palliative care symptom management - central phoapps.centralpho.org.nz/permalink/mom/general...

FEBRUARY 2015

Palliative Care Symptom Management

The Symptom Management Guidelines have been developed for palliative care patients in the

Community. For symptom management of palliative care patients in the Hospital setting contact

Hospital Palliative Care Team if required.

FEBRUARY 2015

Contents Breathlessness/Dyspnoea ...................................................................................................................... 3

Constipation ........................................................................................................................................... 5

Diarrhoea ................................................................................................................................................ 9

Delirium .................................................................................................................................................. 9

Fatigue .................................................................................................................................................. 10

Mouth Discomfort/Xerostomia (dry mouth) and Stomatitis. .............................................................. 10

Nausea and Vomiting ........................................................................................................................... 12

Pain ....................................................................................................................................................... 13

Managing Palliative Care Emergencies ................................................................................................ 18

i. Hypercalcaemia ......................................................................................................................... 18

ii. Spinal Cord Compression .......................................................................................................... 18

iii. Malignant Bowel Obstruction ................................................................................................... 18

iv. Superior Vena Cava Obstruction ............................................................................................... 19

v. Massive Haemorrhage .............................................................................................................. 19

References ............................................................................................................................................ 20

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Physical Control of Symptoms

Breathlessness/Dyspnoea In palliative care, breathlessness is often multi-factorial therefore it is relatively rare to use a specific therapy to treat one cause. The experience of breathlessness may vary between people at the end of life, dependent both on the causes of the symptom and the person's perceptions of the meaning of the symptom. The distress caused by increasing breathlessness should not be underestimated and in order for this symptom to be effectively addressed, the multi-dimensional nature of the symptom means that more than a physical/pharmacological approach may be required.

Use algorithm – see following page.

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BREATHLESSNESS / DYSPNOEA

Did first line treatment fail or was it inappropriate?

Pharmacological treatments Opioids - the aim is to ease the sensation of dyspnoea. Doses should

be monitored on an individual basis.

Benzodiazepines - can be of benefit with anxiety and fear eg Midazolam nasal spray or longer acting Lorazepam used to calm episodes or used pre-emptively.

Nebulised bronchodilators (using spacers) - are effective for reversible airway obstruction and should be considered for a trial period.

Oxygen – can be considered in the presence of hypoxia. Steroids – are of benefit if obstruction, lymphangitis or inflammation

are present or suspected. Evidence for benefit is weak. Towards the end of life non-pharmacological interventions tend to become less effective and a greater reliance on pharmacological approaches is common. * Intra-nasal midazolam 15mg/3ml in a spray bottle at a dose of 1-2 puffs

in each nostril up to hourly PRN.

Morphine Elixir

If Morphine Naive

2.5 mg 4 hourly prn

If on slow release Morphine

2.5 – 5mg prn dose may be adequate & should be trialled if the patient is on higher opioid doses. There is no hard evidence that prn

dose of >10mg is more effective.

Non-Pharmacological treatments Addressing fear and anxiety by active listening,

exploration of the meaning of breathlessness for each individual.

The use of positioning, breathing control, coping strategies, adaptation and energy conservation.

Increasing airflow by use of fan or opening a window. Cold flannel on face.

Referral to physio for assessment & support.

Graduated exercise is helpful if patient is able.

Did second line treatment fail?

Yes

Initial Management Treatment of underlying causes -treating the cancer itself, the complications of cancer (i.e. pleural effusions, anaemia) and concurrent non-cancer causes (i.e. heart or lung disease).

Prevent or manage the related problems of dyspnoea: addressing fear and anxiety by active listening,

exploration of the meaning of breathlessness for each individual.

The use of positioning, breathing control, coping strategies, adaptation and energy conservation.

Ask for help

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Constipation Constipation can be defined as the small, infrequent or difficult passage of hard stools. Causes of constipation are many and varied, and can include reduced activity, poor oral intake, unfamiliar surroundings, or be indirectly due to cancer e.g. hypercalcaemia, drugs such as opioids, or anti-cholinergics, and/or concurrent medical problems e.g. haemorrhoids.

In palliative care a lot of patients are immobile, have small appetites, paralysis, are bed bound and receive constipatory drugs.

