Symptom Control in Palliative Care

Cathy CordenGP VTS ST1

Case Study 1

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

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

Back pain most often thoracic Weakness of lower limbs Sensory level Urinary symptoms

Up to 5% cancer sufferersCa prostate, breast, bronchus,

myeloma

Spinal Cord Compression

http://intqhc.oxfordjournals.org/content/19/6/377.full

Spinal Cord Compression cont

GP can start dexamethasone 16mg/day whilst referring urgently to oncology/spinal centre

MRI scan Radiotherapy Spinal surgery

Hypercalcaemia

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

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

Significant pain Pathological fractures Analgesia Radiotherapy Bisphosphonates Surgical inj steroids/anaesthetics

WHO analgesic ladder

Opioid Analgesia

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

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 ladyMetastatic ovarian carcinomaContinuous vomiting last 4 daysIntermittant bowel obstruction. Last opened

bowels 3 days ago. Abdominal painOn MST 60 mg bd, oramorph prn,

metoclopramide 10mg tds POWishes not to go back to hospital as does

not want NG tube/prolonged hospital stay

Case Study 2

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

Persistent vomiting

Reduced level consciousness

Weak Dysphagia Forgets to take

PO medication Last days of life

Pain Control

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

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

Diamorphine can be combined with any of the following in a driver:

Cyclizine Haloperidol Hyoscine Hydrobromide Hyoscine Butylbromide Levomepromazine Metoclopramide Midazolam

Case Study 3

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

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

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

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

O2 Optimise bronchodilators in COPD Use fan/open window to ease

sensation Position upright Physiotherapy Good oral care

Dyspnoea

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

Pain Urinary retention Constipation Anxiety Uncomfortable positioning Nausea/vomiting SE medication Cerebral irritation

Agitation

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

Oxford Handbook of Palliative Care Derby Hospitals: Syringe Driver

Combinations from CASU www.bathgped.co.uk/presentations www.yorkshire-cancer-net.org.uk/