Symptom Control in Palliative Care

1. Symptom Control in Palliative Care Cathy Corden GP VTS ST1

2. 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

3. 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?

4. Spinal Cord Compression • Back pain most often thoracic • Weakness of lower limbs • Sensory level • Urinary symptoms Up to 5% cancer sufferers Ca prostate, breast, bronchus, myeloma

5. Spinal Cord Compression http://intqhc.oxfordjournals.org/content/19/6/377.full

6. Spinal Cord Compression cont • GP can start dexamethasone 16mg/day whilst referring urgently to oncology/spinal centre • MRI scan • Radiotherapy • Spinal surgery

7. 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

8. 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.

9. Bony metastases • Significant pain • Pathological fractures • Analgesia • Radiotherapy • Bisphosphonates • Surgical inj steroids/anaesthetics

10. WHO analgesic ladder

11. 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.

12. 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

13. 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

14. 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?

15. Syringe Drivers • Persistent vomiting • Reduced level consciousness • Weak • Dysphagia • Forgets to take PO medication • Last days of life

16. 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.

17. Vomiting www.yorkshire-cancer-net.org.uk/

18. 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.

19. Syringe Drivers • Diamorphine can be combined with any of the following in a driver: • Cyclizine • Haloperidol • Hyoscine Hydrobromide • Hyoscine Butylbromide • Levomepromazine • Metoclopramide • Midazolam

20. 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

21. 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

22. 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

23. 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

24. Dyspnoea • O2 • Optimise bronchodilators in COPD • Use fan/open window to ease sensation • Position upright • Physiotherapy • Good oral care

25. 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.

26. Agitation • Pain • Urinary retention • Constipation • Anxiety • Uncomfortable positioning • Nausea/vomiting • SE medication • Cerebral irritation

27. 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.

28. References • Oxford Handbook of Palliative Care • Derby Hospitals: Syringe Driver Combinations from CASU • www.bathgped.co.uk/presentations • www.yorkshire-cancer-net.org.uk/