Assessment

Thorough history taking, (especially past & present bowel habit)

Abdominal and rectal examination

Recording of bowel habits by the patient or family.

Refer to Bristol Chart on Page 36.

Management

Prevention is the key eg. Prescribing laxatives with opioid use and give pt/carer permission to titrate the dose

If a cause can be identified then efforts should be made to rectify this.

Consider switching opioids to less constipating eg methadone or fentanyl

Non-pharmacological intervention

Increase fluids & encourage exercise if appropriate. Fruit juice, kiwi crush may be helpful in some patients

Provide with commode or raised toilet seat if required

Encourage/provide privacy

Pharmacological intervention

Intervention to be considered depends on desired outcome.

Always prescribe laxatives prophylactically and regularly when opioids are prescribed.

Types of Laxatives and Uses

Type Action Example Administration Hints Simulant Stimulate the peristaltic

movement. senna (in Laxsol™) Bisacodyl Fleet™ Dulcolax™

Contraindicated in suspected obstruction.

Can increase abdominal pain.

If given rectally must be inserted at least 4cm into the rectum against the mucous membrane of the rectum, not into the faeces – blunt end first.

Lubricant Lubricate the anorectum and have a stimulant effect.

glycerine Insert into the faeces – pointed end first

Avoid using lubricant with suppositories.

Softeners Change consistency of faeces. Not the laxative of choice where peristaltic action impaired e.g. stroke, Parkinsons, impaction, bowel obstruction.

Lactulose™ - needs to be taken with adequate water.Lax-sachets™ - similar to an osmotic as it draws water but does not affect the electrolyte balance. Coloxyl

At least 125mls of water needs to be taken at the time of administration.

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Types of Laxatives and Uses

Type Action Example Administration Hints Bulk-forming agent

Provides fibre which adds bulk to the stool.

Psyllium husk ( Konsyl-D) Must be taken with a significant amount of water.

Tends to be used to “maintain regularity” and is not appropriate to treat constipation due to opioids.

Hospices of Northland Generalist Palliative Care Guidelines – Revised Electronic Version April 2010

Practice Point: All laxatives require a reasonable water intake to produce the best effect – especially the osmotic laxatives such as Lactulose, softeners and bulk-forming laxatives such as metamucil. Optimise the existing laxative regime rather than an automatic switch from one laxative to another especially in patients who are frail & are eating or drinking less.

Use algorithim – see following page.

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CONSTIPATION

Are faeces easy and

comfortable to pass? Is constipation a risk?

PREVENTION OF CONSTIPATION

Maintain fluids and diet.

Encourage gentle mobility.

If having constipating drugs e.g. opioids, amitriptyline

use:

Laxsol 2 tabs nocte - 4 tabs b.d. Liquid preparations need to

be considered if tablets are a problem.

Dehydration, or immobility: titrate laxative to maintain

passage of a comfortable stool.

Maintain daily bowel record.

INTERVENTION:

Glycerine and Dulcolax suppositories, one of each via rectum,

being careful not to place in stool.

Increase softener and stimulant in daily regime.

Lax-achets – 2-8 sachets per day

IF NECESSARY:

Microlax enema one or two via rectum. Consider fleet enema.

May require manual evacuation under sedative cover. e.g.

midazolam 5 mg subcutaneously.

PREVENTION:

See above.

Is the rectum full?

Exclude obstruction.

Is stool unlikely to be the cause?

(abdominal x-ray early)

Consider appropriate management of

bowel obstruction (see management of

bowel obstruction section).

If colic present consider oil enema, overnight

follow up mane with fleet enema.

If colic not present increase laxative.

Consider Lax- sachets – up to 8/day then review.

In impaction up to 8/day can be given in <6hours.

Is the colon

full?

RETURN TO BEGINNING

Reassess every three days and ask

for advice if necessary

No

No

No

Yes

Yes

Yes

Yes

Reassess

daily

No

Yes

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Diarrhoea

Causes of diarrhoea must be sought and reversed. Infection, malabsorption and constipation/obstruction with overflow are the most common and potentially reversible. Overuse of laxatives is also a common occurrence. Patients undergoing chemotherapy and radiotherapy may also develop diarrhoea. Co-morbidities such as ulcerative colitis or irritable bowel syndrome may also be present. Management

Modify diet

Assess & treat overflow from constipation if present. Encourage fluid intake and use of Lax-sachets 2-8 sachets/day or may need manual removal followed by laxatives.

