EMERGENCIES IN PALLIATIVE CARE &MANAGEMENT IN LAST 48 HOURS OF LIFE

1. EMERGENCIES IN PALLIATIVE CARE &
MANAGEMENT IN LAST 48 HOURS OF
LIFE
Prepared by:
Anish Dhakal
(Aryan)

2. List of Contents
• Emergencies in Palliative Care
– Spinal Cord Compression
– Hypercalcemia of Malignancy
– Superior Venacaval Syndrome
• Last 48 Hours of Life in Palliative Care

3. Spinal Cord Compression
• Incidence
– About 5% of patients with advanced cancer have
spinal cord compression
• Early diagnosis and treatment imperative
• Causes
– More than 40% come from breast, lungs, myeloma
and prostate
• Site
– Most common site is lower dorsal vertebra(70%)
followed by lumbar (20%) and cervical (10%)

4. Spinal Cord Compression
• New or worsening back pain,
– Especially pain at night
– Keeps them awake
• Require full neurological assessment
• Early spinal cord compression may not show
neurological features

5. Signs and symptoms
• Pain (90%)
• Central back pain aggravated by movement,
coughing, straining or lying flat
• A feeling of being unsteady on feet, having difficulty
climbing stairs or walking
• Numbness
• Difficulty controlling bladder, passing very little urine
or passing none at all
• Constipation or problems controlling bowels

6. Examination
• Gait
• Spinal Cord Compression (Above L1)
– Spastic paresis
– Increased reflexes
– Upgoing plantars
– Sensory level
– Local /radicular back pain

7. Examination (contd..)
• Cauda Equina compression (Below L1)
– Flaccid paralysis
– Absent reflexes
– Downgoing plantars
– Dermatomal sensory changes
– Distended bladder/lax anal tone

8. Investigations
• MRI (magnetic resonance imaging) scan
• CT (computerised tomography) scan
• Bone scan

9. Goals of Treatment
• Palliation
• Maintain mobility
• Decrease tumour bulk
• Relieve pain

10. Management
• Treated as acute emergency
• Immobilization of spine
• Consultation with the Oncology team
– Radiotherapy and chemotherapy if necessary
• Mobility

11. Management
• High dose steroids Dexamethasone 10 mg iv stat
and 4 mg 6 hourly orally
• Local Radiotherapy 20-30 gm over-2 weeks
• Strong analgesic
• Consider surgery, if
– No tissue diagnosis
– Unstable spine
– Previous irradiation
• Chemotherapy  chemosensitive tumours
• Physiotherapy
• Rehabilitation

12. Prognosis
• Ambulation preserved in >80% who are
ambulatory at presentation
• 1/3 patients get complete relief, no longer
requiring analgesia
• While 70% experience a significant improvement
• Life prognosis depends on disease

13. HYPERCALCEMIA OF MALIGNANCY
 It occurs in 10% patients with cancer
 Treatment usually improves the symptoms
and improves the quality of life
 It is a poor prognostic sign with many
patients surviving less than 3 months
 Approximately 20% survive a year

14. DISEASES COMMONLY ASSOCIATED
WITH HYPERCALCAEMIA
 multiple myeloma,
 breast,
 renal cell carcinoma,
 lymphoma
 20% of cases occur without bony
metastasis

15. MECHANISMS OF HYPERCALCAEMIA
 Parathyroid Hormone Releasing Protein
PTHrP, secreted by tumour
 Osteoclast activating factors (tumour
induced)
 Increased Vitamin D3 production

16. SYMPTOMS OF HYPERCALCAEMIA
 Nausea
 Anorexia and vomiting
 Constipation
 Thirst and polyuria
 Pain precipitated/ exacerbated
 Gross dehydration
 Drowsiness
 Confusion and coma
 Abnormal neurology
 Mimic metastases, ataxia, fits
 Cardiac arrythmia

17. MANAGEMENT OF HYPERCALCAEMIA
If serum calcium less than 3mmol/L and patient
asymptomatic
 Increase oral fluids
 Consider oral biphosphonates
 Pamidronate and zoledronate

18. Contd…
If serum calcium more than 3mmol/l and patient
symptomatic
 Rehydration with 2-4 of normal saline over 24
hours
 Intravenous biphosphonates(Pamidronate:60-
90mg single dose IV infusion over 2-24 hrs)
 Steroid if hypercalcaemia is due to multiple
myeloma and lymphoma

19. SUPERIOR VANACAVAL SYNDROME
 due to obstruction to venous return to
right side of the heart by extrinsic
compression, intraluminal thrombosis or
invasion of the vessel wall
 More than 75% of the SVCO occurs due
to lung cancer
 15% is due to mediastinal lymphoma

20. SYMPTOMS OF SVC SYNDROME
 Dyspnoea
 neck/face swelling
 trunk/arm swelling
 choking sensation
 feeling of fullness in head /headache
 chest pain,
 cough,
 dysphagia,
 cognitive dysfunction,
 hallucinations
 seizures

