20% do not respond and there is no benefit from retreating them.
    • Effect of pamidronate lasts 20–30d.. Consider maintenance with oral bisphosphonates (e.g. sodium clodronate) started 1wk. after the initial iv pamidronate or regular iv pamidronate. Many initially responsive to bisphosphonates become unresponsive with time.

Further information p.424 P.1010
Respiratory problems Breathlessness Usually multifactorial. Affects 70% of terminally ill patients. It is inevitable that breathlessness has a psychological element as being short of breath is frightening. General management Non-drug measures

  • General reassurance
  • Explanation of reasons for breathlessness and adaptations to lifestyle that might help
  • Proper positioning—breathlessness is improved by sitting upright and straight
  • Try a stream of air over the face e.g. fan, open window
  • Breathing exercises can help—refer to physio. Exercises include diaphragmatic breathing and control of breathing rate; relaxation/distraction training.

Drug treatment

  • Tenaceous secretions—try nebulized saline
  • Oral or subcutaneous opioids ↓ subjective sensation of breathlessness—start with oramorph 2.5mg 4 hrly and titrate upwards
  • Try benzodiazepines—diazepam 2–5mg od/bd for background control and lorazepam 1–2mg sl prn in between
  • Oxygen has a variable effect and is worth a try.

Specific measures

  • Airway compression, bronchoconstriction, or lymphangitis—try steroids (dexamethasone 4–8mg/d.)
  • Intrinsic or extrinsic compression–consider referral for radiotherapy, laser therapy, or stenting
  • Pleural effusion—consider referral for drainage ± pleuradesis
  • Infection—antibiotics. Most people with terminal disease have a depressed immune system, so have a low threshold to treat with a broad-spectrum antibiotic
  • Pneumothorax on CXR—consider referral for chest drain
  • Ascites—consider referral for paracentesis if causing breathlessness
  • Suspected pulmonary emboli—consider anticoagulation
  • Wheeze—try inhaled broncholdilators
  • Excessive upper airway secretions—try hyoscine 0.4–2.4mg/24h. or glycopyrronium 200–600mcg/24h. (consult local palliative care team)
  • Musculoskeletal pain can cause hypoventilation—treat with analgesia
  • Anaemia (Hb <9g/l)—consider referral for transfusion
  • Thick secretions—consider referral for chest physiotherapy
  • Vocal cord palsy—consider referral to an ENT surgeon for teflon injection.

P.1011
Stridor Coarse wheezing sound that results from the obstruction of a major airway e.g. larynx. Management

  • Corticosteroids (e.g. dexamethasone 16mg/d.) can give relief.
  • Consider referral for radiotherapy or endoscopic insertion of a stent if appropriate.
  • If a terminal event—sedate with high doses of midazolam (10–40mg repeated prn).

Cough Troublesome symptom. Management General measures

  • Exclude any treatable cause for cough (e.g. ACE inhibitors)
  • Advise upright body position
  • Steam inhalations or inhalations with menthol or tinct. Benz. Co (Friars balsam) can help
  • Refer for chest physiotherapy, relaxation, and breathing control exercises, if tolerated
  • Simple linctus prn can be helpful. If not, consider low-dose opioid linctus e.g. codeine linctus or oramorph 5mg every 4h.

Specific measures

  • Chest infection—treat with nebulized saline to make secretions less viscous ± antibiotics (if not considered a terminal event)
  • Tumour—consider referral for radiotherapy
  • Post-nasal drip—steam inhalations, steroid nasal spray or drops ± antibiotics
  • Laryngeal irritation—try inhaled steroids
  • Broncospasm—try bronchodilators ± inhaled or oral steroids
  • Gastric reflux—try antacids containing dimethicone (gaviscon, asilone)
  • ↓ of salivary secretions—try hyoscine (see below).

Excessive respiratory secretion Excessive respiratory secretion (death rattle) can be distressing for patients and relatives in attendance. It may be ↓ using:

  • Subcutaneous injection of hyoscine hydrobromide 400–600mcg 4–8 hourly (or 0.6–2.4mg/24h. via syringe driver)–dry mouth is a side-effect and can be distressing.
  • Glycopyrronium 200mcg every 4h. sc or im injection (0.6–1.2mg/24h. via syringe driver).

P.1012
Haematological and vascular problems Bleeding/haemorrhage In all patients likely to bleed (e.g. in endstage leukaemia) pre-warn carers and give them a strategy. Severe, life-threatening bleed Make a decision whether the cause of the bleed is treatable or a terminal event. This is best done in advance—but bleeding can’t always be predicted.

  • Severe bleed—active treatment: p.1040,p.1041,p.1042
  • Severe bleed—no active treatment:
    • Stay with the patient
    • Give sedative medication e.g. midazolam 20–40mg sc/iv or diazepam 10–20mg pr and diamorphine 5–10mg sc/iv
    • Support carers, as big bleeds are extremely distressing.

Non-life threatening bleed First aid measures

  • In all cases—reassure; monitor frequently.
  • Surface bleeding—pressure on wound; if pressure is not working, try kaltostat or adrenaline (1mg/ml or 1:1000) on a gauze pad
  • Nose bleeds—nasal packing or cautery

Follow-up treatment Follow-up is directed at cause if appropriate:

  • Anticoagulants—check INR
  • Treat infection that might exacerbate a bleed
  • Consider minimizing bleeding tendency with tranexamic acid 500mg qds
  • Upper Gl bleeding—stop NSAIDs, start PPI in double standard dose and consider referral for gastroscopy
  • Lower Gl bleeding—consider rectal steroids to ↓ inflammation or rectal tranexamic acid ± referral for colonoscopy
  • Radiotherapy—consider referral if haemoptysis, cutaneous bleeding, or haematuria
  • Referral for chemotherapy or palliative surgery (e.g. cautery) are also options

Anaemia Don’t check for anaemia if there is no intention to transfuse.