If non-infective treat with loperamide or codeine phosphate.

Review drugs – consider antibiotics, modify laxative

Consider bulking agents

Prescribe appropriate anti-diarrhoeal agent eg loperamide, codeine

Seek specialist advice for control of co-morbidities, enzyme replacement eg pancrease

Delirium Delirium is one of the most common neuropsychiatric problems in patients with end stage disease and a major source of distress for patients and their carers. This may be present as a hypo or hyper active state. The course of delirium may fluctuate over a number of hours and shows diurnal variation. Symptoms include:

Disorientation

Fear and dysphoria

Memory impairment

Reduced attention span

Altered sleep wake cycle

Delirium may be classified as hyperactive, hypoactive or mixed. Risk factors include: drugs, infection, metabolic disturbances, hypoxia, dementia, co-morbidities, advanced disease especially with brain involvement and pain. In the frail & elderly constipation & poor mobility may also be triggers for delirium. A good work-up is necessary to find a cause, correct the reversible and offer management. It is important to have a high suspicion of hypoactive delirium as such patients may not receive the appropriate attention as do those with hyperactive delirium. Delirium may also be part of the terminal phase.

Management

Pharmacological intervention

Review drugs including opioids

Correct metabolic disturbances eg hypercalcemia or infection

Start anti psychotics – haloperidol, risperidone, quetiapine or olanzepine

Acute Agitation/paranoia –use parenteral Haloperidol or Methotimeprazine +/- a Benzodiazepine for sedation, but note that benzodiazepines alone may worsen symptoms in non terminal patients.

If terminal, prescribe ongoing sedation with Midazolam for sedation +/- antipsychotic eg levomepromazine (Nozinan)

FEBRUARY 2015


Non Pharmacological intervention

Explanation to patient and family of all that is being undertaken is mandatory.

Ensure there is a safe environment

Prevent sensory overload

Psychological interventions — reassurance, orientating aids (clock, personal belongings, presence of family), emotional support (touch, empathy), clarification, validation and repetition during lucid periods

Family and/or carer support is vital.

Fatigue Fatigue is the term used to encompass physical weakness (asthenia) and mental tiredness. It may be experienced and expressed as easily tiring, generalised weakness or mental tiredness. It is a very common accompaniment of end stage cancer or end organ diseases. It is often assumed that it is an evitable consequence of approaching death. However reversible situations must be excluded. It is also important to exclude the cause of localised weakness that could result from stroke, spinal cord damage or nerve root damage.

Management

Establish cause – eg, hypercalcaemia, dehydration, infection

Review drug regime – eg B.blockers

Correct metabolic abnormalities if appropriate – Dehydration

Non Pharmacological Interventions

Give dietary advice and support, increase calorific intake if appropriate

Adapt activities of daily living to coincide with times of maximal energy

Arrange for help from loved ones, home care, hospice, district nursing as appropriate

Exercise – gradual exercise is helpful & can keep patients & families motivated

Pharmacological Interventions

Corticosteroids - mechanism of action is unclear (studies suggest a modest energy enhancing effect in cancer

patients only) - benefit may decrease after 4-6 weeks – regular review of benefits must be carried out and

slow weaning off carried out when there is no further benefit. - see dose as in anorexia/cachexia (Section 3.1.2). - methylphenidate may occasionally be used under Specialist guidance.

Mouth Discomfort/Xerostomia (dry mouth) and Stomatitis. Good mouth care and oral hygiene is essential to the wellbeing of patients debilitated by advanced disease. Please follow algorithm

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. IS THE MOUTH

HEALTHY? (intact mucosa, clean, moist and

pain free)

PREVENTATIVE MEASURES:

12 hourly brushing with toothpaste, rinse well. Ensure

dentures are cleaned and soaked e.g. Sterident.

12 hourly mouthwash (remove dentures if present)

IS INFECTION PRESENT? - YES

Treat if appropriate

Viral - consider acyclovir

Bacterial - anaerobic use metronidazole orally.