21. SIGNS OF SVC SYNDROME
Mild symptoms
 Dilatation superficial
veins chest
 Engorged jugular
vein
 Facial oedema
 Tachypnoea
 Plethora of face
 Cyanosis
Moderate symptoms
 Arm oedema
 Vocal cord paresis
 Horner’s syndrome
In severe cases
 laryngeal stridor
 coma
 death

22. MANAGEMENT OF SVC SYNDROME
 Rarely requires emergency management
 Most of the time, there is time to get
tissue diagnosis, stage the disease and
implement treatment which may be
chemotherapy for lymphomas and
Radiotherapy for lung carcinoma

23. SYMPTOMATIC MANAGEMENT
• Oxygen
• Psychological management
• Benzodiazepines
• Opioids
• Diuretics
• Dexamethasone 16mg/24 hours
• Radiotherapy to mediastinum
• Chemotherapy if appropriate

24. Emergency management in
last 48 hrs

25. • Terminal phase : The period when day to day
deterioration, particularly of strength, appetite
and awareness, are occurring
• Signs of impending death :
– Rapidly increasing weakness and fatigue
– The patient is usually bed bound
– Decreasing intake of food and fluids
– Difficulty in swallowing
– Decreasing level of consciousness
– The patient is no longer able to take oral drugs

26. Goals for the Terminal Phase
• Ensure the patient’s comfort physically,
emotionally and spiritually
– Dealing with patient and family fears
– Fear of
• Separation from loved ones
• Being a burden to others
• Losing control
• Worsening symptoms
• The unknown
• Dying and of being dead
• End of life peaceful and dignified
– Appropriate closure and good-byes

27. Goals for the Terminal Phase
• Make the memory of the dying process as positive as
possible
• Good communication with the patients
• Key part : Understanding of the desires/cultural
practices of the patient and their family
• Preparing them for what will happen, answering
questions and concerns and keeping them informed
of plans

28. Management
• Assess
– Physical needs (pain control, mouth care and anything else
suggested by symptoms or non verbal signs)
– Psychological needs (especially finding out what the
patient wants to know and gently assessing for anxiety and
fears)
– Spiritual needs (especially looking for “pain/disquiet" and
being aware of particular tasks required)
• Prevention/ minimization of new problems
• Generally investigations, unless looking for treatable
conditions, not necessary

29. Symptomatic Treatment

30. Weakness and Fatigue
• Severe and disabling Reflects muscle weakness
• Tiredness which is not relieved by rest
• Measures
– Gentle assistance with all activities of living
– Tasks should not be hurried
– Avoid unnecessary interventions e.g. measuring
vital signs
– Discontinue non essential drugs and convert oral
pain killers to s/c injections

31. Secretions
• Pooling of secretions , common and can cause
noisy, moist breathing often referred to as ‘death
rattle’ (often distressing to relatives but not
usually to the patient)
• Measures
– Position carefully, turn on alternate sides
– Avoid suctioning
– Swab inside the mouth
– Reassure the family that the patient is not choking

32. Pain
• Difficult to assess if drowsy
• Moaning may be related to agitation or
discomfort rather than pain
• Measures
– Look for facial expression and sweating
– Give appropriate analgesia subcutaneously
– Total Pain
• Emotional; Spiritual
• “Are you worried about dying?”

33. Agitation
• Very common but preventable
• Measures
– Look for reversible causes such as pain, full
bladder or rectum
– Warn the family about the possibility
– Specific drugs can be used that help such as
phenobarbitol, Midazolam

34. Incontinence
• Catheterization
• If diarrhoea occurs, use pads
Always change promptly to preserve
comfort and dignity

35. Breathing Pattern
• Prepare the family and reassure
• Position carefully to prevent obstruction of
airway
• Oxygen is rarely needed
• Drugs such as morphine help ease breathlessness

36. Oral Hygiene
• Maintain good oral hygiene
• Measures
– Keep dentures clean and moist, remove if the
patient is drowsy and agrees
– Use sponge mouth swabs with water or dilute
mouth wash
– Give meticulous mouth care when oral intake is
low

37. Skin Care
• Reposition for comfort only and avoid friction
when repositioning
• Keep skin clean with gentle cleansing
• Deal with incontinence without any delay
• Use pressure relieving devices if available
• Reassess frequently

38. Positioning
• Use plenty of pillows to support
• Do not elevate the head too much
• Change position regularly; between 2 – 4
hourly

39. Hydration and Nutrition
• Families often worry
• Need good explanations
– often patients drink less because they are dying;
they are not dying because they are drinking less
• Keep lips moist
– Ice chips can help but watch for swallowing
difficulties

40. Care of Family and Loved Ones
• Relatives perceptions may be different to what
the patient is actually experiencing
• Measures
– Explore ways they can be involved in care
– Encourage them to continue talking to the
patient, as they may be able to hear them
– Listen to their concerns
– Prepare them for what to expect at the time of
death
– Tell clearly when patient dies