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A challenging weekend--

A challenging weekend--. Sunitha Daniel ST3. Case1. KM, 50 years Admitted to hospice on 22/10/11 Diagnosis locally advanced uterine leiomyosarcoma with lung metastasis Diagnosed in Aug 2010 6 cycles of neoadjuvant chemo(Ifosfamide + Doxorubicin)

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A challenging weekend--

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  1. A challenging weekend-- Sunitha Daniel ST3

  2. Case1 • KM, 50 years • Admitted to hospice on 22/10/11 • Diagnosis locally advanced uterine leiomyosarcoma with lung metastasis • Diagnosed in Aug 2010 • 6 cycles of neoadjuvantchemo(Ifosfamide+ Doxorubicin) • Initial response-decrease in size of tumor and lung mets

  3. TAH with BSO in April 2011 –clear margins • Stable lung disease being considered for resection but progressed with abdominal lymph nodes • Palliative chemo 1st cycle on 06/10/11 • Admitted to SJUH on 11/10/11 with chest pain and SOB • CT scan showed progressive lung disease, pleural effusion and pelvic disease.

  4. Treated with IV antibiotics for neutropenic sepsis • Rapid deterioration in breathing • Referred for management of breathlessness and likely terminal care.

  5. Past History • PE • Fibroid Uterus • 2 Hickman line infections

  6. Social history • Used to work as a clerical staff in fire station (health and safety) • Lives with husband and 2 sons aged 23 and 11. • Family –not coping especially eldest son.

  7. Symptoms • Pain 3/3 severe upper back pain radiating to front of chest ongoing for weeks. Relieved on sitting up, lying to right side. opioid sensitive • Dyspnoea 3/3 on minimal exertion as well as talking. Stopping mid conversation. There was evidence of anxiety • Drowsiness 3/3 Noticed only after CSCI started. Dozing of during conversation.

  8. Examination • Generally looked anxious and tachypnoic • pallor+ • Obs HR 112/mt,RR 28/mt SO2 93% on O2 • Chest bibasalcreps more on left. • Mouth: evidence of oral thrush

  9. Management From SJUH • On CSCI Morphine 90mg +Midazolam 10mg • Dexamethasone 8mg by Oncologist • Diclofenac TDS

  10. At hospice • Discussion with family Aware of progressive disease but told by oncologist about possible chemo if chest improves. • Concerns regarding drowsiness • Patient be rather be more awake. • Continue CSCI with Morphine and but Midazolam 7.5 mg • Reduce Dexamethasone to 4mg.

  11. Progress (23/10/11) • Very agitated night –shouting screaming and moving around • Ongoing pain • PRN Morphine, midazolam and haloperidol overnight • Reviewed: gave stat haloperidol and changed driver to Morphine 100mg and midazolam 20mg. • Worsened during day : worsening hypoxia. ? Dying

  12. D/W consultant Agreed could be dying. To speak with husband but not to speak /involve son (suicidal risk) • Husband visibly upset and shocked –called in family including son • Consultant review • lengthy discussion : patient accepting but not talking about it. • Family agreed for more sedation

  13. Changed CSCI To Oxycodone 50mg and midaz 30mg • Commence LCP (18:00) • Family stayed in . • Called at 00:50 patient still unsettled PRNs 5 in 5 hours • Family upset • Reviewed stat levomepromazine and changed to Oxy 80mg,Midaz 60mg and Levo 12.5mg in CSCI at 3:00am

  14. 24/10/11 • Few more PRNs • Review by Consultant(8am) • Unconscious but not settled moaning with each breath • Family present throughout night • Phenobarbitone 100mg at 9:00am -finally relaxed • RIP at 11:50 am

  15. Case 2 • EB 77 years male • Back ground End stage heart failure sec to IHD • Admitted on 21/10/11 • Worsening Oedema, pain drowsy • Admitted for terminal care

  16. Aware he is dying-‘Please put me to sleep’ • On high dose opiates orally pain uncontrolled but S/C PRN worked. • Symptoms • Pain(3/3) across the chest and back ? Related to heart failure. • Nausea(3/3) • Peripheral oedema(3/3)

  17. Examination • Restless and agitated • SO2 90% BP 99/69 • Raised JVP • Chest Bibasal fine creps and dull to percussion • Abdomen Ascites+

  18. Management • CSCI with Morphine25mg Midazolam 10mg Haloeperidol 3mg • Frusemide CSCI 160mg • Stop non essential meds.

  19. Progress(22/10/11 -23/10/11) • Unsettled night with worsening pain and agitation • Not clear as to cause of agitation? dying • CSCI changed to morph 40mg,midaz 20mg and halo 5mg • Continued to be more agitated all day and night( up all night needing extra nursing care) • D/W Consultant morphine 60mg,midaz 40mg with PRN 5-10mg for Levo PRN, ketorolac BD • Not clear if terminal

  20. 24/10/11 • Still very restless. • Getting up to pass urine at night - catheterize • Still having meals with family during day –agitation and restlessness predominantly at night. • CSCI to Morphine 100mg,midaz 75mg and haloperidol1.5mg(?rigid) • Not clear if dying D/W family- • D/W consultant(16:00) • Stop Frusemide,Switch to Oxycodone,formidaz 30mg in day and 60mg at night,Stop haloperidol Ketorolac CSCI

  21. Not for LCP as not clear if dying CSCI started at 18:00 Settled later in night. RIP during cares at 02:45 am on 25/10/11

  22. Good death (BMJ 2000;320:129) • To know when death is coming, • To understand what can be expected • To be able to retain control of what happens • To be afforded dignity and privacy • To have control over pain relief and other symptom control • To have choice and control over where death occurs. • To have access to information and expertise of whatever kind is necessary

  23. To have access to any spiritual or emotional support • To have access to hospice care in any location, not only in hospital • To have control over who is present and who shares the end • To be able to issue advance directives which ensure wishes are respected • To have time to say goodbye, and control over other aspects of timing • To be able to leave when it is time to go, and not to have life prolonged pointlessly

  24. Factors considered important at the end of life by patients • pain and symptom management, • communication with one's physician, • preparation for death. • opportunity to achieve a sense of completion Ref(JAMA 2000; 284(19): 2476-82)

  25. Diagnosing dying Profound weakness Confined to bed for most of the day Drowsy for extended periods Disorientated Severely limited attention span Loss of interest in food and drink Too weak to swallow medication.

  26. Why is it Important? • Allows withdrawal of unnecessary treatments • Preparation of the patient and family/carers for death. • Establish patient’s PPOC.

  27. NICE Quality Standard for End of Life Care for Adults. • 16 steps for people approaching end of life care • Identification in timely way • Communication and information provided to patients and families. • comprehensive holistic assessments in response to their changing needs and preferences, • physical and specific psychological needs safely, effectively and appropriately met

  28. offered timely personalised support for their social, practical and emotional needs, • offered spiritual and religious support • Families and carers of people approaching the end of life are offered comprehensive holistic assessments. • receive consistent care that is coordinated effectively across all relevant settings

  29. who experience a crisis at any time of day or night receive prompt, safe and effective urgent care. • who may benefit from specialist palliative care, are offered this care in a timely way appropriate to their needs and preferences, • last days of life are identified in a timely way and have their care coordinated and delivered in accordance with their personalised care plan, • Care after death, bereavement support and work force planning and training.

  30. “…we will do all we can not only to help you die peacefully, but to live until you die.” Dame Cicely Saunders

  31. References • YCN symptom management • NICE • BMJ

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