- aerobic use flucloxicillin

If painful apply Bonjela (cholinesalicylate), use Difflam

mouthwash

If candidal overgrowth (white patches or coating):

Using ½ tsp of Sodium Bicarbonate and ½ tsp salt

mixed with a cup of warm water, clean mouth (use

as mouthwash) ensuring dentures are removed prior

to mouthwash.

Use solution to brush teeth and tongue.

Oral nystatins drops QID - ensure dentures are

removed when taking this. Swish around mouth (as

this works on contact only), and then swallow.

Fluconazole 50 mg daily for five days (If severe or

not responding to Nystatin) .

Tongue and Teeth: clean with ½ tsp sodium bicarbonate and ½ tsp salt in

one cup of warmed water. Soak dentures overnight in chlorine releasing

solution e.g. Sterident or Nystatin.

Mucosa: effervescent solution (e.g. soda water or cider water)

IS ULCERATION

PRESENT?

IS THE MOUTH DIRTY?

(coated tongue, mucosa or

teeth; oral debris).

CANDIDA?

Yes

No

IS THE MOUTH

DRY?

Treat cause - dehydration (if appropriate)/infection/anxiety.

- consider medication change

Local measures: frequent sips of water and regular mouthwash/use

atomizer spray with water/ice cubes to suck/frozen fruit juice/pineapple

chunks or juice/moisten lips with aqueous cream / oral lubrication.

Consider: Artificial saliva e.g. Biotene oral gel

Topical analgesics: Benzydamine (Difflam) mouthwash/choline

salicylate gel (Bonjela) dispersible aspirin mouthwash

Consider: Candidal infection (may cause a red, painful mouth without

patches) - see above

Use soft toothbrush or foam sponge toothbrushes

Zylocaine viscous.

IS THE MOUTH

STILL PAINFUL?

RETURN TO BEGINNING

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

FEBRUARY 2015


Nausea and Vomiting These are common symptoms in palliative care. The causes are many and several may be present at any one time.

Important considerations in the management of nausea & vomiting. Attempt to establish a cause Reverse the cause if possible eg hypercalcamia, constipation, UTI Use a ‘broad spectrum’ antiemetic (see table below) whilst the possible cause/causes is being

established. o Domperidone and metoclopramide 10mg tds a/c or qid if prokinesis is to be encouraged o levomepromazine (Nozinan) – 6.25mg nocte o When there is more clarity around the cause choose the appropriate anti-emetic or

combination of anti-emetics. Eg inner ear /peritoneal origin may respond best to anti muscarinic/histminic approach.

Subcutaneous route of administraton Consider other drugs – eg anxiolytics if anxiety induced, gastric protection if gastric irritation is

suspected. Seek specialist advice as control of nausea & vomiting may be complex and difficult. Prescribe regular medication and prn doses.

The following table gives an indication of receptor site affinities for the anti-emetis commonly used in palliative care.

Receptor site affinities of selected antimetics

14-16

Dopamine D2- antagonist

Histamine H1- antagonist

Acetylcholine (muscarinic) antagonist

5HT2- antagonist

5HT3- antagonist

5HT4- antagonist

Metoclopramidea

++ 0 0 0 (+) ++

Domperidonea ++ 0 0 0 0 0

Ondansetronb 0 0 0 0 +++ 0

Cyclizine 0 ++ ++ 0 0 0

Hyoscine hydrobromide 0 0 +++ 0 0 0

Haloperidolb +++ 0 0 0 0 0

Levomepromazinec

(methotrimeprazine)

++ +++ ++ +++ 0 0

Pharmacological activity: 0 none or insignificant, + slight, ++ moderate, +++ marked a. Domperidome & Metoclopramide both have prokinetic activity and encourage gastric emptying. Metoclopramide

crosses the blood-brain barrier and exerts a central effect but may cause dystonic reactions, decreased mental acuity and drowsiness. Domperidone may therefore be a better option for patients who are on antidepressants, anti-psychotics or the elderly.

b. Haloperidol 1.5 – 3mg nocte is the drug of choice for ‘chemically’ induced nausea including that caused by opioids. c. Nozinan (methotrimeprazine) 6.25mg nocte has affinities for several receptor sites and is a good first line broad

spectrum anti-emtic.