  • If Hb <10gldl and symptomatic: Treat any reversible cause (e.g. iron deficiency, Gl bleeding 2° to NSAIDs). Consider transfusion.
  • If transfused: Record whether any benefit is derived (as if not, further transfusions are futile) and the duration of benefit (if <3wk., repeat transfusions are impractical). Monitor for return of symptoms, repeat FBC, and arrange repeat transfusion as needed.

Superior vena cava (SVC) obstruction Due to infiltration of the vessel wall, clot within the superior vena cava, or extrinsic pressure. 75% are due to 1° lung cancer (3% of patients with lung cancer have SVC obstruction). Lymphoma is the other major cause. Presentation

  • Shortness of breath/stridor
  • Headache worse on stooping ± visual disturbances ± dizziness and collapse
  • P.1013

  • Swelling of the face—particularly around the eyes, neck, hands and arms, and/or injected cornea
  • Examination: look for non-pulsatile distention of neck veins and dilated collateral veins (seen as small dilated veins over the anterior chest wall below the clavicles) in which blood courses downwards.

Management

  • Treat breathlessness—opiates (oramorph 5mg 4 hourly) ± benzodiazepine, depending on the level of anxiety
  • Start corticosteroid (dexamethasone 16mg/d.)
  • Refer urgently for oncology opinion. Palliative radiotherapy has a response rate of 70%. Stenting ± thrombolysis is also an option.

Lymphoedema Due to obstruction of lymphatic drainage resulting in oedema with high protein content. Affects ≥1 limbs ± adjacent trunk. If left untreated, lymphoedema becomes increasingly resistant to treatment due to chronic inflammation and subcutaneous fibrosis. Cellulitis causes rapid ↑ in swelling. Causes

  • Axillary, groin, or intrapelvic tumour
  • Extensive axillary or groin surgery
  • Post-operative infection/radiotherapy

Presentation

  • Swollen limb ± pitting
  • Impaired limb mobility and function
  • Discomfort/pain related to tissue swelling and/or shoulder strain
  • Neuralgia pain—especially when axillary nodes are involved
  • Psychological distress
Table 28-4 Management of lymphoedema
Avoid injury to limb In at-risk patients (e.g. patients who have had breast cancer with axillary clearance) or those with lymphoedema, injury to the limb may precipitate or worsen lymphoedema. Do not take blood from the limb or se it for iv access or vaccination.
Skin hygiene Skin care with moisturisers e.g. aqueous cream, emulsiderm Topical treatment of fungal infection
Systemic treatment of bacterial infection
External support Intensive—with compression bandages
Maintenance—with lymphoedema sleeve (contact breast care specialist nurse for more information on obtaining sleeves)
Exercise Gentle daily exercise of affected limb, gradually increasing range of movement
image Must wear a sleeve/bandages when doing exercises
Massage Very gentle finger tip massage in the line of drainage of lymphatics
Diuretics If the condition has developed or deteriorated since prescription of corticosteroid or NSAID or if there is venous component, consider trial of diuretics
Otherwise, diuretics are of no benefit

P.1014
Psychiatric problems Anxiety All patients with terminal disease are anxious at times. When anxiety starts interfering with quality of life, intervention is justified. Management Non-drug measures Often all that is needed:

  • Acknowledgement of the patient’s anxiety
  • Full explanations of questions, supported with written information as needed
  • Support—self-help groups, day care, patients’ groups, specialist home nurses (e.g. MacMillan Nurses)
  • Relaxation training and training in breathing control
  • Physical therapies e.g. aromatherapy, art therapy, exercise.

Drug measures

  • Acute anxiety: Try lorazepma 1–2mg sl prn or diazepam 2–10mg prn
  • Chronic anxiety: Try an antidepressant e.g. fluoxetine 20mg od. Alternatives include reular diazepam 5–10mg od/bd, haloperiodol 1–3m bd/tds, or β-blockers (e.g. propranolol 40mg od tds)—watc for postural hypotension

If anxiety is not rsponding to simple measures, seek specialist help fom eihe te psychiatric or palliative care team. Depression A terminal diagnosis makes paients sad on occasions. Many symptoms of terminal disease (e.g. poor appetite) are also symptoms of depression. 10–20% of erminally ill patients develop clinical depression but, in pracice, it is often dificult to decide whaher a patient is depressed or ust appropriately sad abou his diagnosis and its implications. If in doubt, a trial of anidepressans can help Manaement Non-drug measures

  • Support e.g. day and/or rspite care; cares’ goup; specialist nuse suppot (e.g. MacMillan Nurse; CPM); ↑ help in the home
  • Relaxaion—often ↑ the patient’s felling of control over the situation
  • Explanation—of wories/problems/concerns about the future
  • Physical activity—exercise; writing

Drug measures

  • Consider starting an antidepressant (p.970)
  • All antidepressants take ~2wk. to work
  • If immediate effect is required, consider using flupentixol 1mg od (beware as can cause psychomotor agitation).

If not responding or suicidal, refer for psychiatric opinion. Confusion p.976 Insomnia p.242

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