Regular follow up is necessary and combinations of drugs may be required to achieve as much receptor activity as possible.

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Non Pharmacological Intervention

Consider elements that may affect nausea — smells, dirty mouth, past experiences recalling episodes of vomiting.

Regular mouthcare including the treatment of oral thrush

Education of family to provide small attractive meals.

Ginger and ginger drinks do have anti-nausea effect.

Pain Pain is a multi-dimensional feature occurring in up to 90% of patients who receive palliative care, including those with a non-malignant pathology. It requires constant assessment, management review with attention to detail and prescribing that is tailor made to each particular patient. It requires constant diagnosis of possible causes, the correction of reversible causes, and the search for the most appropriate medication. If uncontrolled, pain has a huge impact on a patient’s quality of life, limiting sleep, rest, mobility, social interaction, work, activities and family life therefore contributing to suffering.

Assessment Each pain described requires an in-depth history taking eg the site, quality, severity, timing and triggering factors need to be explored, including the drugs that have been used and their effect. Other features such as anxiety, reactions to life events, concerns, and family realities must also be extracted.

A good physical examination will help determine the site and type of pain.

The types of pain can be:

1. Somatic – pain in solid body parts.. 2. Visceral – this usually involves the organ capsule and apart from opioids may respond well to the use

of an anti-inflammatory medication. 3. Neuropathic – because the pain is transmitted via injured or affected nerves this pain may require

adjuvant drugs apart from opioids of which Methadone may be the better option. (see below) 4. Incident pain – this pain occurs when triggered by positional change, cough or another precipitant.

It may occur in the absence of a background pain and may be quite challenging to control with drugs only.

5. Break through pain – transient increase in pain. 6. Colicky pain is intermittent pain that occurs with increased organ activity of smooth muscle in the

bladder, uterus or bowel. This requires specific anti-spasmodic medication and can include opioids. 7. Other pain types include headaches from increased intra-cranial pressure, central pain generated

from intracerebral tumours or damage, and sphincter pain such as bladder spasm and anal tenesmus.

Management of Pain The management of pain should follow basic steps which can be effective in up to 90% of patients. Specialist palliative care services or Specialist pain services provide ongoing support and specialist input when this is necessary.

The WHO ladder of Analgesia has been the guide in pain relief. It involves three steps

Mild pain generally controlled by non-opioids or NSAID’s

Moderate pain generally controlled by ‘mild’ opioids +/- NSAID’s

Severe pain necessitating use of ‘strong’ opioids +/- NSAID’s

FEBRUARY 2015


Important Considerations

An NSAID may be used as an initial drug as can paracetamol (+/- codeine) especially in the case where there is inflammatory element to the pain. It should then be considered at every step together with the use of opioids and other drugs.Consider the role of gastro protection with a PPI.

Consider the co-prescripion of a PPI with NSAID use for gastro-protection Pain in palliative care patients is chronic and requires regular medications together with prn doses for

breakthrough episodes.

Most analgesics can be given orally unless this route is compromised by nausea, vomiting, dysphagia or malabsorption.

As pain escalates, the opioid dose must be titrated upwards to reflect the increase in pain. At every step, the inclusion of co-analgesic drugs should be considered. This is especially important in

the case of neuropathically generated pain. Opioids Co-analgesic drugs

Side effects may limit drug tolerance or escalation. If the opioid is effective consider drugs or other measures to counteract these side-effects before switching the opioid eg

Haloperidol for hallucinations

Nozinan or Meloclopramide. Haloperidol for emesis

Laxatives for constipation (required in most cases)

Opioid rotation may become necessary to control pain or minimize side-effects. The following flow chart provides some simple steps as guidelines towards the better choice of opioid. Conversion doses on the other hand are not straightforward and may require specialist advice (see flow chart).

Regular review is necessary and non-drug measures must be considered and explained eg rest, relaxation, distraction, adequate sleep, adaption of life style.

Unrelieved pain or pain escalation may require investigation and referral to specialist services including radiotherapy.

Morphine NSAID’s for inflammation Methadone CorticoSteroids Fentanyl Tricylic anti-depressant eg Amitriptyline Oxycodone Anti-convulsant eg Gabapentin, Na Valproate Benzodiazepines for muscle relaxation, anxiety

Antibiotics for infection

Bisphophonates in bone pain (approved for breast cancer & myeloma)

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Pain requiring opioids

Renal impairment Constipation/bowel obstruction

no yes

morphine Fentanyl +

Oxycodone prn

Effective Not effective

Effective but hallucinations

Oxycodone

Laxatives?

+/- switch

Fentanyl +

Morphine prn

(methadone may

be less constipating)

Not effective –

colic persists

Effective

Return to morphine/use

methadone optimise

laxatives

Is the pain

neuropathic?

Switch to methadone

and add adjuvants

Boney

pain?

Add NSAID and

consider switch to

methadone / RT

Effective


Algorithm for Opioid Use

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Physical Control of Symptoms Morphine Oral morphine is available in the long acting form (m-Eslon or LA Morph) and the quicker/short

acting form (Sevedol tabs or Liquid in several strengths).

The usual starting dose for morphine when used for pain is 2.5 – 5mg 4hrly prn if the pain is intermittent or 10mg 12hrly if the pain is constant.

PRN doses must always be prescribed and the dose of these must increase if the total dose of regular morphine is increasing. As a general rule, the prn dose must be at least 1/6 of the total daily morphine dose. In some cases eg incident pain, the intensity of the episodes far outruns the level of pain at rest and requires higher PRN doses.

Laxatives must always be prescribed regularly with morphine unless contraindicated eg. Ilieostomy. Aniti-emetics may be required and should be prescribed on an as needed basis. Drowsiness may be an initial side-effect which may wear off after a few days.

If or once the oral route becomes difficult, morphine sulphate is available for subcutaneous use. The oral to subcut dose must be halved due to increased bio availability.

Subcutaneous morphine may be given intermittently every 3hrs prn for episodic pain or continuously via a syringe driver. Morphine sulphate mixes well with most other medications when given via this manner.

Consider the use of an adjuvant drug for pain

If the pain is not morphine responsive or if side-effects become intolerable or uncontrollable consider the addition of an adjuvant drug or switch to another opioid. (see flow chart).

Methadone (best under specialist guide) Methadone is available as tablets, liquid or ampoules.

Toxicity sedation and respiratory depression can be sudden and after 4-5 days of accumulation

The starting dose of methadone is usually 2.5mg 12hrly for constant pain or 2.5mg prn 3-4 hrly for intermittent pain, but maximum of 7.5 mg per 24 h for PRN)

PRN doses are the same as the regular and may be given 4hrly, however methadone levels may accumulate and it is therefore necessary to review the total daily dose of Methadone on the second or third day if drowsiness or other side-effects develop.

Requires regular monitoring (4-5 day intervals) when commencing methadone

Specialist advice is usually required to titrate methadone to higher doses.

Methadone may be given i.m or subcutaneously if the oral route is compromised. The conversion from oral to the subcutaneous route is 80%. Caution must be executed with higher doses.

Fentanyl Fentanyl is available as transdermal patches of varying strengths starting from 12.5mcg/hr

patches, or in the injectable form which can be given subcutaneously and is used to titrate against pain levels in an inpatient setting eg. 600mcg of subcutaneous Fentanyl in 24hrs is equivalent to the 12.5mcg/hr patch and converts to between 30-60mg of total daily oral morphine.

There is no quick acting Fentanyl currently available in NZ that may be self administered. Breakthrough pain is best controlled with oral Morphine.

FEBRUARY 2015

Oxycodone Oxycodone is available in 2 forms – the long acting controlled release, 12hrly MR (modified

release) tablets and the quick acting form (oxycodone immediate release).

Oxycodone is twice as potent as morphine mg for mg.

Oxycodone is 80% bioavailable so oral to s/c should respect a20 % reduction in dose for equivalence.

The indications for converting to oxycodone is the lower side-effect (eg hallucinations) profile it may have in some patients.

Pain that is not sensitive to morphine is not responsive to oxycodone but its potentially lower side effect profile may allow better tolerance and escalation of the drug.

FEBRUARY 2015


Managing Palliative Care Emergencies

Situations in palliative care that require urgent attention and a level of suspicion.

i. Hypercalcaemia The features of hypercalcamia include the following: Nausea, vomiting, malaise

Increasing pain

Increasing confusion, delirium and drowsiness

Polyuria

Constipation One should have a level of suspicion if these or some of these symptoms are present especially in cases where there are known boney metastases. Squamous cell lung cancers and renal cancers can commonly produce non-metastatic hypercalcaemia.

These patients need investigation and must be referred to specialist services.

ii. Spinal Cord Compression This requires urgent attention or must be suspected if the following are present in patients with known or suspected boney metastases.

Increasing or changing back pain +/- boney tenderness

Sensory changes in the limbs, perineum, eg paraesthesia, numbness

Constipation, urinary hesitancy/retention

Faecal and/or urinary incontinence

Weakness effecting lower limbs, upper limbs or both On examination there may be a sensory level, sensory abnormalities, reduced reflexes and decreased muscle power. Referral is urgent and management includes high dose steroid & urgent radiotherapy (16 mg od).

iii. Malignant Bowel Obstruction Several conditions may give rise to this. After surgical intervention is excluded, medical management is possible for control of symptoms and possible reversible of the obstruction.

Bowel obstruction must be considered when there is:

No bowel motion or passage of flatus for several days

Nausea & vomiting

Colicky gripey pain +/- background abdominal pain

Abdominal distention

Generalized malaise, fatigue

Dehydration Specialist referral is necessary. Management includes high dose steroid, subcutaneous administration of anti-emetic, analgesics and anti-muscarinics.

FEBRUARY 2015


iv. Superior Vena Cava Obstruction

Requires to be considered especially in lung cancer, particularly small cell.

Breathlessness (caused by laryngeal oedema)

Choking sensation

Neck and facial swelling

Headache / or feeling of fullness in the head

Trunk and arm swelling

May have visual changes

Dizziness

Upper trunk venous engorgement

On examination there may be delated non-pulsatile neck veins, dilated collateral veins of chest and arms and engorged conjunctive, peri-orbital oedema.

Specialist referral is necessary.

Management includes high dose steroids, radiotherapy, chemotherapy and in some cases metal stenting into the SVC.

v. Massive Haemorrhage

The potential to be an extremely distressing event.

Patients at risk generally fall within the disease categories listed below:

Head and beck cancers

Cancer of the bronchus

Gastrointestinal cancer Management includes discussion with patient and families regarding the possibility that this may occur. The use of s/c medications such as midazolam need to be available. Practical information around the availability of dark towels to help protect and clean is also suggested.

FEBRUARY 2015

Physical Control of Symptoms References

Best Practice Vol 3 Issue 1, (1999). Management of Constipation in Older Adults. Available online www.joannabriggs.edu.au.

Costello, H. (2002). Living with cancer related breathlessness. The Cancer Society of NZ Wellington Division Inc.

Doyle, D., Hanks, G., & MacDonald (1998).Oxford Textbook of Palliative Medicine (2nd

edition) Oxford: Oxford University Press.

Hoyal, C., Grant, J., Chamberlain, F., Cox, R., & Campbell, T. (2002). Improving the management of breathlessness using a clinical effectiveness programme. International Journal of Palliative Nursing, Vol 8(2).

Maddocks, I, (2001) Palliative Care: A Guide for General Practitioners (8th

ed.) Dawpark: South Australia.

MacLeod, R., Vella-Brincat, J., & Macleod, A. (2002). The Palliative Care Handbook. Guidelines for Clinical Management and Symptom Control, Hutcheson, Bowman & Stewart.

Regnard, C. & Hockley, J (1995). Flow diagrams in Advanced Cancer and Other Diseases. London: Hodder Headline PLC.

Thomas, K.(2003). Caring for the Dying at Home. Companions on the Journey. Oxford: Radcliffe Medical Press. Twycross, R., & Wilcock, A. (2004). Symptom Management in Advanced Cancer. (3rd edition). Oxford: Radcliffe Medical Press. World Health Organisation (1956) Cancer Pain Relief, WHO, Geneva.

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